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The intensive care management of acute ischemic stroke: an overview

Abstract

Purpose

Acute ischemic stroke (AIS) is a leading cause of morbidity and mortality worldwide. In part due to the availability of more aggressive treatments, increasing numbers of patients with AIS are being admitted to the intensive care unit (ICU). Despite the availability of consensus guidance for the general management of AIS, there is little evidence to support its ICU management. The purpose of this article is to provide a contemporary perspective, and our recommendations, on the ICU management of AIS.

Methods

We reviewed the current general AIS guidelines provided by the European Stroke Organisation, the American Stroke Association, and the UK National Institute for Health and Care Excellence, as well as the wider literature, for the data most relevant to the ICU management of AIS.

Results

There are four interventions in AIS supported by class I evidence: care on a stroke unit, intravenous tissue plasminogen activator within 4.5 h of stroke onset, aspirin within 48 h of stroke onset, and decompressive craniectomy for supratentorial malignant hemispheric cerebral infarction. However, robust evidence for specific AIS management principles in the ICU setting is weak. Management principles currently focus on airway and ventilation management, hemodynamic and fluid optimization, fever and glycemic control, management of anticoagulation, antiplatelet and thromboprophylaxis therapy, control of seizures and surgical interventions for malignant middle cerebral artery and cerebellar infarctions.

Conclusions

We have provided our recommendations for the principles of ICU management of AIS, based on the best available current evidence. Encouragement of large-scale recruitment of patients with AIS into clinical trials should aid the development of robust evidence for the benefit of different interventions in the ICU on outcome.

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References

  1. Lopez AD, Mathers CD, Ezzati M et al (2006) Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. Lancet 367:1747–1757. doi:10.1016/s0140-6736(06)68770-9

    PubMed  Article  Google Scholar 

  2. Donnan GA, Fisher M, Macleod M, Davis SM (2008) Stroke. Lancet 371:1612–1623. doi:10.1016/S0140-6736(08)60694-7

    CAS  PubMed  Article  Google Scholar 

  3. Lees KR, Bluhmki E, von Kummer R et al (2010) Time to treatment with intravenous alteplase and outcome in stroke: an updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials. Lancet 375:1695–1703. doi:10.1016/s0140-6736(10)60491-6

    CAS  PubMed  Article  Google Scholar 

  4. European Stroke Organisation (ESO) Executive Committee, ESO Writing Committee (2008) Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovasc Dis 25:457–507. doi:10.1159/000131083

    Article  Google Scholar 

  5. Jauch EC, Saver JL, Adams HPJ et al (2013) Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 44:870–947. doi:10.1161/STR.0b013e318284056a

    PubMed  Article  Google Scholar 

  6. National Collaborating Centre for Chronic Conditions (2008) Stroke: national clinical guideline for diagnosis and initial management of acute stroke and transient ischaemic attack (TIA). Royal College of Physicians, London

    Google Scholar 

  7. Zazulia AR (2009) Critical care management of acute ischemic stroke. Continuum (Minneap Minn) 15:68–82

    Google Scholar 

  8. Bollaert P-E, Vinatier I, Orlikowski D, Meyer P (2010) Prise en charge de l’accident vasculaire cérébral chez l’adulte et l’enfant par le réanimateur (nouveau-né exclu), (hémorragie méningée exclue): recommandations formalisées d’experts sous l’égide de la Société de réanimation de langue française, Avec la participation du groupe francophone de réanimation et urgences pédiatriques (GFRUP), de la société française neurovasculaire (SFNV), de l’association de neuro-anesthésie et réanimation de langue française (ANARLF), de l’agence de la biomédecine (ABM). Reanimation 19:471–478. doi:10.1016/j.reaurg.2010.06.005

    Article  Google Scholar 

  9. Dirnagl U, Iadecola C, Moskowitz MA (1999) Pathobiology of ischaemic stroke: an integrated view. Trends Neurosci 22:391–397

    CAS  PubMed  Article  Google Scholar 

  10. Sutherland BA, Minnerup J, Balami JS et al (2012) Neuroprotection for ischaemic stroke: translation from the bench to the bedside. Int J Stroke 7:407–418. doi:10.1111/j.1747-4949.2012.00770.x

    PubMed  Article  Google Scholar 

  11. Petty GW, Brown RDJ, Whisnant JP et al (1999) Ischemic stroke subtypes: a population-based study of incidence and risk factors. Stroke 30:2513–2516

    CAS  PubMed  Article  Google Scholar 

  12. Bamford J, Sandercock P, Dennis M et al (1991) Classification and natural history of clinically identifiable subtypes of cerebral infarction. Lancet 337:1521–1526

    CAS  PubMed  Article  Google Scholar 

  13. Hacke W, Kaste M, Bluhmki E et al (2008) Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 359:1317–1329. doi:10.1056/NEJMoa0804656

    CAS  PubMed  Article  Google Scholar 

  14. Ciccone A, Valvassori L, Nichelatti M et al (2013) Endovascular treatment for acute ischemic stroke. N Engl J Med 368:904–913. doi:10.1056/NEJMoa1213701

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  15. Kidwell CS, Jahan R, Gornbein J et al (2013) A trial of imaging selection and endovascular treatment for ischemic stroke. N Engl J Med 368:914–923. doi:10.1056/NEJMoa1212793

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  16. Broderick JP, Palesch YY, Demchuk AM et al (2013) Endovascular therapy after intravenous t-PA versus t-PA alone for stroke. N Engl J Med 368:893–903. doi:10.1056/NEJMoa1214300

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  17. Stroke Unit Trialists’ Collaboration (2013) Organised inpatient (stroke unit) care for stroke. Cochrane Database Syst Rev 9:CD000197. doi:10.1002/14651858.CD000197.pub3

    Google Scholar 

  18. Wijdicks EFM, Sheth KN, Carter BS et al (2014) Recommendations for the management of cerebral and cerebellar infarction with swelling: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. doi:10.1161/01.str.0000441965.15164.d6

    PubMed  Google Scholar 

  19. Rowat AM, Dennis MS, Wardlaw JM (2006) Hypoxaemia in acute stroke is frequent and worsens outcome. Cerebrovasc Dis 21:166–172. doi:10.1159/000090528

    PubMed  Article  Google Scholar 

  20. Ronning OM, Guldvog B (1999) Should stroke victims routinely receive supplemental oxygen? A quasi-randomized controlled trial. Stroke 30:2033–2037

    CAS  PubMed  Article  Google Scholar 

  21. Ali K, Warusevitane A, Lally F et al (2013) The stroke oxygen pilot study: a randomized controlled trial of the effects of routine oxygen supplementation early after acute stroke-effect on key outcomes at six months. PLoS ONE 8:e59274. doi:10.1371/journal.pone.0059274

    PubMed  Article  PubMed Central  Google Scholar 

  22. Rincon F, Kang J, Maltenfort M et al (2014) Association between hyperoxia and mortality after stroke: a multicenter cohort study. Crit Care Med 42:387–396. doi:10.1097/CCM.0b013e3182a27732

    PubMed  Article  Google Scholar 

  23. Rout MW, Lane DJ, Wollner L (1971) Prognosis in acute cerebrovascular accidents in relation to respiratory pattern and blood gas tensions. Br Med J 3:7–9

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  24. Pollock JM, Deibler AR, Whitlow CT et al (2009) Hypercapnia-induced cerebral hyperperfusion: an under recognized clinical entity. AJNR Am J Neuroradiol 30:378–385. doi:10.3174/ajnr.A1316

    CAS  PubMed  Article  Google Scholar 

  25. Bösel J (2014) Tracheostomy in stroke patients. Curr Treat Options Neurol 16:274

    PubMed  Article  Google Scholar 

  26. Santoli F, De Jonghe B, Hayon J et al (2001) Mechanical ventilation in patients with acute ischemic stroke: survival and outcome at one year. Intensive Care Med 27:1141–1146

    CAS  PubMed  Article  Google Scholar 

  27. Hamdy S, Aziz Q, Rothwell JC et al (1997) Explaining oropharyngeal dysphagia after unilateral hemispheric stroke. Lancet 350:686–692. doi:10.1016/S0140-6736(97)02068-0

    CAS  PubMed  Article  Google Scholar 

  28. Bours G, Speyer R, Lemmens J (2009) Bedside screening tests vs. videofluoroscopy or fibreoptic endoscopic evaluation of swallowing to detect dysphagia in patients with neurological disorders: systematic review. J Adv Nurs 65:477–493

    PubMed  Article  Google Scholar 

  29. Geeganage C, Beavan J, Ellender S, Bath PMW (2012) Interventions for dysphagia and nutritional support in acute and subacute stroke. Cochrane Database Syst Rev 10:CD000323. doi:10.1002/14651858.CD000323.pub2

    PubMed  Google Scholar 

  30. Leonardi-Bee J, Bath PM, Phillips SJ, Sandercock PA (2002) Blood pressure and clinical outcomes in the International Stroke Trial. Stroke 33:1315–1320

    PubMed  Article  Google Scholar 

  31. Potter JF, Robinson TG, Ford GA et al (2009) Controlling hypertension and hypotension immediately post-stroke (CHHIPS): a randomised, placebo-controlled, double-blind pilot trial. Lancet Neurol 8:48–56. doi:10.1016/s1474-4422(08)70263-1

    CAS  PubMed  Article  Google Scholar 

  32. He J, Zhang Y, Xu T et al (2014) Effects of immediate blood pressure reduction on death and major disability in patients with acute ischemic stroke: the CATIS randomized clinical trial. JAMA 311:479–489. doi:10.1001/jama.2013.282543

    CAS  PubMed  Article  Google Scholar 

  33. Kaste M, Fogelholm R, Erila T et al (1994) A randomized, double-blind, placebo-controlled trial of nimodipine in acute ischemic hemispheric stroke. Stroke 25:1348–1353

    CAS  PubMed  Article  Google Scholar 

  34. Sandset EC, Bath PM, Boysen G et al (2011) The angiotensin-receptor blocker candesartan for treatment of acute stroke (SCAST): a randomised, placebo-controlled, double-blind trial. Lancet 377:741–750. doi:10.1016/s0140-6736(11)60104-9

    CAS  PubMed  Article  Google Scholar 

  35. Rordorf G, Koroshetz WJ, Ezzeddine MA et al (2001) A pilot study of drug-induced hypertension for treatment of acute stroke. Neurology 56:1210–1213

    CAS  PubMed  Article  Google Scholar 

  36. Asplund K (2002) Haemodilution for acute ischaemic stroke. Cochrane Database Syst Rev 4:CD000103. doi:10.1002/14651858.cd000103

    PubMed  Google Scholar 

  37. Ginsberg MD, Palesch YY, Hill MD et al (2013) High-dose albumin treatment for acute ischaemic stroke (ALIAS) Part 2: a randomised, double-blind, phase 3, placebo-controlled trial. Lancet Neurol 12:1049–1058. doi:10.1016/S1474-4422(13)70223-0

    CAS  PubMed  Article  Google Scholar 

  38. Norris JW, Froggatt GM, Hachinski VC (1978) Cardiac arrhythmias in acute stroke. Stroke 9:392–396

    CAS  PubMed  Article  Google Scholar 

  39. Kerr G, Ray G, Wu O et al (2009) Elevated troponin after stroke: a systematic review. Cerebrovasc Dis 28:220–226. doi:10.1159/000226773

    CAS  PubMed  Article  Google Scholar 

  40. Darki A, Schneck MJ, Agrawal A et al (2013) Correlation of elevated troponin and echocardiography in acute ischemic stroke. J Stroke Cerebrovasc Dis 22:959–961. doi:10.1016/j.jstrokecerebrovasdis.2011.12.004

    PubMed  Article  Google Scholar 

  41. Sörös P, Hachinski V (2012) Cardiovascular and neurological causes of sudden death after ischaemic stroke. Lancet Neurol 11:179–188. doi:10.1016/S1474-4422(11)70291-5

    PubMed  Article  Google Scholar 

  42. Alvarez-Sabin J, Molina CA, Montaner J et al (2003) Effects of admission hyperglycemia on stroke outcome in reperfused tissue plasminogen activator-treated patients. Stroke 34:1235–1241. doi:10.1161/01.str.0000068406.30514.31

    PubMed  Article  Google Scholar 

  43. Southerland AM, Johnston KC (2012) Considering hyperglycemia and thrombolysis in the Stroke Hyperglycemia Insulin Network Effort (SHINE) trial. Ann N Y Acad Sci 1268:72–78. doi:10.1111/j.1749-6632.2012.06731.x

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  44. Kase CS, Furlan AJ, Wechsler LR et al (2001) Cerebral hemorrhage after intra-arterial thrombolysis for ischemic stroke: the PROACT II trial. Neurology 57:1603–1610

    CAS  PubMed  Article  Google Scholar 

  45. Leigh R, Zaidat OO, Suri MF et al (2004) Predictors of hyperacute clinical worsening in ischemic stroke patients receiving thrombolytic therapy. Stroke 35:1903–1907. doi:10.1161/01.STR.0000132571.77987.4c

    CAS  PubMed  Article  Google Scholar 

  46. Uyttenboogaart M, Koch MW, Stewart RE et al (2007) Moderate hyperglycaemia is associated with favourable outcome in acute lacunar stroke. Brain 130:1626–1630. doi:10.1093/brain/awm087

    PubMed  Article  Google Scholar 

  47. Bellolio MF, Gilmore RM, Stead LG (2011) Insulin for glycaemic control in acute ischaemic stroke. Cochrane Database Syst Rev 9:CD005346. doi:10.1002/14651858.CD005346.pub3

    PubMed  Google Scholar 

  48. Rosso C, Corvol J-C, Pires C et al (2012) Intensive versus subcutaneous insulin in patients with hyperacute stroke: results from the randomized INSULINFARCT trial. Stroke 43:2343–2349. doi:10.1161/STROKEAHA.112.657122

    PubMed  Article  Google Scholar 

  49. Wrotek SE, Kozak WE, Hess DC, Fagan SC (2011) Treatment of fever after stroke: conflicting evidence. Pharmacotherapy 31:1085–1091. doi:10.1592/phco.31.11.1085

    PubMed  Article  PubMed Central  Google Scholar 

  50. Phipps MS, Desai RA, Wira C, Bravata DM (2011) Epidemiology and outcomes of fever burden among patients with acute ischemic stroke. Stroke 42:3357–3362. doi:10.1161/strokeaha.111.621425

    PubMed  Article  Google Scholar 

  51. den Hertog HM, van der Worp HB, van Gemert HM et al (2009) The paracetamol (acetaminophen) in stroke (PAIS) trial: a multicentre, randomised, placebo-controlled, phase III trial. Lancet Neurol 8:434–440. doi:10.1016/s1474-4422(09)70051-1

    Article  Google Scholar 

  52. de Ridder IR, de Jong FJ, den Hertog HM et al (2013) Paracetamol (Acetaminophen) in stroke 2 (PAIS 2): Protocol for a randomized, placebo-controlled, double-blind clinical trial to assess the effect of high-dose paracetamol on functional outcome in patients with acute stroke and a body temperature of 36.5 degrees C or above. Int J Stroke. doi:10.1111/ijs.12053

    PubMed  Google Scholar 

  53. Dippel DWJ, van Breda EJ, van der Worp HB et al (2003) Effect of paracetamol (acetaminophen) and ibuprofen on body temperature in acute ischemic stroke PISA, a phase II double-blind, randomized, placebo-controlled trial [ISRCTN98608690]. BMC Cardiovasc Disord 3:2. doi:10.1186/1471-2261-3-2

    PubMed  Article  PubMed Central  Google Scholar 

  54. Wu TC, Grotta JC (2013) Hypothermia for acute ischaemic stroke. Lancet Neurol 12:275–284. doi:10.1016/S1474-4422(13)70013-9

    CAS  PubMed  Article  Google Scholar 

  55. Hertog den HM, van der Worp HB, Tseng M-C, Dippel DW (2009) Cooling therapy for acute stroke. Cochrane Database Syst Rev CD001247. doi: 10.1002/14651858.CD001247.pub2

  56. Meunier JM, Chang W-TW, Bluett B et al (2012) Temperature affects thrombolytic efficacy using rt-PA and eptifibatide, an in vitro study. Ther Hypothermia Temp Manag 2:112–118. doi:10.1089/ther.2012.0007

    PubMed  Article  PubMed Central  Google Scholar 

  57. Choi HA, Badjatia N, Mayer SA (2012) Hypothermia for acute brain injury-mechanisms and practical aspects. Nat Rev Neurol 8:214–222. doi:10.1038/nrneurol.2012.21

    CAS  PubMed  Google Scholar 

  58. Harris B, Andrews PJ, Murray GD et al (2012) Systematic review of head cooling in adults after traumatic brain injury and stroke. Health Technol Assess 16:1–175. doi:10.3310/hta16450

    CAS  Google Scholar 

  59. Bath PM, Iddenden R, Bath FJ (2000) Low-molecular-weight heparins and heparinoids in acute ischemic stroke: a meta-analysis of randomized controlled trials. Stroke 31:1770–1778

    CAS  PubMed  Article  Google Scholar 

  60. Paciaroni M, Agnelli G, Micheli S, Caso V (2007) Efficacy and safety of anticoagulant treatment in acute cardioembolic stroke: a meta-analysis of randomized controlled trials. Stroke 38:423–430. doi:10.1161/01.STR.0000254600.92975.1f

    CAS  PubMed  Article  Google Scholar 

  61. Bath P, Leonardi-Bee J, Bath F (2002) Low molecular weight heparin versus aspirin for acute ischemic stroke: a systematic review. J Stroke Cerebrovasc Dis 11:55–62. doi:10.1053/jscd.2002.126694

    PubMed  Article  Google Scholar 

  62. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group (1995) Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 333:1581–1587. doi:10.1056/NEJM199512143332401

    Article  Google Scholar 

  63. Sandercock PA, van den Belt AG, Lindley RI, Slattery J (1993) Antithrombotic therapy in acute ischaemic stroke: an overview of the completed randomised trials. J Neurol Neurosurg Psychiatr 56:17–25

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  64. Sherman DG, Albers GW, Bladin C et al (2007) The efficacy and safety of enoxaparin versus unfractionated heparin for the prevention of venous thromboembolism after acute ischaemic stroke (PREVAIL Study): an open-label randomised comparison. Lancet 369:1347–1355. doi:10.1016/S0140-6736(07)60633-3

    CAS  PubMed  Article  Google Scholar 

  65. Trials Collaboration CLOTS, Dennis M, Sandercock P et al (2013) The effect of graduated compression stockings on long-term outcomes after stroke: the CLOTS trials 1 and 2. Stroke 44:1075–1079. doi:10.1161/STROKEAHA.111.680298

    Article  Google Scholar 

  66. Dennis M, Sandercock P, CLOTS (Clots in Legs Or sTockings after Stroke) Trials Collaboration et al (2013) Effectiveness of intermittent pneumatic compression in reduction of risk of deep vein thrombosis in patients who have had a stroke (CLOTS 3): a multicentre randomised controlled trial. Lancet 382:516–524. doi:10.1016/S0140-6736(13)61050-8

    CAS  PubMed  Article  Google Scholar 

  67. Kellert L, Schrader F, Ringleb P et al (2013) The impact of low hemoglobin levels and transfusion on critical care patients with severe ischemic stroke: STroke: RelevAnt Impact of HemoGlobin, Hematocrit and Transfusion (STRAIGHT)-an observational study. J Crit Care. doi:10.1016/j.jcrc.2013.11.008

    PubMed  Google Scholar 

  68. LeRoux P (2013) Haemoglobin management in acute brain injury. Curr Opin Crit Care 19:83–91. doi:10.1097/MCC.0b013e32835eba43

    PubMed  Article  Google Scholar 

  69. Dexter F, Hindman BJ (1997) Effect of haemoglobin concentration on brain oxygenation in focal stroke: a mathematical modelling study. Br J Anaesth 79:346–351

    CAS  PubMed  Article  Google Scholar 

  70. Furlan A, Higashida R, Wechsler L et al (1999) Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial. Prolyse in acute cerebral thromboembolism. JAMA 282:2003–2011

    CAS  PubMed  Article  Google Scholar 

  71. Broderick JP (2009) Endovascular therapy for acute ischemic stroke. Stroke 40:S103–S106. doi:10.1161/strokeaha.108.533067

    PubMed  Article  Google Scholar 

  72. Kirkman MA, Smith M (2012) Multimodal intracranial monitoring: implications for clinical practice. Anesthesiol Clin 30:269–287. doi:10.1016/j.anclin.2012.05.007

    PubMed  Article  Google Scholar 

  73. Poca MA, Benejam B, Sahuquillo J et al (2010) Monitoring intracranial pressure in patients with malignant middle cerebral artery infarction: is it useful? J Neurosurg 112:648–657. doi:10.3171/2009.7.JNS081677

    PubMed  Article  Google Scholar 

  74. Rajajee V, Vanaman M, Fletcher JJ, Jacobs TL (2011) Optic nerve ultrasound for the detection of raised intracranial pressure. Neurocrit Care 15:506–515. doi:10.1007/s12028-011-9606-8

    PubMed  Article  Google Scholar 

  75. Unterberg AW, Kiening KL, Härtl R et al (1997) Multimodal monitoring in patients with head injury: evaluation of the effects of treatment on cerebral oxygenation. J Trauma 42:S32–S37

    CAS  PubMed  Article  Google Scholar 

  76. Aries MJ, Coumou AD, Elting JW et al (2012) Near infrared spectroscopy for the detection of desaturations in vulnerable ischemic brain tissue: a pilot study at the stroke unit bedside. Stroke 43:1134–1136. doi:10.1161/strokeaha.111.636894

    PubMed  Article  Google Scholar 

  77. Highton D, Panovska-Griffiths J, Ghosh A et al (2013) Modelling cerebrovascular reactivity: a novel near-infrared biomarker of cerebral autoregulation? Adv Exp Med Biol 765:87–93. doi:10.1007/978-1-4614-4989-8_13

    CAS  PubMed  Article  Google Scholar 

  78. Lee JK, Kibler KK, Benni PB et al (2009) Cerebrovascular reactivity measured by near-infrared spectroscopy. Stroke 40:1820–1826. doi:10.1161/STROKEAHA.108.536094

    PubMed  Article  Google Scholar 

  79. Vespa P, Bergsneider M, Hattori N et al (2005) Metabolic crisis without brain ischemia is common after traumatic brain injury: a combined microdialysis and positron emission tomography study. J Cereb Blood Flow Metab 25:763–774. doi:10.1038/sj.jcbfm.9600073

    CAS  PubMed  Article  Google Scholar 

  80. Schabitz WR, Berger C, Schellinger PD et al (2001) Neurometabolic changes during treatment with moderate hypothermia in a patient suffering from severe middle cerebral artery infarction. Cerebrovasc Dis 12:298–302

    CAS  PubMed  Article  Google Scholar 

  81. Schneweis S, Grond M, Staub F et al (2001) Predictive value of neurochemical monitoring in large middle cerebral artery infarction. Stroke 32:1863–1867

    CAS  PubMed  Article  Google Scholar 

  82. Kanthan R, Shuaib A, Griebel R et al (1996) Glucose-induced decrease in glutamate levels in ischemic human brain by in vivo microdialysis. Neurosci Lett 209:207–209

    CAS  PubMed  Article  Google Scholar 

  83. Purkayastha S, Sorond F (2012) Transcranial Doppler ultrasound: technique and application. Semin Neurol 32:411–420. doi:10.1055/s-0032-1331812

    PubMed  Article  PubMed Central  Google Scholar 

  84. Aries MJH, Elting JW, De Keyser J et al (2010) Cerebral autoregulation in stroke: a review of transcranial Doppler studies. Stroke 41:2697–2704. doi:10.1161/STROKEAHA.110.594168

    PubMed  Article  Google Scholar 

  85. Vahedi K, Hofmeijer J, Juettler E et al (2007) Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. Lancet Neurol 6:215–222. doi:10.1016/s1474-4422(07)70036-4

    PubMed  Article  Google Scholar 

  86. Bereczki D, Fekete I, Prado GF, Liu M (2007) Mannitol for acute stroke. Cochrane Database Syst Rev 3:CD001153. doi:10.1002/14651858.CD001153.pub2

    PubMed  Google Scholar 

  87. Schwarz S, Georgiadis D, Aschoff A, Schwab S (2002) Effects of hypertonic (10%) saline in patients with raised intracranial pressure after stroke. Stroke 33:136–140

    CAS  PubMed  Article  Google Scholar 

  88. Schwarz S, Schwab S, Bertram M et al (1998) Effects of hypertonic saline hydroxyethyl starch solution and mannitol in patients with increased intracranial pressure after stroke. Stroke 29:1550–1555

    CAS  PubMed  Article  Google Scholar 

  89. Kamel H, Navi BB, Nakagawa K et al (2011) Hypertonic saline versus mannitol for the treatment of elevated intracranial pressure: a meta-analysis of randomized clinical trials. Crit Care Med 39:554–559. doi:10.1097/CCM.0b013e318206b9be

    CAS  PubMed  Article  Google Scholar 

  90. Sandercock PA, Soane T (2011) Corticosteroids for acute ischaemic stroke. Cochrane Database Syst Rev 2:CD000064. doi:10.1002/14651858.CD000064.pub2

    Google Scholar 

  91. Beghi E, D’Alessandro R, Beretta S et al (2011) Incidence and predictors of acute symptomatic seizures after stroke. Neurology 77:1785–1793. doi:10.1212/WNL.0b013e3182364878

    CAS  PubMed  Article  Google Scholar 

  92. van Tuijl JH, van Raak EP, de Krom MC et al (2011) Early treatment after stroke for the prevention of late epileptic seizures: a report on the problems performing a randomised placebo-controlled double-blind trial aimed at anti-epileptogenesis. Seizure 20:285–291. doi:10.1016/j.seizure.2010.12.012

    PubMed  Article  Google Scholar 

  93. Camilo O, Goldstein LB (2004) Seizures and epilepsy after ischemic stroke. Stroke 35:1769–1775. doi:10.1161/01.str.0000130989.17100.96

    PubMed  Article  Google Scholar 

  94. Claassen J, Taccone FS, Horn P et al (2013) Recommendations on the use of EEG monitoring in critically ill patients: consensus statement from the neurointensive care section of the ESICM. Intensive Care Med 39:1337–1351. doi:10.1007/s00134-013-2938-4

    CAS  PubMed  Article  Google Scholar 

  95. Huttner HB, Schwab S (2009) Malignant middle cerebral artery infarction: clinical characteristics, treatment strategies, and future perspectives. Lancet Neurol 8:949–958. doi:10.1016/S1474-4422(09)70224-8

    PubMed  Article  Google Scholar 

  96. Briggs DE, Felberg RA, Malkoff MD, Bratina P (2001) Should mild or moderate stroke patients be admitted to an intensive care unit? Stroke 32:871–876

    CAS  PubMed  Article  Google Scholar 

  97. van der Worp HB, Claus SP, Bär PR et al (2001) Reproducibility of measurements of cerebral infarct volume on CT scans. Stroke 32:424–430

    PubMed  Article  Google Scholar 

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Acknowledgments

M.A.K. is a UK National Institute for Health Research (NIHR) Academic Clinical Fellow in Neurosurgery. M.S. is partly funded by the Department of Health’s NIHR funding scheme via the UCLH/UCL Biomedical Research Centre.

Conflicts of interest

M.A.K. has no conflicts of interest to declare. G.C. is Deputy Editor of Intensive Care Medicine. M.S. is Neuroscience Section Editor of Intensive Care Medicine.

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Correspondence to Matthew A. Kirkman.

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Kirkman, M.A., Citerio, G. & Smith, M. The intensive care management of acute ischemic stroke: an overview. Intensive Care Med 40, 640–653 (2014). https://doi.org/10.1007/s00134-014-3266-z

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Keywords

  • Acute ischemic stroke
  • Endovascular therapy
  • Management
  • Neurocritical care
  • Thrombolysis