Opinion statement
Patients admitted with the diagnosis of “stroke” have a variety of different disorders that require specific treatment approaches in the critical care unit. Early thrombolysis for ischemic stroke and improvements in surgical and neurointerventional techniques for the treatment of aneurysms and arteriovenous malformations in patients with subarachnoid hemorrhage have been milestones in the past decade, but the evolvement of general management principles in critical care and the dedication of neurointensivists are equally important for improved outcomes. Strategies, which have been developed in other areas of intensive care medicine (eg, in patients with septic shock, acute respiratory distress syndrome, or trauma), need to be adopted and modified for the stroke patient. Prevention of iatrogenic complications and nosocomial infections is of utmost importance and requires sufficient numbers of trained personnel and high-quality equipment. Although the focus of attention in stroke patients is “brain resuscitation,” comorbidities often limit the diagnostic and therapeutic options, and overall cardiopulmonary and metabolic functions need to be optimized in order to prevent secondary injury and allow the brain to recover. As part of a holistic approach to the rehabilitation process, psychologic and spiritual support for the patient must start early on in the intensive care unit, and family members should be involved in the patient’s care and provided with special support as well.
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References and Recommended Reading
Varelas PN, Conti MM, Spanaki MV, et al.: The impact of a neurointensivist-led team on a semiclosed neurosciences intensive care unit. Crit Care Med 2004, 32:2191–2198.
Suarez JI, Zaidat OO, Suri MF, et al.: Length of stay and mortality in neurocritically ill patients: impact of a specialized neurocritical care team. Crit Care Med 2004, 32:2311–2317.
Qureshi AI, Suarez JI, Yahia AM, et al.: Timing of neurologic deterioration in massive middle cerebral artery infarction: a multicenter review. Crit Care Med 2003, 31:272–277.
Klijn CJ, Hankey GJ: Management of acute ischaemic stroke: new guidelines from the American Stroke Association and European Stroke Initiative. Lancet Neurol 2003, 2:698–701.
Sacco RL, Adams R, Albers G, et al.: Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: a statement for healthcare professionals from the American Heart Association/American Stroke Association Council on Stroke: co-sponsored by the Council on Cardiovascular Radiology and Intervention: the American Academy of Neurology affirms the value of this guideline. Circulation 2006, 113:e409–e449.
Cholley BP, Payen D: Noninvasive techniques for measurements of cardiac output. Curr Opin Crit Care 2005, 11:424–429.
Jensen MB, Sloth E, Larsen KM, Schmidt MB: Transthoracic echocardiography for cardiopulmonary monitoring in intensive care. Eur J Anaesthesiol 2004, 21:700–707.
Kopelnik A, Fisher L, Miss JC, et al.: Prevalence and implications of diastolic dysfunction after subarachnoid hemorrhage. Neurocrit Care 2005, 3:132–138.
White H, Venkatesh B: Applications of transcranial Doppler in the ICU: a review. Intensive Care Med 2006, 32:981–994.
Rabinstein AA, Friedman JA, Weigand SD, et al.: Predictors of cerebral infarction in aneurysmal subarachnoid hemorrhage. Stroke 2004, 35:1862–1866.
Schummer W, Schummer C, Schelenz C, et al.: Modified ECG-guidance for optimal central venous catheter tip positioning. A transesophageal echocardiography controlled study. Anaesthesist 2005, 54:983–990.
Naidech AM, Kreiter KT, Janjua N, et al.: Cardiac troponin elevation, cardiovascular morbidity, and outcome after subarachnoid hemorrhage. Circulation 2005, 112:2851–2856.
Tung P, Kopelnik A, Banki N, et al.: Predictors of neurocardiogenic injury after subarachnoid hemorrhage. Stroke 2004, 35:548–551.
Tung RH, Garcia C, Morss AM, et al.: Utility of B-type natriuretic peptide for the evaluation of intensive care unit shock. Crit Care Med 2004, 32:1643–1647.
Maramattom BV, Weigand S, Reinalda M, et al.: Pulmonary complications after intracerebral hemorrhage. Neurocrit Care 2006, 5:115–119.
Caples SM, Gay PC: Noninvasive positive pressure ventilation in the intensive care unit: a concise review. Crit Care Med 2005, 33:2651–2658.
Keenan SP, Sinuff T, Cook DJ, Hill NS: Does noninvasive positive pressure ventilation improve outcome in acute hypoxemic respiratory failure? A systematic review. Crit Care Med 2004, 32:2516–2523.
Craven DE: Preventing ventilator-associated pneumonia in adults: sowing seeds of change. Chest 2006, 130:251–260.
Silvester W, Goldsmith D, Uchino S, et al.: Percutaneous versus surgical tracheostomy: a randomized controlled study with long-term follow-up. Crit Care Med 2006, 34:2145–2152.
Yilmaz M, Dosemeci L, Cengiz M, et al.: Repeat percutaneous tracheostomy in the neurocritically ill patient. Neurocrit Care 2006, 5:120–123.
Petrucci N, Iacovelli W: Ventilation with smaller tidal volumes: a quantitative systematic review of randomized controlled trials. Anesth Analg 2004, 99:193–200.
Decailliot F, Demoule A, Maggiore SM, et al.: Pressure-volume curves with and without muscle paralysis in acute respiratory distress syndrome. Intensive Care Med 2006, 32:1322–1328.
Treggiari MM, Walder B, Suter PM, Romand JA: Systematic review of the prevention of delayed ischemic neurological deficits with hypertension, hypervolemia, and hemodilution therapy following subarachnoid hemorrhage. J Neurosurg 2003, 98:978–984.
Schmid-Elsaesser R, Kunz M, Zausinger S, et al.: Intravenous magnesium versus nimodipine in the treatment of patients with aneurysmal subarachnoid hemorrhage: a randomized study. Neurosurgery 2006, 58:1054–1065.
Treschan TA, Peters J: The vasopressin system: physiology and clinical strategies. Anesthesiology 2006, 105:599–612
Dimopoulou I, Kouyialis AT, Orfanos S, et al.: Endocrine alterations in critically ill patients with stroke during the early recovery period. Neurocrit Care 2005, 3:224–229.
Siraux V, De Backer D, Yalavatti G, et al.: Relative adrenal insufficiency in patients with septic shock: comparison of low-dose and conventional corticotropin tests. Crit Care Med 2005, 33:2479–2486.
Gonzalez H, Nardi O, Annane D: Relative adrenal failure in the ICU: an identifiable problem requiring treatment. Crit Care Clin 2006, 22:105–118.
Diringer MN, Zazulia AR: Osmotic therapy: fact and fiction. Neurocrit Care 2004, 1:219–233.
Ogden AT, Mayer SA, Connolly ES Jr.: Hyperosmolar agents in neurosurgical practice: the evolving role of hypertonic saline. Neurosurgery 2005, 57:207–215.
Wysowski DK, Pollock ML: Reports of death with use of propofol (Diprivan) for nonprocedural (long-term) sedation and literature review. Anesthesiology 2006, 105:1047–1051.
Ahlen K, Buckley CJ, Goodale DB, Pulsford AH: The ‘propofol infusion syndrome’: the facts, their interpretation and implications for patient care. Eur J Anaesthesiol 2006, 23:990–998.
Bourgoin A, Albanese J, Wereszczynski N, et al.: Safety of sedation with ketamine in severe head injury patients: comparison with sufentanil. Crit Care Med 2003, 31:711–717.
Kohrs R, Durieux ME: Ketamine: teaching an old drug new tricks. Anesth Analg 1998, 87:1186–1193.
Albanese J, Arnaud S, Rey M, et al.: Ketamine decreases intracranial pressure and electroencephalographic activity in traumatic brain injury patients during propofol sedation. Anesthesiology 1997, 87:1328–1334.
Himmelseher S, Durieux ME: Revising a dogma: ketamine for patients with neurological injury? Anesth Analg 2005, 101:524–534.
Harscher S, Reichart R, Terborg C, et al.: Outcome after decompressive craniectomy in patients with severe ischemic stroke. Acta Neurochir (Wien) 2006, 148:31–37; discussion 37.
Murthy JM, Chowdary GV, Murthy TV, et al.: Decompressive craniectomy with clot evacuation in large hemispheric hypertensive intracerebral hemorrhage. Neurocrit Care 2005, 2:258–262.
Kilincer C, Asil T, Utku U, et al.: Factors affecting the outcome of decompressive craniectomy for large hemispheric infarctions: a prospective cohort study. Acta Neurochir (Wien) 2005, 147:587–594; discussion 594.
Yao Y, Liu W, Yang X, et al.: Is decompressive craniectomy for malignant middle cerebral artery territory infarction of any benefit for elderly patients? Surg Neurol 2005, 64:165–169; discussion 169.
Vahedi K, Benoist L, Kurtz A, et al.: Quality of life after decompressive craniectomy for malignant middle cerebral artery infarction. J Neurol Neurosurg Psychiatry 2005, 76:1181–1182.
Rhoney DH, Parker D Jr.: Use of sedative and analgesic agents in neurotrauma patients: effects on cerebral physiology. Neurol Res 2001, 23:237–259.
Riker RR, Fraser GL: Adverse events associated with sedatives, analgesics, and other drugs that provide patient comfort in the intensive care unit. Pharmacotherapy 2005, 25:8S–18S.
Rovasalo A, Tohmo H, Aantaa R, et al.: Dexmedetomidine as an adjuvant in the treatment of alcohol withdrawal delirium: a case report. Gen Hosp Psychiatry 2006, 28:362–363.
Riker RR, Picard JT, Fraser GL: Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients. Crit Care Med 1999, 27:1325–1329.
De Keulenaer BL, Philpot S, Wilkinson M, et al.: Central anticholinergic syndrome in the intensive care unit. Eur J Anaesthesiol 2004, 21:499–501.
Latronico N, Bertolini G, Guarneri B, et al.: Simplified electrophysiological evaluation of peripheral nerves in critically ill patients: the Italian multi-centre CRIMYNE study. Crit Care 2007, 11:R11.
Visser LH: Critical illness polyneuropathy and myopathy: clinical features, risk factors and prognosis. Eur J Neurol 2006, 13:1203–1212.
Van den Berghe G, Wilmer A, Milants I, et al.: Intensive insulin therapy in mixed medical/surgical intensive care units: benefit versus harm. Diabetes 2006, 55:3151–3159.
Van Den Berghe G, Wouters PJ, Bouillon R, et al.: Outcome benefit of intensive insulin therapy in the critically ill: insulin dose versus glycemic control. Crit Care Med 2003, 31:359–366.
Meijering S, Corstjens AM, Tulleken JE, et al.: Towards a feasible algorithm for tight glycaemic control in critically ill patients: a systematic review of the literature. Crit Care 2006, 10:R19.
Ho KM, Dobb GJ, Webb SA: A comparison of early gastric and post-pyloric feeding in critically ill patients: a meta-analysis. Intensive Care Med 2006, 32:639–649.
Bistrian BR, McCowen KC: Nutritional and metabolic support in the adult intensive care unit: key controversies. Crit Care Med 2006, 34:1525–1531.
Fraser JF, Stieg PE: Hyponatremia in the neurosurgical patient: epidemiology, pathophysiology, diagnosis, and management. Neurosurgery 2006, 59:222–229.
Meloni BP, Zhu H, Knuckey NW: Is magnesium neuroprotective following global and focal cerebral ischaemia? A review of published studies. Magnes Res 2006, 19:123–137.
Wartenberg KE, Schmidt JM, Claassen J, et al.: Impact of medical complications on outcome after subarachnoid hemorrhage. Crit Care Med 2006, 34:617–623; quiz 624.
Uzzan B, Cohen R, Nicolas P, et al.: Procalcitonin as a diagnostic test for sepsis in critically ill adults and after surgery or trauma: a systematic review and meta-analysis. Crit Care Med 2006, 34:1996–2003.
Mayer SA, Kowalski RG, Presciutti M, et al.: Clinical trial of a novel surface cooling system for fever control in neurocritical care patients. Crit Care Med 2004, 32:2508–2515.
Wittman JJ Jr, Hirsch LJ: Continuous electroencephalogram monitoring in the critically ill. Neurocrit Care 2005, 2:330–341.
Hummel FC, Cohen LG: Non-invasive brain stimulation: a new strategy to improve neurorehabilitation after stroke? Lancet Neurol 2006, 5:708–712.
Little KM, Alexander MJ: Medical versus surgical therapy for spontaneous intracranial hemorrhage. Neurosurg Clin N Am 2002, 13:339–347.
Mayer SA, Rincon F: Treatment of intracerebral haemorrhage. Lancet Neurol 2005, 4:662–672.
Mathews M, Newman R, Chappell ET: Management of coagulopathy in the setting of acute neurosurgical disease and injury. Neurocrit Care 2006, 5:141–152.
van der Schaaf I, Algra A, Wermer M, et al.: Endovascular coiling versus neurosurgical clipping for patients with aneurysmal subarachnoid haemorrhage. Cochrane Database Syst Rev 2005, 4:CD003085.
Kato Y, Sano H, Dong PT, et al.: The effect of clipping and coiling in acute severe subarachnoid hemorrhage after International Subarachnoid Aneurysmal Trial (ISAT) results. Minim Invasive Neurosurg 2005, 48:224–227.
Hoh BL, Cheung AC, Rabinov JD, et al.: Results of a prospective protocol of computed tomographic angiography in place of catheter angiography as the only diagnostic and pretreatment planning study for cerebral aneurysms by a combined neurovascular team. Neurosurgery 2004, 54:1329–1340; discussion 1340–1342.
Meschi M, Detrenis S, Musini S, et al.: Facts and fallacies concerning the prevention of contrast medium-induced nephropathy. Crit Care Med 2006, 34:2060–2068.
Roitberg BZ, Khan N, Alp MS, et al.: Bedside external ventricular drain placement for the treatment of acute hydrocephalus. Br J Neurosurg 2001, 15:324–327.
Rebuck JA, Murry KR, Rhoney DH, et al.: Infection related to intracranial pressure monitors in adults: analysis of risk factors and antibiotic prophylaxis. J Neurol Neurosurg Psychiatry 2000, 69:381–384.
Poon WS, Ng S, Wai S: CSF antibiotic prophylaxis for neurosurgical patients with ventriculostomy: a randomised study. Acta Neurochir Suppl 1998, 71:146–148.
Janardhan V, Biondi A, Riina HA, et al.: Vasospasm in aneurysmal subarachnoid hemorrhage: diagnosis, prevention, and management. Neuroimaging Clin N Am 2006, 16:483–496.
Myburgh JA: “Triple H” therapy for aneurysmal subarachnoid haemorrhage: real therapy or chasing numbers? Crit Care Resusc 2005, 7:206–212.
Lee KH, Lukovits T, Friedman JA: “Triple-H” therapy for cerebral vasospasm following subarachnoid hemorrhage. Neurocrit Care 2006, 4:68–76.
Sacco RL, Chong JY, Prabhakaran S, Elkind MS: Experimental treatments for acute ischaemic stroke. Lancet 2007, 369:331–341.
Rehberg S, Ertmer C, Van Aken H, et al.: Role of levosimendan in intensive care treatment of myocardial insufficiency. Anaesthesist 2007, 56:30–43.
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Schulz-Stübner, S. Intensive care unit management of patients with stroke. Curr Treat Options Neurol 9, 427–441 (2007). https://doi.org/10.1007/s11940-007-0044-z
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DOI: https://doi.org/10.1007/s11940-007-0044-z