Management of ischemic stroke in the hyperacute phase

Abstract

Over the last 15 years, advances in acute ischemic stroke (AIS) management have led to a significant reduction in the morbidity and mortality related to this serious disease. This has resulted from progress in imaging technology, increased access to imaging procedures, enhanced coordination in stroke care from emergency departments to rehabilitation centers, development of organized inpatient stroke units, and to the widespread use of acute thrombolysis. Once the diagnosis of AIS is confirmed by neuroimaging, the etiological work up is conducted in parallel with therapeutic measures by stroke units. The intravenous administration of recombinant tissue plasminogen activator (rt-PA) remains the most beneficial intervention in emergency stroke management, but it must be administered within 4.5 hours following the onset of symptoms and only in eligible patients. Recently, several procedures for increasing the efficacy of arterial recanalization have emerged, including intra-arterial administration of thrombolytic agents, mechanical reopening techniques, development of new thrombolytic agents, protocol modifications that allow treatment beyond 4.5 hours or in individuals >80 years old, and remote patient evaluation via telemedicine. So far, no potentially neuroprotective drug has shown to improve outcome following stroke. In addition, pulmonary status, blood pressure, glucose, temperature, and cardiac function must be closely monitored in patients undergoing treatment for AIS. Complications such as cerebral edema, hemorrhagic transformation, seizure, infection, and venous thromboembolic disease worsen the prognosis, and must be prevented or treated. Like myocardial infarction, ischemic stroke should be considered as a treatable emergency. Widespread public education regarding stroke symptoms, novel treatments, and time constraints for effective therapy should increase the number of patients that present within the first hours after stroke. Since "time is brain," early presentation is key to transforming trial results into effective stroke therapies.