Management of Acute Ischemic Stroke

Abstract

Objectives: Concise "synthetic" review of the state of the art of management of acute ischemic stroke.

Data sources: Available literature on PubMed.

Study selection: We selected landmark studies, recent clinical trials, observational studies, and professional guidelines on the management of stroke including the last 10 years.

Data extraction: Eligible studies were identified and results leading to guideline recommendations were summarized.

Data synthesis: Stroke mortality has been declining over the past 6 decades, and as a result, stroke has fallen from the second to the fifth leading cause of death in the United States. This trend may follow recent advances in the management of stroke, which highlight the importance of early recognition and early revascularization. Recent studies have shown that early recognition, emergency interventional treatment of acute ischemic stroke, and treatment in dedicated stroke centers can significantly reduce stroke-related morbidity and mortality. However, stroke remains the second leading cause of death worldwide and the number one cause for acquired long-term disability, resulting in a global annual economic burden.

Conclusions: Appropriate treatment of ischemic stroke is essential in the reduction of mortality and morbidity. Management of stroke involves a multidisciplinary approach that starts and extends beyond hospital admission.

Figure 1.

Organization of stroke centers. EVT = endovascular therapy, IV tPA = IV tissue plasminogen activator.

Figure 2.

Alberta Stroke Program Early CT Score (ASPECTS). Scoring for each of the 10 zones. Each zone is graded either 1 (normal) or 0 (abnormal). The sum of all zones gives the ASPECTS. A, Normal looking brain with ASPECTS = 10. B, Brain with ischemic changes and ASPECTS less than 6. C = caudate, Ic = internal capsule, In = insular cortex, M = middle cerebral artery, P = putamen.

Figure 3.

CT-angiography demonstrating an abrupt occlusion of the patient’s left middle cerebral artery (arrow). L = left, R = right.

Figure 4.

Mismatch ratio analysis of cerebral blood flow (CBF) by quantitative analysis of thresholds in time-to-maximum (T-max) to transit in a patient with a right middle cerebral artery occlusion. CBF in dark gray and T-max in light gray. A ratio of greater than 1.8 usually indicates eligibility for endovascular therapy. RAPID = rapid processing of perfusion and diffusion image analysis system.