[Management of cerebral ischemia in acute phase]

Acute stroke management is becoming a major challenge for the next decades because of the increasing life expectancy, and subsequent increase of burden of atherosclerotic disease, atrial fibrillation and intracranial small vessel disease. New advances in stroke management has been mainly based on the development of stroke unit facilities. Stroke centers allow a multi-disciplinairy approach of stroke care, involving stroke neurologists, neuroradiologists, cardiologists, specialized nurses, physiotherapists, occupational therapists, speech therapists, psychologists, social workers, etc... Compared to a usual care, treatment in stroke unit avoids 40 deaths, allows 50 more patients returning home, and reduces the length of stay by 30%. This tremendous benefit is explained by a better knowledge of acute stroke complications by the entire stroke team. This allows their prevention, early detection, diagnosis and immediate treatment. Early emphasis is also put on rehabilitation in stroke units. They also are the right place for using powerful treatment but delicate to prescribe such as intravenous thrombolysis. After its approval by regulatory agencies in western countries, intravenous thrombolysis has a grade 1A recommendation (the highest level of recommendation) by both North American and European neurovascular societies. However, after three hours of stroke onset, thrombolysis is no longer effective and safe. The real challenge for the next years will be to adapt our health systems to increase access to care in stroke unit and to thrombolysis, and to develop education campaigns directed towards patients, general practitioners and emergency physicians to increase their awareness on warning signs of stroke.