Critical care assessment and management of acute ischemic stroke

The resuscitation and treatment of patients with an acute stroke has evolved measurably during the past 2 decades. Acute ischemic stroke represents a true emergency where time is crucial and, therefore, evaluation and treatment often proceed simultaneously. Advanced imaging techniques can provide information about the state of brain perfusion, metabolism, and the cerebrovascular anatomy to help identify patients with viable brain tissue who may derive the greatest benefit from available therapies. Currently, several agents are available for rapid restoration of perfusion to ischemic brain. These include intravenous administration of recombinant tissue-type plasminogen activator (tPA), which is effective within a 3-hour period, and intraarterial thrombolytic therapy, which may be effective within 6 hours. In addition, newer agents such as ancrod and abciximab may be effective within the acute time period. Optimal care requires a multidisciplinary approach with attention to a wide variety of therapeutic issues while maintaining adequate brain perfusion to reverse or halt the ischemic process. Herein, the author examines the important therapeutic concerns in the critical care management of ischemic stroke, including the management of elevated intracranial pressure, elevated and low blood pressure, cardiac complications, and potential metabolic disturbances.