Anesthesia considerations for the patient with acute ischemic stroke

Stroke is the leading cause of long-term disability in the United States. Hence immediate diagnosis must be made by CT or MRI and therapy instituted rapidly. Anesthesiologists must be aware of the concept of "penumbra" and maintain collateral flow. Blood pressure management is crucial. American Stroke Council recommends blood pressure reduction if systolic >220 mm Hg and diastolic >120 mm Hg. However if thrombolytic therapy is being used, blood pressure must be reduced to systolic <180 mmHg and diastolic < 105 mm Hg. Cerebral autoregulation may be dysfunctional in ischemic brain. Anesthesia management requires control of the airway to prevent aspiration, maintain adequate oxygenation and ventilation, and management of raised intra cranial pressure. Complications of intra-arterial thrombolysis include intracerebral hemorrhage. Frequent neurological exams are warranted. Extensive cerebral swelling may require hemi craniectomy. "Time is Brain" hence urgent thrombolysis is the key to a good outcome.