Stroke: diagnosis and management of acute ischemic stroke

Acute ischemic stroke is an emergency. Approximately 2 million neurons are lost during each minute of stroke. Intravenous tissue plasminogen activator improves the likelihood of a good outcome. However, benefit is heavily time dependent. Patients treated within 90 minutes of symptom onset have better outcomes than those treated beyond that point. Rapid evaluation and management are key, and a minimum number of tests should be obtained before management. Different imaging studies, including computed tomography, magnetic resonance imaging, computed tomographic angiography, magnetic resonance angiography, and perfusion studies, are useful for evaluation of acute stroke. Trade-offs exist between studies, such as better resolution versus greater delay. There is no evidence at present to suggest that additional imaging sequences improve patient outcomes. Intra-arterial management has yet to be proven beneficial to patients who have had strokes. Emergent stenting and sonothrombosis are of uncertain value. Aggressive blood pressure lowering should be avoided early after ischemic stroke. Anticoagulation with heparin or heparinoids is of no benefit to the majority of patients with strokes, and there does not appear to be a role for corticosteroids. Emergent surgical decompression with hemicraniectomy may be lifesaving for patients with large hemispheric or posterior fossa infarctions who become drowsy.