Emergency and critical care management of acute ischaemic stroke

Ischaemic stroke is a devastating condition that is the leading cause of disability in the USA. Over the last 2 decades, the focus of management has shifted from secondary stroke prevention to acute treatment. Coordinated care starts in the field with the emergency medical service providers and continues in the ambulance and the emergency department through to the intensive care unit. After diagnosis and stabilization, a major goal is reperfusion therapy with intravenous fibrinolytics. Neuroimaging research is focused on improving patient selection, expanding treatment windows, and increasing the safety of therapeutic intervention. The role of adjunctive intra-arterial and mechanical thrombectomy remains undefined, and methods to improve reperfusion using sonolysis and new-generation fibrinolytics are currently investigational. Treatment in the intensive care unit targets prevention of secondary brain injury through optimization of blood pressure, cerebral perfusion, glucose, and temperature management, ventilation, and oxygenation. The most feared complications include malignant cerebral edema and symptomatic hemorrhagic transformation. Decompressive craniectomy is life saving, but questions regarding patient selection and timing remain. Hyperosmolar agents are currently used to mitigate cerebral edema, but newer agents to prevent the formation of cerebral edema at the molecular level are being studied. We outline a practical approach to current emergency and intensive care management based on consensus guidelines and the best available evidence.