Chapter 10 - Critical care in acute ischemic stroke

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Abstract

Most ischemic strokes are managed on the ward or on designated stroke units. A significant proportion of patients with ischemic stroke require more specialized care. Several studies have shown improved outcomes for patients with acute ischemic stroke when neurocritical care services are available. Features of acute ischemic stroke patients requiring intensive care unit-level care include airway or respiratory compromise; large cerebral or cerebellar hemisphere infarction with swelling; infarction with symptomatic hemorrhagic transformation; infarction complicated by seizures; and a large proportion of patients require close management of blood pressure after thrombolytics. In this chapter, we discuss aspects of acute ischemic stroke care that are of particular relevance to a neurointensivist, covering neuropathology, neurodiagnostics and imaging, blood pressure management, glycemic control, temperature management, and the selection and timing of antithrombotics. We also focus on the care of patients who have received intravenous thrombolysis or mechanical thrombectomy. Complex clinical decision making in decompressive hemicraniectomy for hemispheric infarction and urgent management of basilar artery thrombosis are specifically addressed.

Introduction

Every year in the USA approximately 795 000 people experience a new or recurrent stroke, amounting to about one stroke every 40 seconds (Mozaffarian et al., 2015). Ischemic strokes represent approximately 87% of that total, with the remainder hemorrhagic. In 2011, stroke accounted for approximately one out of every 20 deaths in the USA. In 2013, the US Burden of Disease Collaborators reported that stroke was second only to lung cancer and ischemic heart disease in years of life lost and death (Murray et al., 2013).

Risk factors for acute ischemic stroke include age, sex, hypertension, diabetes mellitus, cardiac dysrhythmias, structural heart disease, smoking, physical inactivity, and family history (Mohr et al., 2004, Meschia et al., 2014). As our population ages and life expectancy increases, the global incidence and prevalence of acute ischemic stroke are expected to increase, perhaps dramatically. The 2014 Global Burden of Disease Study found that the absolute numbers of people with first stroke, stroke-related deaths, and disability-adjusted life-years had significantly increased from 1990 to 2010, with low- and middle-income countries disproportionately affected (Feigin et al., 2014).

Over the last 20 years, the acute management of stroke patients in many regions has transitioned to designated stroke centers and stroke units. Admission to a dedicated stroke center is associated with increased thrombolysis use (Lattimore et al., 2003, Gropen et al., 2006) and decreased mortality (Xian et al., 2011, Kim et al., 2013). Similarly, admission to a designated stroke unit is associated with improved outcomes, including reduced hospital length of stay and decreased mortality (Candelise et al., 2007, Zhu et al., 2009). However, up to 15–20% of acute stroke patients may benefit from a higher level of care than even a dedicated stroke unit (Coplin, 2012).

Several studies have shown improved outcomes for acute ischemic stroke patients when neurocritical care services are available. A 2008 prospective study evaluated clinical outcomes in 100 ischemic stroke patients before and after the appointment of a full-time neurointensivist. In the adjusted analysis, patients in the postappointment group had a shorter intensive care unit (ICU) length of stay and hospital length of stay (Varelas et al., 2008). Similarly, a retrospective chart review of 400 patients with acute ischemic stroke managed at a large academic hospital found reductions in ICU and hospital lengths of stay following the institution of a specialized neurocritical care team (Bershad et al., 2008).

In 2005, the Brain Attack Coalition formally recommended that comprehensive stroke centers have an ICU available for acute ischemic stroke patients (Alberts et al., 2005).

In this chapter all aspects of ICU care in the more complicated types of strokes are discussed.

Section snippets

Airway management

Patients with acute ischemic stroke complicated by depressed level of consciousness or facial or bulbar weakness may have a reduced ability to protect their airway. Airway compromise can lead to aspiration or respiratory failure. In addition, many ischemic stroke patients have comorbid cardiopulmonary disease that may be exacerbated by the physiologic sequelae of acute stroke (or even by its therapeutics, as in the case of overly aggressive intravenous (IV) fluid hydration). As a result, some

Neuropathology

Much of the therapy delivered to critically ill acute stroke patients is aimed at limiting the extent of cerebral infarction. A basic appreciation of the pathophysiology of cerebral ischemia and its consequences is helpful in understanding the rationale behind these therapies. This section will briefly address several neuropathologic topics important to neurointensivists: the ischemic penumbra, reperfusion injury and hemorrhagic transformation of infarcted tissue, and cerebral edema.

Clinical presentation

IV tPA treatment for stroke brought new importance to the fast and accurate diagnosis of acute ischemic stroke (NINDS rt-PA Stroke Study Group, 1995). Much of the initial evaluation of a stroke patient is aimed at quickly determining whether he or she is a candidate for IV tPA or endovascular intervention.

Neurodiagnostics and neuroimaging

This section will primarily focus on diagnostic and imaging modalities that are of use in the evaluation of acute and critically ill ischemic stroke patients. For example, we will not discuss long-term ambulatory cardiac ECG (event) monitoring, which is typically employed after a patient has left the ICU setting. We will not separately discuss carotid Doppler ultrasound, which is used to screen for carotid artery stenosis and occlusion but not typically relevant to acute stroke ICU decision

Hospital course and management

This section focuses on many of the largest issues facing neurointensivists in the management of acute ischemic stroke patients. The first part addresses acute management, including IV thrombolysis and endovascular therapies. The second part covers management of acute ischemic stroke patients in the ICU setting, including blood pressure, glycemic, and temperature management.

Blood pressure management

In acute ischemic stroke patients, blood pressure can be considered a surrogate for cerebral perfusion pressure, given that intracranial pressure changes are usually insignificant (Sheth and Sims, 2012). Hypotension is rarely associated with acute ischemic stroke and, when present, is usually the result of a medication effect or a comorbid medical issue such as sepsis, aortic dissection, or unstable arrhythmia (Jauch et al., 2013). As such, the identification of hypotension should spur a search

Clinical trials and guidelines

A number of important clinical trials involving acute ischemic stroke patients are discussed in the above and proceeding text. The AHA/ASA guidelines for the early management of patients with acute ischemic stroke, which is frequently cited above, provide a comprehensive summary of early acute ischemic stroke care building on clinical trial results and expert opinion (Jauch et al., 2013). This publication is a critical resource for neurointensivists managing acute ischemic stroke patients.

Complex clinical decisions

A common decision encountered by neurointensivists is when to initiate or resume anticoagulation in patients with a clinical indication (such as atrial fibrillation) after acute ischemic stroke. The risk of recurrent stroke must be weighed against the risk of hemorrhagic transformation, particularly in patients with large infarcts.

A 2008 Cochrane review addressed this question, analyzing 24 trials enrolling 23 748 patients who were randomized to early anticoagulation (started within 2 weeks of

Neurorehabilitation

In this section we will briefly address three topics that may be useful to NICU teams managing acute ischemic stroke patients.

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