Acute ischemic stroke

Primary care providers play an instrumental role in both coordinating prevention efforts and facilitating emergency care for patients with signs and symptoms of acute ischemic stroke. Acute Ischemic stroke, also known as brain attack, is the third leading cause of death and the leading cause of adult disability in the United States. Acute ischemic stroke is currently considered a medical emergency that can respond to early treatment. In addition, primary and secondary prevention activities have proved effective. This article reviews the current literature regarding the types of stroke as well as specific information about prevention, signs and symptoms, and management. Guidelines for assessment and emergency care for patients with acute ischemic stroke are also provided.     

Acute ischemic stroke therapy

Data from the European Cooperative Acute Stroke Study (ECASS) III trial demonstrated that tissue plasminogen activator given up to 4.5 h after stroke onset improves outcome and treatment guidelines support its use during this time window. Intra-arterial therapy with tissue plasminogen activator or devices is commonly used at large tertiary centers up to 6–8 h after stroke onset, but conclusive evidence of efficacy remains lacking. During the acute phase after stroke onset, blood pressure elevations should be reduced as should substantial elevations in blood glucose. Statins are recommended in essentially all noncardioembolic stroke patients. The most important future directions for acute stroke therapy are to extend the therapeutic time window and to increase the proportion of patients treated within the currently documented 4.5-h time window. Imaging-guided selection of appropriate patients will likely be a key factor for extending the therapeutic time window and both diffusion/perfusion MRI and perfusion computed tomography will be useful imaging modalities in this effort.     

Acute ischemic stroke therapy

Data from the European Cooperative Acute Stroke Study (ECASS) III trial demonstrated that tissue plasminogen activator given up to 4.5 h after stroke onset improves outcome and treatment guidelines support its use during this time window. Intra-arterial therapy with tissue plasminogen activator or devices is commonly used at large tertiary centers up to 6–8 h after stroke onset, but conclusive evidence of efficacy remains lacking. During the acute phase after stroke onset, blood pressure elevations should be reduced as should substantial elevations in blood glucose. Statins are recommended in essentially all non-cardioembolic stroke patients. The most important future directions for acute stroke therapy are to extend the therapeutic time window and to increase the proportion of patients treated within the currently documented 4.5-h time window. Imaging-guided selection of appropriate patients will likely be a key factor for extending the therapeutic time window and both diffusion/perfusion MRI and perfusion computed tomography will be useful imaging modalities in this effort.     

Acute ischemic stroke review.

More than 700,000 people have a stroke each year in the United States. A diagnosis of stroke formerly elicited a nihilistic approach, but this has substantially changed in the last decade. Currently, time is brain, and it is important for all disciplines to work together to initiate acute stroke protocols in the emergency department and identify patients within the therapeutic time window for thrombolytic and neuroprotective therapies. Evolving protocols, management, and nursing care all have important implications during the acute phase of ischemic stroke. Patient and family education on risk reduction must also be addressed by the entire healthcare team.     

Acute ischemic stroke: emergent evaluation and management

This article discusses stroke, the third leading cause of death and number one cause of adult disability in the United States, inflicting a devastating physical, emotional, and financial toll on its victims and their families. The last decade has seen the emergence of new treatments for acute stroke, energizing stroke care providers and spreading a sense of optimism among them. Because effective stroke treatment is extremely time-dependent, it is paramount that emergency physicians understand and excel in their critical role at the forefront of stroke management. This article outlines the emergent evaluation and management of acute ischemic stroke, emphasizing the importance of the emergency physician in acute stroke treatment.     

Acute ischemic coronary artery disease and ischemic stroke: similarities and differences

Although acute myocardial infarction (MI) and acute ischemic stroke share similarities, physicians need to recognize important differences in pathophysiology and how these differences affect acute treatment and prevention to provide optimal patient care. Potential causes of acute ischemic stroke are substantially more heterogeneous than for acute MI, and available acute therapies are substantially more limited. In acute ischemic stroke patients, diagnostic evaluation is paramount in determining eligibility for treatment with the only approved therapy, which must be administered within 3 hours after stroke onset. For patients having acute MI, reperfusion therapy by percutaneous intervention or thrombolytic drug therapy is well established. Because atherosclerosis is a common pathway to acute MI and acute ischemic stroke, modifying associated known risk factors is required for primary and secondary prevention of both conditions. Pharmacologic therapies recommended for secondary prevention include beta-blockers and angiotensin-converting enzyme inhibitors for MI, oral anticoagulants for stroke, and statins and antiplatelet agents for both conditions. Aspirin is recommended for preventing recurrence of both MI and stroke; agents inhibiting the adenosine diphosphate pathway of platelet activation, such as ticlopidine and clopidogrel, are also beneficial. Recent studies suggest the benefits associated with adding aspirin to clopidogrel do not outweigh the significant increase in bleeding risk. The synergistic effects of aspirin plus extended-release dipyridamole make this combination twice as effective than aspirin alone in secondary prevention of ischemic stroke. An ongoing study is directly comparing the combination of aspirin plus extended-release dipyridamole with clopidogrel for the prevention of recurrent stroke.     

Acute ischemic stroke therapy: current status and future directions

Evaulation of: Selker HP, Beshansky JR, Sheehan PR et al. Out-of-hospital administration of intravenous glucose–insulin–potassium in patients with suspected acute coronary syndromes: the IMMEDIATE randomized controlled trial. JAMA 9(307), 1925–1933 (2012).

Catecholamine release in conjunction with an acute coronary syndrome induces metabolic changes that impair the situation for the ischemic myocardium. Attempts have been made to improve the prognosis in patients with acute coronary syndrome by means of infusing glucose–insulin–potassium in order to improve glucose metabolism and decrease beta-oxidation of free fatty acids. A trial, IMMEDIATE, tested this concept in a new way by initiating glucose–insulin–potassium during transportation to hospital, is discussed in this article.     

Acute ischemic stroke in a trauma cohort: Incidence and diagnostic challenges

Introduction

Diagnosis of acute ischemic stroke is critical for acute intervention. Its diagnosis may be obscured in trauma patients due to confounding injuries. We report its incidence in trauma patients following their presentation at our institution.

Acute ischemic stroke: Relationship of brain lesion location & functional outcome

Purpose. To establish, using brain spiral computerised tomography (SCT) and modified Barthel index (MBI), whether the location of cerebral infarction could be correlated with functional outcome in acute ischemic stroke patients who undergo early intensive rehabilitation.

Methods. Observational cohort, assessor blinded and correlational prospective 12-weeks study that included 111 acute ischemic stroke patients, admitted consecutively to an early intensive inpatient rehabilitation programme (5 days a week, 3–5 h a day) during 2003. Confirmation of diagnosis and stratification was done by brain SCT. Brain lesion locations were correlated to motor performance and functional outcome, on admission and discharge, using MBI.

Results. Statistical analysis demonstrated a significant correlation between motor performance, functional outcome and brain lesion locations. The groups with deep, combined deep and large superficial, small superficial and large superficial infarcts showed the most consistent improvement in that order of frequency. Normal brain SCT group did not reach statistical significance (p = 0.051) while the bi-hemispheric infarcts group did not show any change. The inter and intra group differences were highly significant (p < 0.05).

Conclusions. Immediate non-contrasted brain SCT may act as an independent predictor of final functional outcome in acute ischemic stroke. It may provide clinicians with an opportunity to offer realistic expectations to stroke patients and their relatives.     

补体与缺血性脑卒中的研究现状

1引言脑卒中,俗称脑中风,是由某些特定的危险因素及遗传因素共同导致的一种异质、多因素疾病〔1〕,主要以脑部缺血及出血性损伤为主要表现,脑血管阻塞或破裂可以引起脑血流循环障碍致脑组织功能或结构损害。主要分为出血性脑卒中及缺血性脑卒中,后者包括脑梗死、脑血栓形成。目前,脑卒中已位居发展中国家致死和致残最常见因素的第二位〔2〕,其中以缺血性脑卒中最为常见     

Headache and ischemic stroke

Migraine is a common neurological condition affecting yearly 1%–10% of all men and 3%–20% of all women. Focal neurological symptoms (auras), most commonly visual and sensory, occur in 4% of migraine attacks. Migraine with and without aura seems to be associated with an increased stroke risk. Migraine with aura may mimic transient ischemic attacks and may induce stroke (migrainous stroke). Headache is also a common symptom during ischemic stroke In this review, we present the evidence about each of these circumstances to better understand the relationship between headache, especially migraine, and ischemic stroke. Received: 27 September 2001 / Accepted in revised form: 27 December 2001