Edited by Prof Marek Mirski
Management of Acute Stroke has been forever a challenging clinical practice. Acute Stroke is too often a catastrophic neurological and life event, especially when a patient requires an ICU setting. Time, of course, is the essence of neuronal loss under conditions of ischemia, and unfortunately our brains are the most vulnerable of the vital organs to loss of nutrient supply. If a large ischemic or hemorrhagic lesion occurs despite taking the best medical or surgical preventive steps, then the brief windows of opportunity to ameliorate the neuronal injury thereafter must be taken full advantage of.
It is encouraging that Stroke Awareness campaigns have largely been successful in educating the public about the risk factors for stroke, as well as some simple clinical algorithms to diagnose a stroke early and thus enable early patient admission to a stroke center. Recent years have also demonstrated that acute thrombotic stroke is amenable to more than simply a “3-hr window for tPA”. The time window has been shown safe to be extended under certain conditions, and we now have documented benefit observed with intra-arterial thrombolysis and thrombectomy therapy. Certain stroke patient populations now live in better times, and we are encouraged that further improvements to therapy will continue.
It is also true, however, that medical therapies for other clinical conditions such as heart dysrhythmias, venous stasis, and post-stent management to name but a few have increased the risk for cerebral vascular events – particularly hemorrhagic stroke.
Stroke and ICU specialists thus find themselves in the familiar “two steps forward, one step backward” in combatting stroke, and ICU stroke admissions hence are likely not to see a demonstrable decline in the near term.
Herein we have several topics of acute stroke management that I believe are highly relevant. In light of the proliferation of the placement of patients on antithrombotic therapy, Dr. Hagen Huttner from the University Hospital Erlangen Germany presents a fine update on the reversal of anti-coagulation agents in patients with acute intracerebral haemorrhage, and Dr. Leonardo de Oliveira Manoel from the University of Toronto discusses the surgical treatment option for acute intracerebral haemorrhage. To provide an overview of the recent “two-steps forward” success of ischemic stroke therapy, Dr. Tudor Jovin from the University of Pittsburgh offers a review of thrombectomy in acute ischemic stroke/ Ischemic stroke treated with IV thrombolysis.
Of course, too often acute stroke has its tragic consequences, and the goals & limits of aggressive management thereafter poses challenging decision-making. Dr. Thomas Beez from the University of Dusseldorf Germany presents the difficult topic of the option therapy of decompressive craniectomy in acute stroke patients.
We do hope that the ICU provider will find these timely and helpful.