Adjunctive Therapy

Fibrinolytic agents have prothrombotic properties as well. The plasmin generated by thrombolysis leads to the production of thrombin, which is a potent platelet activator and converts fibrinogen to fibrin. Indeed, studies have shown early reocclusion in as many as 17 of the patients treated with IAT 17 and 34 of the patients treated with IV rt-PA.63 Therefore, a strong rationale exists for the adjuvant use of antithrombotic agents. Systemic anticoagulation with IV heparin during the...

Anterior Circulation Thrombolysis

Middle Cerebral Artery Occlusion and the PROACT Trial The safety and efficacy of IAT in the anterior circulation have been evaluated in two randomized, multicenter, placebo-controlled trials. In the Prolyse in Acute Cerebral Throm-boembolism (PROACT) I and II trials, patients with proximal MCA (M1 or M2 segment) occlusions within 6 hours of symptom onset were treated with recombinant prourokinase (r-pro-UK) or placebo.22,23 In the PROACT-I trial, 26 patients with a median NIHSS of 17 were...

Monitoring Of Intracranial Pressure In Ischemic Stroke Patients

Patients with massive cerebral infarction may require ICP monitoring, as this may help to guide therapy and predict outcome. Schwab et al.102 evaluated 48 patients with massive hemispheric infarctions and clinical signs of elevated ICP. They found that ICP measurements correlated well with the patient's clinical status, CT findings and outcome, although they did not find a significant effect of their therapies for elevated ICP on patient outcomes. Multiple methods of monitoring ICP are avail...

Current Barriers In Acute Stroke Care Pre Hospital Delays

Fewer than half of all patients with acute stroke are seen in the emergency department (ED) within 3 hours of symptom onset.4 Patients in remote locations or in hospitals without available stroke expertise may have even more limited access to thrombolysis. In a study of non-urban East Texas communities in the United States, only 1.4 of patients with ischemic stroke received IV rt-PA,5 versus 14.7 at a university hospital in Houston, the nearest major city.6 Other studies have linked racial,...

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Approximates the truly uniform sensitivity achieved by CTP. , However, this more uniform sensitivity comes at the expense of lower contrast, generally requiring twice the usual dose of gadolinium. Some researchers have used MRP pulse sequences that simultaneously acquire both spin-echo and gradient-echo images not only to correct for differences in sensitivity to vessels, but also to quantitatively distinguish between hemodynamic conditions of vessels of different sizes.109 The clinical...

Medical Measures to Control Cerebral Edema

Hyperventilation reduces ICP by reducing CBF. Carbon dioxide is a potent cerebral vasodilator, and thus vasoconstriction is induced by rapidly decreasing the pCO2 (thereby concomitantly increasing the CSF pH), subsequently reducing the entry of blood into the cerebral circulation and lowering the ICP. The effect is almost immediate, reducing ICP typically within minutes. However, it is short lived, and may theoretically result in worsening of the cerebral infarction volume secondary to...

Initial Stabilization

In stroke patients presenting to the ED, the first goal of treatment is immediate cardiac and respiratory stabilization. The systemic blood pressure is most often elevated in the setting of an acute stroke as the result of a catecholamine surge, and if the patient is hypotensive, the clinician should consider a concomitant cardiac process, such as myocardial infarction (MI), congestive heart failure (CHF), or pulmonary embolism (PE). Stroke patients commonly have airway compromise, either...

Decompressive Hemicraniectomy

Decompressive hemicraniectomy is primarily intended to treat the high intracranial pressure associated with massive MCA infarction and subsequent swelling (Fig. 6.3). Focal areas of ischemia may result when intracranial pressure is greater than 20 mmHg, and global ischemia can occur when intracranial pressure exceeds 50mmHg.33 Therefore, removal of a large part of the calvarium, theoretically reducing intracranial hypertension, ongoing ischemia, and preventing swollen tissue from displacing...

Establishing The Diagnosis Of Ischemic Stroke

Subinsular White Matter

Recent years have seen the emergence of successful treatment strategies for ischemic stroke, but these are most effective only when initiated within several hours after stroke onset. Therefore, extremely rapid diagnosis and initiation of treatment are critical in avoiding death or severe disability. Unfortunately, there are a variety of other clinical conditions that may mimic the presentation of acute ischemic stroke. These include intracranial hemorrhage, seizure, sepsis, cardiogenic syncope,...

Subacute Care and Management

In other experiences, subacute TeleStroke consultation has been shown to improve resource allocation in poststroke management by reducing the length of hospital stays. In one of two small rural hospitals in Ireland, patients were offered a neurological consultation with a neurologist 120 km away using a real-time video link. Hospital stay was significantly shorter for those admitted to the hospital with telemedicine resources (p 0.045). Diagnosis by the teleneurologist was accurate in all...

Clinical Trials of Aspirin in Acute Ischemic Stroke

Clinical Approach Ischemic Stroke

Three large randomized trials have examined the efficacy of aspirin treatment within 48 hours of stroke onset. IST compared 300 mg aspirin to no aspirin and also compared two doses of UFH to no heparin in a 3X2 factorial design.18 IST found no significant difference in death and dependency at 6 months in patients treated with aspirin, heparin, or neither of these drugs. There was, however, a nonsignificant trend at 6 months toward a smaller percentage of the aspirin group being dead or...

The MERCI and MultiMERCI Trials

The MERCI trial was a prospective single-arm, multicenter trial designed to test the safety and efficacy of the MERCI clot retrieval device to restore the patency of intracranial arteries in the first 8 hours of an acute stroke. All patients were ineligible for IV rt-PA. The occlusion sites were the intracranial vertebral artery, basilar artery, ICA, ICA terminus, or proximal MCA branches (M1 or M2). Primary outcomes were of recanalization and safety, and secondary outcomes were neurological...