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DOI: 10.1055/s-0030-1268859
Acute Ischemic Stroke Management: Medical Management
Publikationsverlauf
Publikationsdatum:
04. Januar 2011 (online)

ABSTRACT
The initial management of a patient with suspected stroke necessitates a rapid and focused evaluation. Establishing the time of symptom onset, performing a focused neurologic examination, and interpreting ancillary tests facilitates delivery of acute stroke therapies to eligible patients. This review emphasizes the fundamentals of urgent stroke evaluation and evidence-based acute ischemic stroke therapies. Results from randomized clinical trials of intravenous thrombolysis, glucose management, and blood pressure management in acute ischemic stroke patients will be highlighted. External ultrasound as an adjunct to intravenous thrombolysis and treatment of those patients that wake up with stroke symptoms will also be discussed.
KEYWORDS
Acute ischemic stroke - ischemic stroke management - tissue plasminogen activator
REFERENCES
- 1 Messé S R, Tanne D, Demchuk A M, Cucchiara B L, Levine S R, Kasner S E. Multicenter rt-PA Stroke Survey Group . Dosing errors may impact the risk of rt-PA for stroke: the Multicenter rt-PA Acute Stroke Survey. J Stroke Cerebrovasc Dis. 2004; 13 (1) 35-40
- 2 Lyden P, Lu M, Jackson C et al.. Underlying structure of the National Institutes of Health Stroke Scale: results of a factor analysis. NINDS tPA Stroke Trial Investigators. Stroke. 1999; 30 (11) 2347-2354
- 3 Adams Jr H P, Davis P H, Leira E C et al.. Baseline NIH Stroke Scale score strongly predicts outcome after stroke: A report of the Trial of Org 10172 in Acute Stroke Treatment (TOAST). Neurology. 1999; 53 (1) 126-131
- 4 Goldstein L B, Samsa G P. Reliability of the National Institutes of Health Stroke Scale. Extension to non-neurologists in the context of a clinical trial. Stroke. 1997; 28 (2) 307-310
- 5 Fischer U, Arnold M, Nedeltchev K et al.. NIHSS score and arteriographic findings in acute ischemic stroke. Stroke. 2005; 36 (10) 2121-2125
- 6 Brott T, Reed R L. Intensive care for acute stroke in the community hospital setting. The first 24 hours. Stroke. 1989; 20 (5) 694-697
- 7 Lyden P, Claesson L, Havstad S, Ashwood T, Lu M. Factor analysis of the National Institutes of Health Stroke Scale in patients with large strokes. Arch Neurol. 2004; 61 (11) 1677-1680
- 8 Woo D, Broderick J P, Kothari R U et al.. Does the National Institutes of Health Stroke Scale favor left hemisphere strokes? NINDS t-PA Stroke Study Group. Stroke. 1999; 30 (11) 2355-2359
- 9 Kasner S E. Clinical interpretation and use of stroke scales. Lancet Neurol. 2006; 5 (7) 603-612
- 10 Adams Jr H P, del Zoppo G, Alberts M J American Heart Association/American Stroke Association Stroke Council et al. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Circulation. 2007; 115 (20) e478-e534
- 11 Sagar G, Riley P, Vohrah A. Is admission chest radiography of any clinical value in acute stroke patients?. Clin Radiol. 1996; 51 (7) 499-502
- 12 Besson G, Robert C, Hommel M, Perret J. Is it clinically possible to distinguish nonhemorrhagic infarct from hemorrhagic stroke?. Stroke. 1995; 26 (7) 1205-1209
- 13 Mader T J, Mandel A. A new clinical scoring system fails to differentiate hemorrhagic from ischemic stroke when used in the acute care setting. J Emerg Med. 1998; 16 (1) 9-13
- 14 Grotta J C, Chiu D, Lu M et al.. Agreement and variability in the interpretation of early CT changes in stroke patients qualifying for intravenous rtPA therapy. Stroke. 1999; 30 (8) 1528-1533
- 15 Barber P A, Demchuk A M, Zhang J, Buchan A M. Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. ASPECTS Study Group. Alberta Stroke Programme Early CT Score. Lancet. 2000; 355 (9216) 1670-1674
- 16 von Kummer R, Nolte P N, Schnittger H, Thron A, Ringelstein E B. Detectability of cerebral hemisphere ischaemic infarcts by CT within 6 h of stroke. Neuroradiology. 1996; 38 (1) 31-33
- 17 Hacke W, Kaste M, Fieschi C The European Cooperative Acute Stroke Study (ECASS) et al. Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke. JAMA. 1995; 274 (13) 1017-1025
- 18 Patel S C, Levine S R, Tilley B C National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group et al. Lack of clinical significance of early ischemic changes on computed tomography in acute stroke. JAMA. 2001; 286 (22) 2830-2838
- 19 Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med. 1995; 333 (24) 1581-1587
- 20 Kwiatkowski T G, Libman R B, Frankel M National Institute of Neurological Disorders and Stroke Recombinant Tissue Plasminogen Activator Stroke Study Group et al. Effects of tissue plasminogen activator for acute ischemic stroke at one year. N Engl J Med. 1999; 340 (23) 1781-1787
- 21 Wahlgren N, Ahmed N, Dávalos A SITS-MOST investigators et al. Thrombolysis with alteplase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST): an observational study. Lancet. 2007; 369 (9558) 275-282
- 22 Sattin J A, Olson S E, Liu L, Raman R, Lyden P D. An expedited code stroke protocol is feasible and safe. Stroke. 2006; 37 (12) 2935-2939
- 23 Sylaja P N, Dzialowski I, Krol A, Roy J, Federico P, Demchuk A M. Calgary Stroke Program . Role of CT angiography in thrombolysis decision-making for patients with presumed seizure at stroke onset. Stroke. 2006; 37 (3) 915-917
- 24 Selim M, Kumar S, Fink J, Schlaug G, Caplan L R, Linfante I. Seizure at stroke onset: should it be an absolute contraindication to thrombolysis?. Cerebrovasc Dis. 2002; 14 (1) 54-57
- 25 Liang B A, Lew R, Zivin J A. Review of tissue plasminogen activator, ischemic stroke, and potential legal issues. Arch Neurol. 2008; 65 (11) 1429-1433
- 26 Derex L, Nighoghossian N. Intracerebral haemorrhage after thrombolysis for acute ischaemic stroke: an update. J Neurol Neurosurg Psychiatry. 2008; 79 (10) 1093-1099
- 27 Larrue V, von Kummer R, del Zoppo G, Bluhmki E. Hemorrhagic transformation in acute ischemic stroke. Potential contributing factors in the European Cooperative Acute Stroke Study. Stroke. 1997; 28 (5) 957-960
- 28 Intracerebral hemorrhage after intravenous t-PA therapy for ischemic stroke. The NINDS t-PA Stroke Study Group. Stroke. 1997; 28 (11) 2109-2118
- 29 Derex L, Hermier M, Adeleine P et al.. Clinical and imaging predictors of intracerebral haemorrhage in stroke patients treated with intravenous tissue plasminogen activator. J Neurol Neurosurg Psychiatry. 2005; 76 (1) 70-75
- 30 Demchuk A M, Morgenstern L B, Krieger D W et al.. Serum glucose level and diabetes predict tissue plasminogen activator-related intracerebral hemorrhage in acute ischemic stroke. Stroke. 1999; 30 (1) 34-39
- 31 D'Addesio J P. Should thrombolytic therapy be the first-line treatment for acute ischemic stroke?. N Engl J Med. 1998; 338 (11) 762 author reply 762-763
- 32 Winkler D T, Fluri F, Fuhr P et al.. Thrombolysis in stroke mimics: frequency, clinical characteristics, and outcome. Stroke. 2009; 40 (4) 1522-1525
- 33 Scott P A, Silbergleit R. Misdiagnosis of stroke in tissue plasminogen activator-treated patients: characteristics and outcomes. Ann Emerg Med. 2003; 42 (5) 611-618
- 34 Chernyshev O Y, Martin-Schild S, Albright K C et al.. Safety of tPA in stroke mimics and neuroimaging-negative cerebral ischemia. Neurology. 2010; 74 (17) 1340-1345
- 35 Hommel M, Boissel J P, Cornu C MAST Study Group et al. Termination of trial of streptokinase in severe acute ischaemic stroke. Lancet. 1995; 345 (8941) 57
- 36 Haley Jr E C, Lyden P D, Johnston K C, Hemmen T M. TNK in Stroke Investigators . A pilot dose-escalation safety study of tenecteplase in acute ischemic stroke. Stroke. 2005; 36 (3) 607-612
- 37 Haley Jr E C, Thompson J L, Grotta J C Tenecteplase in Stroke Investigators et al. Phase IIB/III trial of tenecteplase in acute ischemic stroke: results of a prematurely terminated randomized clinical trial. Stroke. 2010; 41 (4) 707-711
- 38 Hacke W, Donnan G, Fieschi C ATLANTIS Trials Investigators et al. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet. 2004; 363 (9411) 768-774
- 39 Del Zoppo G J, Saver J L, Jauch E C, Adams Jr H P. American Heart Association Stroke Council . Expansion of the time window for treatment of acute ischemic stroke with intravenous tissue plasminogen activator: a science advisory from the American Heart Association/American Stroke Association. Stroke. 2009; 40 (8) 2945-2948
- 40 Barreto A D, Martin-Schild S, Hallevi H et al.. Thrombolytic therapy for patients who wake-up with stroke. Stroke. 2009; 40 (3) 827-832
- 41 Alexandrov A V, Molina C A, Grotta J C CLOTBUST Investigators et al. Ultrasound-enhanced systemic thrombolysis for acute ischemic stroke. N Engl J Med. 2004; 351 (21) 2170-2178
- 42 Tsivgoulis G, Eggers J, Ribo M et al.. Safety and efficacy of ultrasound-enhanced thrombolysis: a comprehensive review and meta-analysis of randomized and nonrandomized studies. Stroke. 2010; 41 (2) 280-287
- 43 Scott J F, Robinson G M, French J M, O'Connell J E, Alberti K G, Gray C S. Prevalence of admission hyperglycaemia across clinical subtypes of acute stroke. Lancet. 1999; 353 (9150) 376-377
- 44 Gray C S, Hildreth A J, Alberti G K, O'Connell J E. GIST Collaboration . Poststroke hyperglycemia: natural history and immediate management. Stroke. 2004; 35 (1) 122-126
- 45 Bruno A, Biller J, Adams Jr H P Trial of ORG 10172 in Acute Stroke Treatment (TOAST) investigators et al. Acute blood glucose level and outcome from ischemic stroke. Trial of ORG 10172 in Acute Stroke Treatment (TOAST) Investigators. Neurology. 1999; 52 (2) 280-284
- 46 Bruno A, Levine S R, Frankel M R et al.. NINDS rtPA Stroke Study Group. Admission glucose level and clinical outcomes in the NINDS rtPA Stroke Trial. Neurology. 2002; 59 669-674
- 47 Lindsberg P J, Roine R O. Hyperglycemia in acute stroke. Stroke. 2004; 35 (2) 363-364
- 48 Gray C S, Hildreth A J, Sandercock P A GIST Trialists Collaboration et al. Glucose-potassium-insulin infusions in the management of post-stroke hyperglycaemia: the UK Glucose Insulin in Stroke Trial (GIST-UK). Lancet Neurol. 2007; 6 (5) 397-406
- 49 Johnston K C, Hall C E, Kissela B M, Bleck T P, Conaway M R. GRASP Investigators . Glucose Regulation in Acute Stroke Patients (GRASP) trial: a randomized pilot trial. Stroke. 2009; 40 (12) 3804-3809
- 50 Phillips S J. Pathophysiology and management of hypertension in acute ischemic stroke. Hypertension. 1994; 23 (1) 131-136
- 51 Heitsch L, Jauch E C. Management of hypertension in the setting of acute ischemic stroke. Curr Hypertens Rep. 2007; 9 (6) 506-511
Kevin BarrettM.D. M.Sc.
Department of Neurology, Mayo Clinic Florida
4500 San Pablo Road South, Jacksonville, FL 32224
eMail: Barrett.kevin@mayo.edu