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Treatment of Acute Ischemic Stroke 239

sufficient flow to maintain normal cellular function. ysis with rtPA and endovascular thrombectomy with
This explains why the acute neurologic deficits ex- a retrievable stent improve neurologic outcomes in
ceed what would be expected for the established patients with acute ischemic stroke. Both treatments
infarct core at the time of presentation and why neu- should be administered as quickly as possible after
rologic function can improve after reperfusion. This stroke onset can be combined and are safe in ap-
collateral flow, however is often tenuous and can propriately selected candidates. IV thrombolysis and
sustain viability only for a limited period of time. mechanical thrombectomy can produce reperfusion
Thus without recanalization the ischemic penum- injury after recanalization. Reperfusion injury can
bra is destined to progress to infarction. Collateral manifest with hemorrhage and edema. It is more
flow can be protected by avoiding blood pressure severe when the area of established infarction is
drops and supported by the administration of IV larger. Good patient selection (ie, absence of large
fluids. The value of keeping the head of the bed ischemic core ) and prompt treatment are crucial to
flat for patients with acute ischemic stroke is avoid this complication.
being investigated in the ongoing head position Intravenous Thrombolysis
in stroke trial (Headpost) and should be weighed
against the risk of aspiration. Hemodynamic aug- IV Thrombolysis with rtPA is proven to be effective
mentation with vasopressors may be beneficial in in improving functional outcomes after an ischemic
well selected cases (such as patients with cervical stroke up to 4.5 hours after symptom onset. The US
internal carotid artery occlusion without tandem food and drug administration (FDA) has only ap-
intracranial occlusion) but the safety and efficacy proved rtPA for use within 3 hours of stroke onset
of this strategy is otherwise unknown. Invasive ,but regulatory agencies in most other countries (in-
interventions to improve collateral flow remain cluding those in the European union) have approved
investigational. its administration within 4.5 hours of stroke onset.
(3) Despite promising results in basic and transla- The initial evaluation of a patient with a possible
tional experiments numerous neuroprotective agents acute stroke in emergency department should focus
have failed to improve outcomes in clinical trials on establishing whether the patient is eligible for
. Hypoglycemia can exacerbate energy failure and reperfusion therapy .Necessary information includes
should be strictiy averted. Hypoglycemia might the time the patient was last known to be well, med-
also be deleterious so far , we know that it cor- ical conditions or recent surgery that could con-
relates with worse outcomes after an ischemic traindicate thrombolysis, neurologic examination
stroke but do not have proof that its corrections to calculate the National institutes of health stroke
improves out comes. scale (NIHSS) score, a capillary glucose level, blood
pressure and brain imaging (CT scan with a
The stroke Hyperglycemia insulin Network Effort CT angiogram depending on whether endovascular
(SHINE) trial is a randomized controlled trial com- therapy is being considered).
paring tight glycemic control with IV insulin to
maintain a glucose level between 80 mg/dl and
130 mg/dl versus strandard glycemic control using Indications
subcutaneous insulin dosed according to a sliding • Clinical diagnosis of stroke
scale to keep the glucose level lower than 180 • Onset of symptoms to time of drug
mg/dl in patients with acute ischemic stroke
within 12 hours of symptom onset It is hoped • administration ≤4.5hrs
that this trial will answer the question whether • CT scan showing no hemorrhage or
tight glycemic control is safe and beneficial after
an acute ischemic stroke . Fever is associated with • edema of >1/3 of the MCA territory
worse clinical results; thus treating fever may be • Age ≥ 18 years
beneficial. The value of hypothermia continues
to be investigated preventing infections (which nota- • Consent by patient or surrogate
bly includes dysphagia assessment before any oral
intake) and early recurrent strokes are additional Contraindications
priorities in the care of the patient with acute stroke.
ACUTE REPERFUSION TREATMENTS:
There is incontrovertible evidence that IV thrombol-

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