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Semin Neurol 2015; 35(06): 629-637
DOI: 10.1055/s-0035-1564301
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Acute Care of Ischemic Stroke Patients in the Hospital

Karl M. Meisel
1   Department of Neurology, University of California, San Francisco, California
,
Ahmad M. Thabet
1   Department of Neurology, University of California, San Francisco, California
,
S. Andrew Josephson
1   Department of Neurology, University of California, San Francisco, California
› Author Affiliations
Further Information

Publication History

Publication Date:
23 November 2015 (online)

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Abstract

Ischemic stroke is a leading cause of death and disability worldwide. Recent advances in acute treatment provide hope that the impact of this disease will be reduced. Rapid assessment for large vessel occlusion is now a key element in acute stroke care given advances in endovascular therapy. Because access to acute therapies is limited, development of systems of care to triage appropriate patients to specialized centers is essential. Acute hospitalization management requires multiple strategies including initiation of secondary prevention measures. In addition to preventing further stroke, physicians can also improve long-term survival by preventing the complications of stroke in the hospital and ensuring longitudinal poststroke care and rehabilitation following discharge.

Keywords

acute ischemic stroke - secondary stroke prevention - endovascular therapy - thrombectomy - thrombolysis - acute stroke treatment - anticoagulation - antiplatelet medications
 

  • References

  • 1 Mozaffarian D, Benjamin EJ, Go AS , et al. Heart disease and stroke statistics-2015 update: a report from the American Heart Association. American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2015; 131: e229-e322
    PubMedGoogle Scholar
  • 2 Walter S, Kostopoulos P, Haass A , et al. Diagnosis and treatment of patients with stroke in a mobile stroke unit versus in hospital: a randomised controlled trial. Lancet Neurol 2012; 11 (5) 397-404
    CrossrefPubMedGoogle Scholar
  • 3 Parker SA, Bowry R, Wu TC , et al. Establishing the first mobile stroke unit in the United States. Stroke 2015; 46 (5) 1384-1391
    CrossrefPubMedGoogle Scholar
  • 4 Leonardi-Bee J, Bath PM, Phillips SJ, Sandercock PA ; IST Collaborative Group. Blood pressure and clinical outcomes in the International Stroke Trial. Stroke 2002; 33 (5) 1315-1320
    CrossrefPubMedGoogle Scholar
  • 5 Jauch EC, Saver JL, Adams Jr HP , et al; American Heart Association Stroke Council; Council on Cardiovascular Nursing; Council on Peripheral Vascular Disease; Council on Clinical Cardiology. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013; 44 (3) 870-947
    CrossrefPubMedGoogle Scholar
  • 6 Adams Jr HP, Davis PH, Leira EC , 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
    CrossrefPubMedGoogle Scholar
  • 7 Fischer U, Arnold M, Nedeltchev K , et al. NIHSS score and arteriographic findings in acute ischemic stroke. Stroke 2005; 36 (10) 2121-2125
    CrossrefPubMedGoogle Scholar
  • 8 Barber PA, Demchuk AM, Zhang J, Buchan AM. 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
    CrossrefPubMedGoogle Scholar
  • 9 Inoue M, Mlynash M, Straka M , et al. Clinical outcomes strongly associated with the degree of reperfusion achieved in target mismatch patients: pooled data from the Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution Studies. Stroke 2013; 44 (7) 1855-1890
    PubMedGoogle Scholar
  • 10 The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. 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: 1581-1587
    CrossrefPubMedGoogle Scholar
  • 11 Saver JL, Gornbein J, Grotta J , et al. Number needed to treat to benefit and to harm for intravenous tissue plasminogen activator therapy in the 3 to 4.5 hour window: joint outcome table analysis of the ECASS 3 trial. Stroke 2009; 40: 2433-2437
    CrossrefPubMedGoogle Scholar
  • 12 Fonarow GC, Smith EE, Saver JL , et al. Timeliness of tissue-type plasminogen activator therapy in acute ischemic stroke: patient characteristics, hospital factors, and outcomes associated with door-to-needle times within 60 minutes. Circulation 2011; 123: 750-758
    CrossrefPubMedGoogle Scholar
  • 13 Hacke W, Kaste M, Bluhmki E , et al; ECASS Investigators. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 2008; 359 (13) 1317-1329
    CrossrefPubMedGoogle Scholar
  • 14 Hacke W, Donnan G, Fieschi C , et al; ATLANTIS Trials Investigators; ECASS Trials Investigators; NINDS rt-PA Study Group Investigators. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet 2004; 363 (9411) 768-774
    CrossrefPubMedGoogle Scholar
  • 15 Smith EE, Abdullah AR, Petkovska I, Rosenthal E, Koroshetz WJ, Schwamm LH. Poor outcomes in patients who do not receive intravenous tissue plasminogen activator because of mild or improving ischemic stroke. Stroke 2005; 36 (11) 2497-2499
    CrossrefPubMedGoogle Scholar
  • 16 Cucchiara BL, Jackson B, Weiner M, Messe SR. Usefulness of checking platelet count before thrombolysis in acute ischemic stroke. Stroke 2007; 38 (5) 1639-1640
    CrossrefPubMedGoogle Scholar
  • 17 Bhatia R, Hill MD, Shobha N , et al. Low rates of acute recanalization with intravenous recombinant tissue plasminogen activator in ischemic stroke: real-world experience and a call for action. Stroke 2010; 41 (10) 2254-2258
    CrossrefPubMedGoogle Scholar
  • 18 Smith WS, Sung G, Starkman S , et al; MERCI Trial Investigators. Safety and efficacy of mechanical embolectomy in acute ischemic stroke: results of the MERCI trial. Stroke 2005; 36 (7) 1432-1438
    CrossrefPubMedGoogle Scholar
  • 19 Berkhemer OA, Fransen PS, Beumer D , et al; MR CLEAN Investigators. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 2015; 372 (1) 11-20
    CrossrefPubMedGoogle Scholar
  • 20 Goyal M, Demchuk AM, Menon BK , et al; ESCAPE Trial Investigators. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 2015; 372 (11) 1019-1030
    CrossrefPubMedGoogle Scholar
  • 21 Campbell BC, Mitchell PJ, Kleinig TJ , et al; EXTEND-IA Investigators. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med 2015; 372 (11) 1009-1018
    CrossrefPubMedGoogle Scholar
  • 22 Saver JL, Goyal M, Bonafe A , et al; SWIFT PRIME Investigators. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med 2015; 372 (24) 2285-2295
    CrossrefPubMedGoogle Scholar
  • 23 Demaerschalk BM, Raman R, Ernstrom K, Meyer BC. Efficacy of telemedicine for stroke: pooled analysis of the Stroke Team Remote Evaluation Using a Digital Observation Camera (STRokE DOC) and STRokE DOC Arizona telestroke trials. Telemed J E Health 2012; 18 (3) 230-237
    CrossrefPubMedGoogle Scholar
  • 24 Wang H, Tang Y, Rong X , et al. Effects of early blood pressure lowering on early and long-term outcomes after acute stroke: an updated meta-analysis. PLoS ONE 2014; 9 (5) e97917
    CrossrefPubMedGoogle Scholar
  • 25 Vahedi K, Hofmeijer J, Juettler E , et al; DECIMAL, DESTINY, and HAMLET investigators. Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. Lancet Neurol 2007; 6 (3) 215-222
    CrossrefPubMedGoogle Scholar
  • 26 Jüttler E, Unterberg A, Woitzik J , et al; DESTINY II Investigators. Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke. N Engl J Med 2014; 370 (12) 1091-1100
    CrossrefPubMedGoogle Scholar
  • 27 Ingeman A, Andersen G, Hundborg HH, Svendsen ML, Johnsen SP. In-hospital medical complications, length of stay, and mortality among stroke unit patients. Stroke 2011; 42 (11) 3214-3218
    CrossrefPubMedGoogle Scholar
  • 28 Linares G, Mayer SA. Hypothermia for the treatment of ischemic and hemorrhagic stroke. Crit Care Med 2009; 37 (7, Suppl): S243-S249
    CrossrefPubMedGoogle Scholar
  • 29 Westendorp WF, Nederkoorn PJ, Vermeij JD, Dijkgraaf MG, van de Beek D. Post-stroke infection: a systematic review and meta-analysis. BMC Neurol 2011; 11: 110-117
    CrossrefPubMedGoogle Scholar
  • 30 Chen YD, Li SJ, Sun FH, Liu YY, Hu WL. Monitoring of medical complications after acute ischemic stroke in a neurological intensive care unit. Eur Neurol 2011; 66 (4) 204-209
    CrossrefPubMedGoogle Scholar
  • 31 Gould CV, Umscheid CA, Agarwal RK , et al. Guideline for prevention of catheter-associated urinary tract infections. 2009 . Available at: http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf . Accessed May 5, 2015
    PubMedGoogle Scholar
  • 32 Mitchell AJ. Clinical implications of poststroke hypothalamo-pituitary adrenal axis dysfunction: a critical literature review. J Stroke Cerebrovasc Dis 1997; 6 (6) 377-388
    CrossrefPubMedGoogle Scholar
  • 33 Alvarez-Sabín J, Molina CA, Montaner J , et al. Effects of admission hyperglycemia on stroke outcome in reperfused tissue plasminogen activator—treated patients. Stroke 2003; 34 (5) 1235-1241
    CrossrefPubMedGoogle Scholar
  • 34 Gray CS, Hildreth AJ, Sandercock PA , et al; GIST Trialists Collaboration. 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
    CrossrefPubMedGoogle Scholar
  • 35 Lansberg MG, O'Donnell MJ, Khatri P , et al; American College of Chest Physicians. Antithrombotic and thrombolytic therapy for ischemic stroke: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141 (2, Suppl): e601S-e636S
    CrossrefPubMedGoogle Scholar
  • 36 Chollet F, Tardy J, Albucher JF , et al. Fluoxetine for motor recovery after acute ischaemic stroke (FLAME): a randomised placebo-controlled trial. Lancet Neurol 2011; 10 (2) 123-130
    CrossrefPubMedGoogle Scholar
  • 37 Outpatient Service Trialists. Therapy-based rehabilitation services for stroke patients at home. Cochrane Database Syst Rev 2003; 1 (1) CD002925
    PubMedGoogle Scholar
  • 38 Elijovich L, Josephson SA, Fung GL, Smith WS. Intermittent atrial fibrillation may account for a large proportion of otherwise cryptogenic stroke: a study of 30-day cardiac event monitors. J Stroke Cerebrovasc Dis 2009; 18 (3) 185-189
    CrossrefPubMedGoogle Scholar
  • 39 Manolio TA, Kronmal RA, Burke GL, O'Leary DH, Price TR. Short-term predictors of incident stroke in older adults. The Cardiovascular Health Study. Stroke 1996; 27 (9) 1479-1486
    CrossrefPubMedGoogle Scholar
  • 40 Loke YK, Brown JW, Kwok CS, Niruban A, Myint PK. Association of obstructive sleep apnea with risk of serious cardiovascular events: a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes 2012; 5 (5) 720-728
    CrossrefPubMedGoogle Scholar
  • 41 Poisson SN, Glidden D, Johnston SC, Fullerton HJ. Deaths from stroke in US young adults, 1989-2009. Neurology 2014; 83 (23) 2110-2115
    CrossrefPubMedGoogle Scholar
  • 42 Poisson SN, Schardt TQ, Dingman A, Bernard TJ. Etiology and treatment of arterial ischemic stroke in children and young adults. Curr Treat Options Neurol 2014; 16 (10) 315
    CrossrefPubMedGoogle Scholar
  • 43 Markus HS, Levi C, Feldman A , et al. CADISS trial investigators. Antiplatelet treatment compared with anticoagulation treatment for cervical artery dissection (CADISS): a randomised trial. Lancet Neurol 2015; 14: 361-367
    CrossrefPubMedGoogle Scholar
  • 44 Kernan WN, Ovbiagele B, Black HR , et al; American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on Peripheral Vascular Disease. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45 (7) 2160-2236
    CrossrefPubMedGoogle Scholar
  • 45 Johnson ES, Lanes SF, Wentworth III CE, Satterfield MH, Abebe BL, Dicker LW. A metaregression analysis of the dose-response effect of aspirin on stroke. Arch Intern Med 1999; 159 (11) 1248-1253
    CrossrefPubMedGoogle Scholar
  • 46 Wang Y, Wang Y, Zhao X , et al; CHANCE Investigators. Clopidogrel with aspirin in acute minor stroke or transient ischemic attack. N Engl J Med 2013; 369 (1) 11-19
    CrossrefPubMedGoogle Scholar
  • 47 Diener HC, Cunha L, Forbes C, Sivenius J, Smets P, Lowenthal A. European Stroke Prevention Study. 2. Dipyridamole and acetylsalicylic acid in the secondary prevention of stroke. J Neurol Sci 1996; 143 (1-2) 1-13
    CrossrefPubMedGoogle Scholar
  • 48 Sacco RL, Diener HC, Yusuf S , et al; PRoFESS Study Group. Aspirin and extended-release dipyridamole versus clopidogrel for recurrent stroke. N Engl J Med 2008; 359 (12) 1238-1251
    CrossrefPubMedGoogle Scholar
  • 49 Singer DE, Albers GW, Dalen JE, Go AS, Halperin JL, Manning WJ. Antithrombotic therapy in atrial fibrillation: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126 (3, Suppl) 429S-456S
    CrossrefPubMedGoogle Scholar
  • 50 Connolly SJ, Ezekowitz MD, Yusuf S , et al; RE-LY Steering Committee and Investigators. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009; 361 (12) 1139-1151
    CrossrefPubMedGoogle Scholar
  • 51 Granger CB, Alexander JH, McMurray JJ , et al; ARISTOTLE Committees and Investigators. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med 2011; 365 (11) 981-992
    CrossrefPubMedGoogle Scholar
  • 52 Pisters R, Lane DA, Nieuwlaat R, de Vos CB, Crijns HJ, Lip GY. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest 2010; 138 (5) 1093-1100
    CrossrefPubMedGoogle Scholar
  • 53 North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 1991; 325: 445-453
    CrossrefPubMedGoogle Scholar
  • 54 Brott TG, Hobson II RW, Howard G , et al; CREST Investigators. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med 2010; 363 (1) 11-23
    CrossrefPubMedGoogle Scholar
  • 55 Amarenco P, Bogousslavsky J, Callahan III A , et al; Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) Investigators. High-dose atorvastatin after stroke or transient ischemic attack. N Engl J Med 2006; 355 (6) 549-559
    CrossrefPubMedGoogle Scholar
  • 56 Fonarow GC, Smith EE, Reeves MJ , et al; Get With The Guidelines Steering Committee and Hospitals. Hospital-level variation in mortality and rehospitalization for medicare beneficiaries with acute ischemic stroke. Stroke 2011; 42 (1) 159-166
    CrossrefPubMedGoogle Scholar
  • 57 Bushnell CD, Olson DM, Zhao X , et al; AVAIL Investigators. Secondary preventive medication persistence and adherence 1 year after stroke. Neurology 2011; 77 (12) 1182-1190
    CrossrefPubMedGoogle Scholar
  • 58 Park JH, Ovbiagele B. Optimal combination secondary prevention drug treatment and stroke outcomes. Neurology 2015; 84 (1) 50-56
    CrossrefPubMedGoogle Scholar