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Semin Neurol 2008; 28(5): 645-656
DOI: 10.1055/s-0028-1105975
© Thieme Medical Publishers

Ischemic Stroke and ICU Care

Rafael H. Llinas1
  • 1Department of Neurology, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
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Publication History

Publication Date:
29 December 2008 (online)

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ABSTRACT

Acute ischemic stroke is a common disorder with a significant impact on morbidity and mortality in the United States. The number of interventions for acute stroke patients has increased over the past 15 years and patients increasingly require intensive care. There are several issues that are specific to ischemic stroke patients in intensive care unit (ICU) settings, including the care of the postthrombolytic stroke patient, respiratory issues in stroke care, evaluation of worsening or change in neurological status, and attention to factors that affect the ischemic penumbra. The management of the stroke patient in the critical care setting is discussed in this article.

KEYWORDS

Ischemic stroke - hypertension - intracranial pressure - neurocritical care

REFERENCES

  • 1 Govan L, Langhorne P, Weir C J. Does the prevention of complications explain the survival benefit of organized inpatient (stroke unit) care? Further analysis of a systematic review.  Stroke. 2007;  38(9) 2536-2540
    CrossrefPubMedGoogle Scholar
  • 2 Adams Jr H P, Del Zoppo G, Alberts M J 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.  Stroke. 2007;  38(5) 1655-1711
    CrossrefPubMedGoogle Scholar
  • 3 Sulter G, Elting J W, Langedijk M, Maurits N M, De Keyser J. Admitting acute ischemic stroke patients to a stroke care monitoring unit versus a conventional stroke unit: a randomized pilot study.  Stroke. 2003;  34(1) 101-104
    CrossrefPubMedGoogle Scholar
  • 4 Gorter P M, Olijhoek J K, van der Graaf Y, Algra A, Rabelink T J, Visseren F LJ. Prevalence of the metabolic syndrome in patients with coronary heart disease, cerebrovascular disease, peripheral arterial disease or abdominal aortic aneurysm.  Atherosclerosis. 2004;  173(2) 363-369
    PubMedGoogle Scholar
  • 5 Stoffers H EJH, Rinkens P ELM, Kester A DM, Kaiser V, Knottnerus J A. The prevalence of asymptomatic and unrecognized peripheral arterial occlusive disease.  Int J Epidemiol. 1996;  25(2) 282-290
    CrossrefPubMedGoogle Scholar
  • 6 Briggs D E, Felberg R A, Malkoff M D, Bratina P, Grotta J C. Should mild or moderate stroke patients be admitted to an intensive care unit?.  Stroke. 2001;  32(4) 871-876
    PubMedGoogle Scholar
  • 7 Diringer M N, Edwards D F. Admission to a neurologic/neurosurgical intensive care unit is associated with reduced mortality rate after intracerebral hemorrhage.  Crit Care Med. 2001;  29(3) 635-640
    CrossrefPubMedGoogle Scholar
  • 8 Suarez J I, Zaidat O O, Suri M F et al.. Length of stay and mortality in neurocritically ill patients: impact of a specialized neurocritical care team.  Crit Care Med. 2004;  32(11) 2311-2317
    PubMedGoogle Scholar
  • 9 Mirski M A, Chang C WJ, Cowan R. Impact of a neuroscience intensive care unit on neurosurgical patient outcomes and cost of care: Evidence-based support for an intensivist-directed specialty ICU model of care.  J Neurosurg Anesthesiol. 2001;  13(2) 83-92
    CrossrefPubMedGoogle Scholar
  • 10 Hemphill J C, Bleck T, Carhuapoma J R et al.. Is neurointensive care really optional for comprehensive stroke care?.  Stroke. 2005;  36(11) 2344-2345
    PubMedGoogle Scholar
  • 11 Hill M D, Barber P A, Takahashi J, Demchuk A M, Feasby T E, Buchan A M. Anaphylactoid reactions and angioedema during alteplase treatment of acute ischemic stroke.  CMAJ. 2000;  162(9) 1281-1284
    PubMedGoogle Scholar
  • 12 Mills G C, Arntfield R T, Sedran R J. Acute allergic reaction due to the administration of fibrinolytic therapy for ST-segment elevation myocardial infarction: Case report and discussion.  CJEM. 2003;  5(6) 421-423
    PubMedGoogle Scholar
  • 13 Rudolf J, Grond M, Prince W S, Schmulling S, Heiss W D. Evidence of anaphylaxy after alteplase infusion.  Stroke. 1999;  30(5) 1142-1143
    PubMedGoogle Scholar
  • 14 Molinaro G, Gervais N, Adam A. Biochemical basis of angioedema associated with recombinant tissue plasminogen activator treatment: an in vitro experimental approach.  Stroke. 2002;  33(6) 1712-1716
    CrossrefPubMedGoogle Scholar
  • 15 Hill M D, Lye T, Moss H et al.. Hemi-orolingual angioedema and ACE inhibition after alteplase treatment of stroke.  Neurology. 2003;  60(9) 1525-1527
    CrossrefPubMedGoogle Scholar
  • 16 Mueller H S, Rao A K, Forman S A. Thrombolysis in myocardial infarction (TIMI): comparative studies of coronary reperfusion and systemic fibrinogenolysis with two forms of recombinant tissue-type plasminogen activator.  J Am Coll Cardiol. 1987;  10(3) 479-490
    PubMedGoogle Scholar
  • 17 Topol E J, Morris D C, Smalling R W et al.. A multicenter, randomized, placebo-controlled trial of a new form of intravenous recombinant tissue-type plasminogen activator (activase) in acute myocardial infarction.  J Am Coll Cardiol. 1987;  9(6) 1205-1213
    PubMedGoogle Scholar
  • 18 Marler J R. Tissue plasminogen activator for acute ischemic stroke.  N Engl J Med. 1995;  333(24) 1581-1587
    CrossrefPubMedGoogle Scholar
  • 19 Lewandowski C A, Frankel M, Tomsick T A et al.. Combined intravenous and intra-arterial r-TPA versus intra-arterial therapy of acute ischemic stroke emergency management of stroke (EMS) bridging trial.  Stroke. 1999;  30(12) 2598-2605
    CrossrefPubMedGoogle Scholar
  • 20 Broderick J P. The interventional management of stroke (IMS) II study.  Stroke. 2007;  38(7) 2127-2135
    CrossrefPubMedGoogle Scholar
  • 21 Del Zoppo G J, Higashida R T, Furlan A J, Pessin M S, Rowley H A, Gent M. PROACT: a phase II randomized trial of recombinant pro-urokinase by direct arterial delivery in acute middle cerebral artery stroke.  Stroke. 1998;  29(1) 4-11
    CrossrefPubMedGoogle Scholar
  • 22 Furlan A, Higashida R, Wechsler L et al.. Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial.  JAMA. 1999;  282(21) 2003-2011
    CrossrefPubMedGoogle Scholar
  • 23 Kremen S A, Wu M N, Ovbiagele B. Hemopericardium following intravenous thrombolysis for acute ischemic stroke.  Cerebrovasc Dis. 2005;  20(6) 478-479
    CrossrefPubMedGoogle Scholar
  • 24 Bushnell C D, Phillips-Bute B G, Laskowitz D T, Lynch J R, Chilukuri V, Borel C O. Survival and outcome after endotracheal intubation for acute stroke.  Neurology. 1999;  52(7) 1374-1381
    PubMedGoogle Scholar
  • 25 Grotta J. Elective intubation for neurologic deterioration after stroke.  Neurology. 1995;  45(4) 640-644
    PubMedGoogle Scholar
  • 26 Steiner T, Mendoza G, De Georgia M, Schellinger P, Holle R, Hacke W. Prognosis of stroke patients requiring mechanical ventilation in a neurological critical care unit.  Stroke. 1997;  28(4) 711-715
    PubMedGoogle Scholar
  • 27 Duke B J, Ryu R K, Brega K E, Coldwell D M. Traumatic bilateral jugular vein thrombosis: Case report and review of the literature.  Neurosurgery. 1997;  41(3) 680-683
    CrossrefPubMedGoogle Scholar
  • 28 Kotani J, Nitta K, Sakuma Y, Sugioka S, Fujita N, Ueda Y. Effects of bilateral jugular vein ligation on intracranial pressure and cerebrospinal fluid outflow resistance in cats.  Br J Oral Maxillofac Surg. 1992;  30(3) 171-173
    CrossrefPubMedGoogle Scholar
  • 29 Toung T JK, Miyabe M, McShane M J, RCSI F, Rogers M C, Traystman R J. Effect of PEEP and jugular venous compression on canine cerebral blood flow and oxygen consumption in the plead elevated position.  Anesthesiology. 1988;  68 53-58
    PubMedGoogle Scholar
  • 30 Morfit H M, Cleveland Jr H. Permanent increased intracranial pressure following unilateral radical neck dissection.  AMA Arch Surg. 1958;  76(5) 713-719
    PubMedGoogle Scholar
  • 31 Schwarz S, Georgiadis D, Aschoff A, Schwab S. Effects of body position on intracranial pressure and cerebral perfusion in patients with large hemispheric stroke.  Stroke. 2002;  33(2) 497-501
    CrossrefPubMedGoogle Scholar
  • 32 Hung O R, Hare G M, Brien S. Head elevation reduces head-rotation associated increased ICP in patients with intracranial tumors.  Can J Anaesth. 2000;  47(5) 415-420
    PubMedGoogle Scholar
  • 33 Caricato A, Conti G, Francesco Della Corte M D et al.. Effects of PEEP on the intracranial system of patients with head injury and subarachnoid hemorrhage: The role of respiratory system compliance.  J Trauma. 2005;  58(3) 571-576
    CrossrefPubMedGoogle Scholar
  • 34 Georgiadis D, Schwarz S, Baumgartner R, Veltkamp R, Schwab S. Influence of positive end-expiratory pressure on intracranial pressure and cerebral perfusion pressure in patients with acute stroke.  Stroke. 2001;  32(9) 2088-2092
    CrossrefPubMedGoogle Scholar
  • 35 Muench E, Bauhuf C, Roth H et al.. Effects of positive end-expiratory pressure on regional cerebral blood flow, intracranial pressure, and brain tissue oxygenation.  Crit Care Med. 2005;  33(10) 2367-2372
    CrossrefPubMedGoogle Scholar
  • 36 Shapiro H M, Marshall L F. Intracranial pressure responses to PEEP in head-injured patients.  J Trauma. 1978;  18(4) 254-256
    PubMedGoogle Scholar
  • 37 Stewart A R, Finer N N, Peters K L. Effects of alterations of inspiratory and expiratory pressures and inspiratory/expiratory ratios on mean airway pressure, blood gases, and intracranial pressure.  Pediatrics. 1981;  67(4) 474-481
    PubMedGoogle Scholar
  • 38 Weimar C, Mieck T, Buchthal J, Ehrenfeld C E, Schmid E, Diener H C. Neurologic worsening during the acute phase of ischemic stroke.  Arch Neurol. 2005;  62(3) 393-397
    CrossrefPubMedGoogle Scholar
  • 39 Papazian L, Albanese J, Thiron X, Perrin G, Durbec O, Martin C. Effect of bolus doses of midazolam on intracranial pressure and cerebral perfusion pressure in patients with severe head injury.  Br J Anaesth. 1993;  71(2) 267-271
    CrossrefPubMedGoogle Scholar
  • 40 Lyden P, Shuaib A, Ng K et al.. Clomethiazole Acute Stroke Study in ischemic stroke (CLASS-I): final results.  Stroke. 2002;  33(1) 122-128
    CrossrefPubMedGoogle Scholar
  • 41 Wahlgren N G, Ranasinha K W, Rosolacci T et al.. Clomethiazole acute stroke study (CLASS) results of a randomized, controlled trial of clomethiazole versus placebo in 1360 acute stroke patients.  Stroke. 1999;  30(1) 21-28
    PubMedGoogle Scholar
  • 42 Benbadis S R, Sila C A, Cristea R L. Mental status changes and stroke.  J Gen Intern Med. 1994;  9(9) 485-487
    CrossrefPubMedGoogle Scholar
  • 43 Saxena R, Lewis S, Berge E, Sandercock P AG, Koudstaal P J. Risk of early death and recurrent stroke and effect of heparin in 3169 patients with acute ischemic stroke and atrial fibrillation in the international stroke trial.  Stroke. 2001;  32(10) 2333-2337
    CrossrefPubMedGoogle Scholar
  • 44 Burn J, Dennis M, Bamford J, Sandercock P, Wade D, Warlow C. Epileptic seizures after a first stroke: the Oxfordshire community stroke project.  BMJ. 1997;  315(7122) 1582-1587
    PubMedGoogle Scholar
  • 45 Arboix A, Garcia-Eroles L, Massons J B, Oliveres M, Comes E. Predictive factors of early seizures after acute cerebrovascular disease.  Stroke. 1997;  28(8) 1590-1594
    PubMedGoogle Scholar
  • 46 Carrera E, Michel P, Despland P A et al.. Continuous assessment of electrical epileptic activity in acute stroke.  Neurology. 2006;  67(1) 99-104
    CrossrefPubMedGoogle Scholar
  • 47 Rumbach L, Sablot D, Berger E, Tatu L, Vuillier F, Moulin T. Status epilepticus in stroke report on a hospital-based stroke cohort.  Neurology. 2000;  54(2) 350-354
    CrossrefPubMedGoogle Scholar
  • 48 Rao M A, Misra M, Duara R, Jayakumar K, Neelakandhan K S. Acute phenytoin toxicity mimicking stroke following cardiopulmonary bypass.  Indian J Thoracic Cardiovascular Surgery. 2006;  22(1) 19-21
    PubMedGoogle Scholar
  • 49 Ryvlin P, Montavont A, Nighoghossian N. Optimizing therapy of seizures in stroke patients.  Neurology. 2006;  67(suppl 4) S3
    PubMedGoogle Scholar
  • 50 Semplicini A, Maresca A, Boscolo G et al.. Hypertension in acute ischemic stroke: a compensatory mechanism or an additional damaging factor?.  Arch Intern Med. 2003;  163(2) 211-216
    CrossrefPubMedGoogle Scholar
  • 51 Fischberg G M, Lozano E, Rajamani K, Ameriso S, Fisher M J. Stroke precipitated by moderate blood pressure reduction.  J Emerg Med. 2000;  19(4) 339-346
    CrossrefPubMedGoogle Scholar
  • 52 Leonard M B, Kasner S E, Feldman H I, Schulman S L. Adverse neurologic events associated with rebound hypertension after using short-acting nifedipine in childhood hypertension.  Pediatr Emerg Care. 2001;  17(6) 435-437
    CrossrefPubMedGoogle Scholar
  • 53 Rupp H, Maisch B, Brilla C G. Drug withdrawal and rebound hypertension: Differential action of the central antihypertensive drugs moxonidine and clonidine.  Cardiovasc Drugs Ther. 1996;  10 251-262
    CrossrefPubMedGoogle Scholar
  • 54 Geyskes G G, Boer P, Dorhout Mees E J. Clonidine withdrawal. Mechanism and frequency of rebound hypertension.  Br J Clin Pharmacol. 1979;  7(1) 55-62
    CrossrefPubMedGoogle Scholar
  • 55 Frewin D B, Penhall R K. Rebound hypertension after sudden discontinuation of methyldopa therapy.  Med J Aust. 1977;  1(18) 659
    PubMedGoogle Scholar
  • 56 Keim H J, Drayer J I, Case D B et al.. A role for renin in rebound hypertension and encephalopathy after infusion of saralasin acetate (Sar1-Ala8-angiotensin II).  N Engl J Med. 1976;  295(21) 1175-1177
    PubMedGoogle Scholar
  • 57 Rordorf G, Koroshetz W J, Ezzeddine M A, Segal A Z, Buonanno F S. A pilot study of drug-induced hypertension for treatment of acute stroke.  Neurology. 2001;  56(9) 1210-1213
    PubMedGoogle Scholar
  • 58 Shah Q A, Patel S, Qureshi A I. Induced hypertension in patients with partial recanalization after intra-arterial thrombolysis for acute ischemic stroke.  J Neurosurg Anesthesiol. 2008;  20(2) 154-155
    CrossrefPubMedGoogle Scholar
  • 59 Hillis A E, Ulatowski J A, Barker P B et al.. A pilot randomized trial of induced blood pressure elevation: effects on function and focal perfusion in acute and subacute stroke.  Cerebrovasc Dis. 2003;  16(3) 236-246
    CrossrefPubMedGoogle Scholar
  • 60 Jørgensen H S, Nakayama H, Raaschou H O, Olsen T S. Effect of blood pressure and diabetes on stroke in progression.  Lancet. 1994;  344(8916) 156-159
    CrossrefPubMedGoogle Scholar
  • 61 Azzimondi G, Bassein L, Nonino F et al.. Fever in acute stroke worsens prognosis: a prospective study.  Stroke. 1995;  26(11) 2040-2043
    PubMedGoogle Scholar
  • 62 Boysen G, Christensen H. Stroke severity determines body temperature in acute stroke.  Stroke. 2001;  32(2) 413-417
    PubMedGoogle Scholar
  • 63 Castillo J, Davalos A, Marrugat J, Noya M. Timing for fever-related brain damage in acute ischemic stroke.  Stroke. 1998;  29(12) 2455-2460
    PubMedGoogle Scholar
  • 64 Busto R, Dietrich W D, Globus M Y, Valdes I, Scheinberg P, Ginsberg M D. Small differences in intraischemic brain temperature critically determine the extent of ischemic neuronal injury.  J Cereb Blood Flow Metab. 1987;  7(6) 729-738
    CrossrefPubMedGoogle Scholar
  • 65 Krieger D W, De Georgia M A, Abou-Chebl A et al.. Cooling for acute ischemic brain damage (COOL AID): an open pilot study of induced hypothermia in acute ischemic stroke.  Stroke. 2001;  32(8) 1847-1854
    CrossrefPubMedGoogle Scholar
  • 66 De Georgia M A, Krieger D W, Abou-Chebl A et al.. Cooling for acute ischemic brain damage (COOL AID): a feasibility trial of endovascular cooling.  Neurology. 2004;  63(2) 312-317
    CrossrefPubMedGoogle Scholar
  • 67 Kasner S E, Wein T, Piriyawat P et al.. Acetaminophen for altering body temperature in acute stroke: a randomized clinical trial.  Stroke. 2002;  33(1) 130-134
    CrossrefPubMedGoogle Scholar
  • 68 Bruno A, Levine S R, Frankel M R et al.. Admission glucose level and clinical outcomes in the NINDS rt-PA stroke trial.  Neurology. 2002;  59(5) 669-674
    CrossrefPubMedGoogle Scholar
  • 69 Capes S E, Hunt D, Malmberg K, Pathak P, Gerstein H C. Stress hyperglycemia and prognosis of stroke in nondiabetic and diabetic patients: a systematic overview.  Stroke. 2001;  32(10) 2426-2432
    CrossrefPubMedGoogle Scholar
  • 70 Walters M R, Weir C J, Lees K R. A randomized, controlled pilot study to investigate the potential benefit of intervention with insulin in hyperglycaemic acute ischaemic stroke patients.  Cerebrovasc Dis. 2006;  22(2–3) 116-122
    CrossrefPubMedGoogle Scholar
  • 71 Yip P K, He Y Y, Hsu C Y et al.. Effect of plasma glucose on infarct size in focal cerebral ischemia-reperfusion.  Neurology. 1991;  41(6) 899-905
    PubMedGoogle Scholar
  • 72 Lin B, Ginsberg M, Busto R. Hyperglycemic exacerbation of neuronal damage following forebrain ischemia: Microglial, astrocytic and endothelial alterations.  Acta Neuropathol. 1998;  96(6) 610-620
    CrossrefPubMedGoogle Scholar

Rafael H LlinasM.D. 

Department of Neurology, Johns Hopkins Bayview Medical Center, Neurology B122b

4940 Eastern Avenue, Baltimore, MD 21224

Email: rllinas@jhmi.edu