State of the ArtTreatment of acute ischemic stroke*,**
Introduction
The US Food and Drug Administration (FDA) approved intravenous tissue plasminogen activator (tPA) as the first treatment for acute ischemic stroke in June 1996. Since then, stroke has been in the forefront of discussion not only because of this new treatment but also because it is a major and growing health problem in the United States.1 Stroke is a medical emergency that requires rapid initial evaluation and management to decrease its impact on patients and on society.2 Other therapies are being developed that may also require rapid emergency department evaluation and treatment.3
The National Institute of Neurologic Disorders and Stroke (NINDS) defines the term “stroke” as a sudden loss of brain function resulting from an interference with the blood supply to the brain. It limits stroke to an acute vascular phenomenon that includes both ischemic strokes and hemorrhagic strokes. Acute ischemic stroke makes up the majority (85%) of the annual 600,000 strokes in the United States, with a mortality rate of 20% to 50%, making it the third leading cause of death. Disability is the major sequela of stroke with 4.4 million survivors, 70% of whom do not return to gainful employment even 7 years after the stroke. Direct and indirect costs for stroke care in the United States exceed $51 billion per year.1
This article reviews the pathophysiology of acute ischemic stroke, its diagnosis, special issues in acute supportive care, acute primary therapy, and future directions.
Section snippets
Pathophysiology of acute ischemic stroke
Acute vascular occlusion is the central event in acute ischemic stroke precipitating the primary injury by limiting the flow of oxygen and glucose to a region of the brain. The occlusion is rarely complete. The residual cerebral blood flow (CBF) depends on the degree of obstruction and the availability of collateral flow. Because the brain does not store energy, it relies on a continuous supply of nutrients to meet its metabolic demands. Ultimately, the amount of injury is proportional to the
Clinical trials
Thrombolysis for acute ischemic stroke is a strategy that dates back to the 1950s. The first modern randomized trials, which involved intravenous streptokinase, failed. The Multicenter Acute Stroke Trial of Europe (MAST-E),11 the Multicenter Acute Stroke of Italy (MAST-I),12 and the Australian Streptokinase Trial (ASK)13 were stopped early because of increased early mortality and high intracerebral hemorrhage (ICH) rates. They used 1.5 million units of streptokinase over 1 hour started within 6
Diagnosis
Acute ischemic stroke occurs at a median age of 65 years, just at the beginning of the retirement years. It is characterized by a sudden onset of focal neurologic deficit, which is generally maximal at the time of onset, but can wax and wane over the initial few hours. Approximately 5% of patients with acute ischemic stroke present with a seizure, and up to 30% have a headache.31 Those at greatest risk often have risk factors similar to those for coronary artery disease, or a history of
Clinical experience
Clinical experience (phase 4 studies or postmarketing surveillance data) in treating acute stroke patients provides insight into the feasibility, safety, and efficacy of applying this therapy to daily practice.
The Standard Treatment with Alteplase to Reverse Stroke (STARS) study is the largest prospective report of consecutively treated patients.72 STARS reported 3.3% of 389 patients had a symptomatic ICH, with 35% having minimal or no disability, and 43% being independent at 30 days. Together
Future challenges
Despite recent advances, most stroke patients do not currently meet treatment inclusion criteria, mainly because of time of presentation. This provides 2 main arenas for future work regarding acute thrombolytic treatment of stroke. One is to find ways to better educate the public about the signs and symptoms of stroke and the need for rapid access to health care using the 911 system. Previous studies have shown that public education can have a dramatic effect on decreasing the time from symptom
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Cited by (41)
Analysis of the demographic characteristics and clinical profile of acute ischemic strokes admitted to the emergency centre in the Somalia population
2022, African Journal of Emergency MedicineCitation Excerpt :There was no significant difference in mortality rates between rtPA therapy administered ischemic stroke patients and not administered ones, too (10.6% vs 13.6%, P = 0.714). In the literature, it has been reported that 80-85% of stroke cases are ischemic and 15-20% are haemorrhagic [3]. In the INTERSTROKE study, this rate was found to be 78% [10].
Temporal sustainability of guideline based door-to-needle times for intravenous thrombolysis for acute ischemic stroke
2020, Journal of Clinical NeuroscienceCitation Excerpt :Organized changes had to be brought in hospital systems and education of stakeholders regarding the steps involved in IVT helped to reduce the DTN < 60 min worldwide. This involved pre-arrival notification to hospital, development of protocol for patient flow and management, single call activation of the hospital based stakeholders in acute care, emptying the CT gantry, rapid access to the Alteplase in emergency department, and synchronized teamwork development between physician, nurses, pharmacist, technologist of emergency, radiology and neurology departments [2–4]. Yet, there are unique challenges for implementation of the targets times for IVT in each country, each city and even to different hospitals in same city.
Imaging the Head and Brain
2011, Diagnostic Imaging for the Emergency PhysicianImplementation of evidence into practice: Development of a tool to improve emergency nursing care of acute stroke
2009, Australasian Emergency Nursing Journal
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Editor’s Note:This article continues a series of special contributions addressing state-of-the-art techniques, topics, or concepts. State-of-the-art articles will be featured in Annals on a regular basis in the next several volumes.
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Address for reprints: Christopher Lewandowski, MD, Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI 48202;,313-916-1553, fax 313-916-7437;,E-mail [email protected].