The intensive care management of acute ischemic stroke: an overview

Purpose: Acute ischemic stroke (AIS) is a leading cause of morbidity and mortality worldwide. In part due to the availability of more aggressive treatments, increasing numbers of patients with AIS are being admitted to the intensive care unit (ICU). Despite the availability of consensus guidance for the general management of AIS, there is little evidence to support its ICU management. The purpose of this article is to provide a contemporary perspective, and our recommendations, on the ICU management of AIS. Methods: We reviewed the current general AIS guidelines provided by the European Stroke Organisation, the American Stroke Association, and the UK National Institute for Health and Care Excellence, as well as the wider literature, for the data most relevant to the ICU management of AIS. Results: There are four interventions in AIS supported by class I evidence: care on a stroke unit, intravenous tissue plasminogen activator within 4.5 h of stroke onset, aspirin within 48 h of stroke onset, and decompressive craniectomy for supratentorial malignant hemispheric cerebral infarction. However, robust evidence for specific AIS management principles in the ICU setting is weak. Management principles currently focus on airway and ventilation management, hemodynamic and fluid optimization, fever and glycemic control, management of anticoagulation, antiplatelet and thromboprophylaxis therapy, control of seizures and surgical interventions for malignant middle cerebral artery and cerebellar infarctions. Conclusions: We have provided our recommendations for the principles of ICU management of AIS, based on the best available current evidence. Encouragement of large-scale recruitment of patients with AIS into clinical trials should aid the development of robust evidence for the benefit of different interventions in the ICU on outcome.