Management of Stroke in a Non-neurointensive Care Unit



Stroke is a leading cause of acquired adult disability and is defined as a clinical syndrome of rapidly developing clinical signs of focal (or global in case of coma) disturbance of cerebral function lasting more than 24 hours. If a patient has a new neurological deficit for less than 4.5 hours they may be a candidate for thrombolysis.

Assessment of a patient with stroke involves clinical history, examination, blood investigations and CT/MRI imaging. Points to note on history include establishing if there is any history of trauma which may point to a haemorrhagic stroke or dissection as well as an assessment of cardiovascular risk factors. Clinical examination is useful in attempting to isolate where a particular brain injury may have occurred and there are a number of useful clinical signs to assist this evaluation. The National Institute of Health Stroke Scale (NIHSS) is a helpful clinical scale used to establish clinical stroke severity. Radiological investigation may be useful in confirming the clinical suspicion regarding stroke location and differentiating haemorrhagic from non-haemorrhagic (ischaemic) stroke.

It may be appropriate to admit a stroke patient to ICU for a number of reasons including the need for mechanical ventilation, haemodynamic monitoring/management, associated organ support(s), post-operative monitoring (e.g. post craniectomy) or, in the case of a catastrophic brain injury, the management of a potential organ donor.

Specific therapies for ischaemic stroke may include thrombolysis, antiplatelet agents and statin therapies as well as supportive therapies such as pneumatic compression devices (thromboprophylaxis), stress ulcer prophylaxis (for ventilated patients) and modest glycaemic control.

Haemorrhagic stroke (including haemorrhagic transformation of an ischaemic stroke as well as subarachnoid haemorrhage) requires urgent neurosurgical referral. In patients with posterior fossa ischaemic strokes and large anterior circulation ischaemic strokes, there should be a low threshold for neurosurgical referral for decompression surgery.

The perioperative management of the carotid endarterectomy patient requires careful haemodynamic monitoring as well as high clinical suspicion for new neurology which may require surgical re-intervention.

A number of stroke ‘mimics’ exist and should be considered when assessing a patient with a possible stroke. Prognostication in stroke can be difficult and requires experienced and multi-disciplinary inputs. Neurorehabilitation is key to returning patients to their functional baseline. Where appropriate, end-of-life care should be focused on symptom management. In the case of a catastrophic brain injury, management for potential organ donation should be considered if appropriate.


Stroke Intensive Care Unit Disabilities Long-term outcome Management 


  1. 1.
    Feigin VL, Lawes CMM, Bennett DA, Barker-Collo SL, Parag V (2009) Worldwide stroke incidence and early case fatality reported in 56 population-based studies: a systematic review. Lancet Neurol 8:355–369CrossRefPubMedGoogle Scholar
  2. 2.
    Johnston SC, Mendis S, Mathers CD (2009) Global variation in stroke burden and mortality: estimates from monitoring, surveillance, and modelling. Lancet Neurol 8:345–354CrossRefPubMedGoogle Scholar
  3. 3.
    Kirkman MA, Citerio G, Smith M (2014) The intensive care management of acute ischemic stroke: an overview. Intensive Care Med 40(5):640–653CrossRefPubMedGoogle Scholar
  4. 4.
    Hatano S (1976) Experience from a multicentre stroke register: a preliminary report. Bull World Health Organ 54:541–553PubMedPubMedCentralGoogle Scholar
  5. 5.
    Searls DE, Pazdera L, Korbel E, Vysata O, Caplan LR (2012) Symptoms and signs of posterior circulation ischemia in the New England Medical Center posterior circulation registry. Arch Neurol 69:346CrossRefPubMedGoogle Scholar
  6. 6.
    Merwick A, Werring DJ (2014) Posterior circulation ischaemic stroke. BMJ 348:g3175CrossRefPubMedGoogle Scholar
  7. 7.
    Mattle HP, Arnold M, Lindsberg PJ, Schonewille WJ, Schroth G (2011) Basilar artery occlusion. Lancet Neurol 10:1002–1014CrossRefPubMedGoogle Scholar
  8. 8.
    Caplan L (2000) Posterior circulation ischemia: then, now, and tomorrow. The Thomas Willis lecture-2000. Stroke 31:2011–2023CrossRefPubMedGoogle Scholar
  9. 9.
    Brott T, Adams HP Jr, Olinger CP (1989) Measurement of acute cerebral infarction: a clinical examination scale. Stroke 20:864–870CrossRefPubMedGoogle Scholar
  10. 10.
    Stroke Unit Trialists’ Collaboration (2007) Organised inpatient (stroke unit) care for stroke. Cochrane Database Syst Rev. 2013 Sep 11;9:CD00019. doi:  10.1002/14651858.CD000197.pub3
  11. 11.
    Langhorne P, Dennis MS (1998) Stroke units, an evidence based approach. BMJ Publishing group, LondonGoogle Scholar
  12. 12.
    Adams HP, del Zoppo G, Alberts MJ et al (2007) Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association. Stroke 38:1655–1711CrossRefPubMedGoogle Scholar
  13. 13.
    Teasdale G, Jennett B (1974) Assessment of coma and impaired consciousness. A practical scale. Lancet 13(2):81–84CrossRefGoogle Scholar
  14. 14.
    Saposnik G, Guzik AK, Reeves M, Ovbiagele B, Johnston SC (2013) Stroke prognostication using age and NIH stroke scale: SPAN-100. Neurology 80(1):21–28CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Hacke W, Kaste M, Bluhmki E, Brozman M, Dávalos A, Guidetti D, Larrue V, Lees KR, Medeghri Z, Machnig T, Schneider D, von Kummer R, Wahlgren N, Toni D, ECASS Investigators (2008) Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 359(13):1317–1329. doi: 10.1056/NEJMoa0804656 CrossRefPubMedGoogle Scholar
  16. 16.
    Tameem A, Krovvidi H (2013) Cerebral physiology. Contin Educ Anaesth Crit Care Pain 13(4):113–118CrossRefGoogle Scholar
  17. 17.
    Aaslid R, Lindegaard K-F, Sorteberg W, Nornes H (1989) Cerebral autoregulation dynamics in humans. Stroke 20:45–52CrossRefPubMedGoogle Scholar
  18. 18.
    Merwick A, Ginsberg L, Simister S (2014) Lying in wait – the creeping vasculopathy. Stroke following herpes zoster ophthalmicus. Cerebrovasc Dis 37(Supplement 1):408Google Scholar
  19. 19.
    Sylaja PN, Coutts SB, Krol A, Hill MD, Demchuk AM, VISION Study Group (2008) When to expect negative diffusion-weighted images in stroke and transient ischemic attack. Stroke 39:1898–1900CrossRefPubMedGoogle Scholar
  20. 20.
    Oppenheim C, Stanescu R, Dormont D, Crozier S, Marro B, Samson Y et al (2000) False-negative diffusion-weighted MR findings in acute ischemic stroke. AJNR Am J Neuroradiol 21:1434–1440PubMedGoogle Scholar
  21. 21.
    Cotter PE, Martin PJ, Ring L, Warburton EA, Belham M, Pugh PJ (2013) Incidence of atrial fibrillation detected by implantable loop recorders in unexplained stroke. Neurology 80(17):1546–1550CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Ferro JM, Massaro AR, Mas JL (2010) Aetiological diagnosis of ischaemic stroke in young adults. Lancet Neurol 9(11):1085–1096CrossRefPubMedGoogle Scholar
  23. 23.
    Hankey GJ, Eikelboom JW, van Bockxmeer FM, Lofthouse E, Staples N, Baker RI (2001) Inherited thrombophilia in ischemic stroke and its pathogenic subtypes. Stroke 32(8):1793–1799CrossRefPubMedGoogle Scholar
  24. 24.
    The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group (1995) Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 333:1581–1587Google Scholar
  25. 25.
    Whiteley WN, Thompson D, Murray G, Cohen G, Lindley RI, Wardlaw J, Sandercock P, IST-3 Collaborative Group (2014) Effect of alteplase within 6 hours of acute ischemic stroke on all-cause mortality (third international stroke trial). Stroke 45(12):3612–3617CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Mishra NK, Ahmed N, Andersen G, Egido JA, Lindsberg PJ, Ringleb PA, Wahlgren NG, VISTA collaborators; SITS collaborators, Lees KR (2010) Thrombolysis in very elderly people: controlled comparison of SITS International Stroke Thrombolysis Registry and Virtual International Stroke Trials Archive. BMJ 341:c6046CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Brown SG, Macdonald SP, Hankey GJ (2013) Do risks outweigh benefits in thrombolysis for stroke? BMJ 347:f5215CrossRefPubMedGoogle Scholar
  28. 28.
    Lancet Neurol (2015) Endovascular stent thrombectomy: the new standard of care for large vessel ischaemic stroke 14(8):846–854. doi:  10.1016/S1474-4422(15)00140-4 Google Scholar
  29. 29.
    The European Stroke Organization (ESO) Executive Committee and the ESO Writing Committee (2008) Guidelines for Management of Ischaemic Stroke and Transient Ischaemic Attack 2008. Cerebrovasc Dis 25:457–507CrossRefGoogle Scholar
  30. 30.
    Amarenco P, Benavente O, Goldstein LB, Callahan A 3rd, Sillesen H, Hennerici MG et al (2009) Results of the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) trial by stroke subtypes. Stroke 40(4):1405–1409CrossRefPubMedGoogle Scholar
  31. 31.
    Amarenco P, Goldstein LB, Sillesen H, Benavente O, Zweifler RM, Callahan A 3rd et al (2010) Coronary heart disease risk in patients with stroke or transient ischemic attack and no known coronary heart disease: findings from the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) trial. Stroke 41(3):426–430CrossRefPubMedGoogle Scholar
  32. 32.
    Merwick Á, Albers GW, Arsava EM, Ay H, Calvet D, Coutts SB et al (2013) Reduction in early stroke risk in carotid stenosis with transient ischemic attack associated with statin treatment. Stroke 44:2814–2820CrossRefPubMedGoogle Scholar
  33. 33.
    Ní Chróinín D, Callaly EL, Duggan J, Merwick Á, Hannon N, Sheehan O, Marnane M, Horgan G, Williams EB, Harris D, Kyne L, McCormack PME, Moroney J, Grant T, Williams D, Daly L, Kelly PJ (2011) Association between acute statin therapy, survival, and improved functional outcome after ischaemic stroke – the North Dublin Population Stroke Study. Stroke 42(4):1021–1029CrossRefPubMedGoogle Scholar
  34. 34.
    McKinney JS, Kostis WJ (2012) Statin therapy and the risk of intracerebral hemorrhage: a meta-analysis of 31 randomized controlled trials. Stroke 43(8):2149–2156CrossRefPubMedGoogle Scholar
  35. 35.
    Wang Y, Wang Y, Zhao X, Liu L, Wang D, Wang C et al (2013) Clopidogrel with aspirin in acute minor stroke or transient ischemic attack. N Engl J Med 369:11–19CrossRefPubMedGoogle Scholar
  36. 36.
    CLOTS Trials Collaboration, Dennis M, Sandercock PA, Reid J, Graham C, Murray G, Venables G, Rudd A, Bowler G. et al (2009) Effectiveness of thigh-length graduated compression stockings to reduce the risk of deep vein thrombosis after stroke (Trial 1): a multicentre, randomised controlled trial. Lancet 373(9679):1958–1965. doi:  10.1016/S0140-6736(09)60941-7
  37. 37.
    CLOTS (Clots in Legs Or sTockings after Stroke) Trials Collaboration, Dennis M, Sandercock P, Reid J, Graham C, Forbes J, Murray G (2013) Effectiveness of intermittent pneumatic compression in reduction of risk of deep vein thrombosis in patients who have had a stroke (CLOTS 3): a multicentre randomised controlled trial. Lancet 382(9891):516–524CrossRefGoogle Scholar
  38. 38.
    Gubitz G, Sandercock P, Counsell C (2008) Anticoagulants for acute ischemic stroke. Cochrane Database Syst Rev (4):CD000024Google Scholar
  39. 39.
    Oppenheimer S (2006) Cerebrogenic cardiac arrhythmias: cortical lateralization and clinical significance. Clin Auton Res 16(1):6–11CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Finfer S, Chittock DR, Su SY et al (2009) Intensive versus conventional glucose control in critically ill patients. N Engl J Med 360(13):1283–1297CrossRefPubMedGoogle Scholar
  41. 41.
    Lovelock CE, Anslow P, Molyneux AJ, Byrne JV, Kuker W, Pretorius PM, Coull A, Rothwell PM (2009) Substantial observer variability in the differentiation between primary intracerebral hemorrhage and hemorrhagic transformation of infarction on CT brain imaging. Stroke 40(12):3763–3767CrossRefPubMedGoogle Scholar
  42. 42.
    Charidimou A, Gang Q, Werring DJ (2012) Sporadic cerebral amyloid angiopathy revisited: recent insights into pathophysiology and clinical spectrum. J Neurol Neurosurg Psychiatry 83(2):124–137CrossRefPubMedGoogle Scholar
  43. 43.
    Ducros A, Fiedler U, Porcher R, Boukobza M, Stapf C, Bousser MG (2010) Hemorrhagic manifestations of reversible cerebral vasoconstriction syndrome: frequency, features, and risk factors. Stroke 41(11):2505–2511CrossRefPubMedGoogle Scholar
  44. 44.
    Pisters R, Lane DA, Nieuwlaat R, de Vos CB, Crijns HJGM, Lip GYH (2010) A novel user-friendly score (HAS-BLED) to assess one year risk of major bleeding in atrial fibrillation patients: the Euro Heart Survey. Chest 138:1093–1100CrossRefPubMedGoogle Scholar
  45. 45.
    Shaw CM, Alvord EC Jr, Berry RG (1959) Swelling of the brain following ischemic infarction with arterial occlusion. Arch Neurol 1:161–177CrossRefPubMedGoogle Scholar
  46. 46.
    Vahedi K, Hofmeijer J, Jüttler E, Vicaut E, George B, Algra A, Amelink GJ, Schmiedeck P, Schwab S, Rothwell PM, Bousser MG, van der Worp HB, Hacke W (2007) Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. Lancet Neurol 6:215–222CrossRefPubMedGoogle Scholar
  47. 47.
    National Collaborating Centre for Chronic Conditions (2008) Stroke: national clinical guideline for diagnosis and initial management of acute stroke and transient ischaemic attack (TIA), Royal College of Physicians, London. [Cited 2015 Jan 3]. Available from
  48. 48.
    Alhazzani W, Alenezi F, Jaeschke RZ et al (2013) Proton pump inhibitors versus histamine 2 receptor antagonists for stress ulcer prophylaxis in critically ill patients: a systematic review and meta-analysis. Crit Care Med 41(3):693–705CrossRefPubMedGoogle Scholar
  49. 49.
    Krag M, Perner A, Wetterslev J, Wise MP, Hylander Møller M (2014) Stress ulcer prophylaxis versus placebo or no prophylaxis in critically ill patients. A systematic review of randomised clinical trials with meta-analysis and trial sequential analysis. Intensive Care Med 40(1):11–22CrossRefPubMedGoogle Scholar
  50. 50.
    Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL et al (2011) 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. Stroke 42(8):e420–e463CrossRefPubMedGoogle Scholar
  51. 51.
    Lewis SC, Warlow CP, Bodenham AR et al (2008) General anaesthesia versus local anaesthesia for carotid surgery (GALA): a multicentre, randomised controlled trial. Lancet 372(9656):2132–2142CrossRefPubMedGoogle Scholar
  52. 52.
    Vaniyapong T, Chongruksut W, Rerkasem K (2013) Local versus general anaesthesia for carotid endarterectomy. Cochrane Database Syst Rev 2013 Dec 19;12Google Scholar
  53. 53.
    Ladak N, Thompson J (2012) General or local anaesthesia for carotid endarterectomy? Contin Educ Anaesth Crit Care Pain 12(2):92–96Google Scholar
  54. 54.
    van der Worp HB, Macleod MR, Bath PM, Demotes J, Durand-Zaleski I, Gebhardt B, Gluud C, Kollmar R, Krieger DW, Lees KR, Molina C, Montaner J, Roine RO, Petersson J, Staykov D, Szabo I, Wardlaw JM, Schwab S (2014) EuroHYP-1 investigators. EuroHYP-1: European multicenter, randomized, phase III clinical trial of therapeutic hypothermia plus best medical treatment vs. best medical treatment alone for acute ischemic stroke. Int J Stroke 9(5):642–645. doi: 10.1111/ijs.12294, Epub 2014 May 15CrossRefPubMedGoogle Scholar
  55. 55.
    Faigle R, Sharrief A, Marsh EB, Llinas RH, Urrutia VC (2014) Predictors of critical care needs after IV thrombolysis for acute ischemic stroke. PLoS One 9(2):e88652. doi: 10.1371/journal.pone.0088652 CrossRefPubMedPubMedCentralGoogle Scholar
  56. 56.
    Marnane M, Ni Chroinin D, Callaly E, Sheehan O, Merwick A, Hannon N, Horgan G, Kyne L, Moroney J, McCormack PME, Dolan E, Duggan J, Williams D, Crispino-O’Connell G, Kelly PJ (2011) Stroke recurrence within the time-window recommended for carotid endarterectomy. Neurology 77:738–743CrossRefPubMedGoogle Scholar
  57. 57.
    Huttner HB, Schellinger PD, Hartmann M, Köhrmann M, Juettler E, Wikner J et al (2006) Hematoma growth and outcome in treated neurocritical care patients with intracerebral hemorrhage related to oral anticoagulant therapy: comparison of acute treatment strategies using vitamin K, fresh frozen plasma, and prothrombin complex concentrates. Stroke 37:1465–1470CrossRefPubMedGoogle Scholar
  58. 58.
    Rosand J, Hylek EM, O’Donnell HC, Greenberg SM (2000) Warfarin-associated hemorrhage and cerebral amyloid angiopathy: a genetic and pathologic study. Neurology 55(7):947–951. doi:  10.1212/WNL.55.7.947 Google Scholar
  59. 59.
    Brewer L, Horgan F, Hickey A, Williams D (2013) Stroke rehabilitation: recent advances and future therapies. QJM 106(1):11–25CrossRefPubMedGoogle Scholar
  60. 60.
    Bauby J-D (1997) The diving bell and the butterfly: a memoir of life in death. Random House, Inc, New YorkGoogle Scholar
  61. 61.
    Aliaga M, Forel JM, De Bourmont S et al (2015) Diagnostic yield and safety of CT scans in ICU. Intensive Care Med 41(3):436–443CrossRefPubMedGoogle Scholar
  62. 62.
    Australia & New Zealand Intensive Care Society Statement on Brain Death Determination. Available at Accessed Feb 2015
  63. 63.
    McClave SA, Martindale RG, Vanek VW et al (2009) Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). J Parenter Enteral Nutr 33(3):277–316Google Scholar

Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  1. 1.Neurology DepartmentChelsea and Westminster Hospital NHS Foundation TrustLondonUK
  2. 2.Consultant in Adult Critical Care MedicineRoyal Brompton Hospital, Royal Brompton and Harefield NHS Foundation TrustLondonUK

Personalised recommendations