Neuro-Intensive Care Units and Management of Acute Stroke Patients: Benefits and Limitations

  • W. Hacke
  • M. Spranger
  • Th. Steiner


Reduction of mortality and improvement of outcome are the major goals of new therapeutic strategies in acute ischemic stroke. Some subtypes of acute ischemic stroke such as intracranial internal carotid artery (ICA) occlusion, proximal middle cerebral artery (MCA) occlusion, basilar thrombosis, and space-occupying infarcts carry a high mortality of more than 80% in selected cohorts [1,2]. Aggressive approaches to acute ischemic stroke such as thrombolytic therapy, hypervolemic-hypertensive therapy, or decompressive surgery require management in specialized neurological critical care units: computed tomographic (CT) scans, magnetic resonance imaging (MRI), Doppler ultrasound, and electrophysiological and intracranial pressure monitoring device are essential and should be readily available. A 24-h-shift service by neurologists and close collaboration with neurosurgery and neuroradiology are necessary. Another challenge of critical care in acute ischemic stroke is reduction of mortality from cardiovascular complications and nosocomial infections. Mortality within the first 4 weeks after an ischemic stroke is greatly influenced by coexistent cardiovascular disease [3,4]. In total, about 8%–10% of acute stroke victims may require critical care treatment.


Mean Arterial Pressure Acute Stroke Acute Ischemic Stroke Thrombolytic Therapy Cerebral Perfusion Pressure 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


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  1. 1.
    Hacke W, Zeumer H, Ferbert A, Brückmann H, del Zoppo GJ (1988) Intrarterial firbrinolytic therapy improves outcome in patients with acute vertebrobasilar occlusive disease. Stroke 19: 1216–1222PubMedCrossRefGoogle Scholar
  2. 2.
    Rieke K, Krieger D, Adams HP, Aschoff A, Meyding-Lamade U, Hacke W (1993) Therapeutic strategies in space-occupying cerebellar infarction based on clinical, neuro-radiological, and neurophysiological data. Cerebrovasc Dis 3: 45–55CrossRefGoogle Scholar
  3. 3.
    Chambers BR, Norris JW, Shurvell BL, Hachinski VC (1987) Prognosis of acute stroke. Neurology 37: 221–225PubMedGoogle Scholar
  4. 4.
    del Zoppo GJ, Pessin MS, Mori E, Hacke W (1991) Thrombolytic intervention in acute thrombotic and embolic stroke. Semin Neurol 11: 368–384PubMedCrossRefGoogle Scholar
  5. 5.
    Britton M, Carlsson A, De Faire U (1986) Blood pressure cause with acute stroke and matched controls. Stroke 17: 861–864PubMedCrossRefGoogle Scholar
  6. 6.
    Powers WJ (1993) Acute hypertension after stroke: the scientific basis for treatment decisions. Neurology 43: 461–467PubMedGoogle Scholar
  7. 7.
    Yatsu FM, Zivin J (1985) Hypertension in acute ischemic strokes. Not to treat. Arch Neurol 42: 999–1000PubMedCrossRefGoogle Scholar
  8. 8.
    Hacke W, Krieger D, Hirschberg M (1991) General principles in the treatment of acute ischemic stroke. Cerebrovasc Dis 1: 93–99CrossRefGoogle Scholar
  9. 9.
    Strandgaard S, Paulsen OB (1992) Regulation of cerebral blood flow in health and disease. J Cardiovasc Pharmacol 19 (suppl 6): 89–93CrossRefGoogle Scholar
  10. 10.
    Hayashi M, Kobayashi H, Kawano H, Handa Y, Hirose S (1987) Treatment of systemic hypertension and intracranial hypertension in cases of brain hemorrhage. Stroke 19: 314–321CrossRefGoogle Scholar
  11. 11.
    Brott T, MacCarthey EP (1989) Antihypertensive therapy in stroke. In: Fischer M (ed) Medical therapy of acute stroke. Dekker, New York, pp 117–143Google Scholar
  12. 12.
    Hacke W, del Zoppo GJ, Furlan AJ, von Kummer R (in press) In: Hanley D (ed) Principles and practice of neurocritical care. Williams and Wilkins, BaltimoreGoogle Scholar
  13. 13.
    Raichle ME (1983) The pathophysiology of brain ischemia. Ann Neurol 13: 2–10PubMedCrossRefGoogle Scholar
  14. 14.
    Toni D, Sacchetti ML, Argentino C, Gentile M, Cavallentti C, Frontoni M, Fieschi C (1992) Does hyperglycemia play a role on the outcome of acute ischaemic stroke patients? J Neurol 239: 382–386PubMedGoogle Scholar
  15. 15.
    Wagner KR, Kleinholz M, de Courten-Myers GM, Myers RE (1992) Hyperglycemic versus normoglycemic stroke: topography of brain metabolites, intracellular pH, and infarct size. J Cereb Blood Flow Metab 12: 213–222PubMedCrossRefGoogle Scholar
  16. 16.
    Awad IA, Carter P, Spetlzer RF, Medina M, Williams FW (1987) Clinical vasospasm after subarachnoid hemorrhage: response to hypervolemic hemodilution and arterial hypertension. Stroke 18: 365–372PubMedCrossRefGoogle Scholar
  17. 17.
    Finn S, Stephensen SA, Miller CA, Drobnich L, Hunt W (1986) Observations on the perioperative management of aneurysmal subarachnoid hemorrhage. J Neurosurg 65: 48–62PubMedCrossRefGoogle Scholar
  18. 18.
    Baker RN, Broward JA, Fang HC, Fisher CM, Groch SN, Heyman A (1962) Anticoagulant therapy in cerebral infarction. Neurology 12: 823–835PubMedGoogle Scholar
  19. 19.
    Carter AB (1961) Anticoagulant treatment in progressing stroke. BMJ 2: 70–73PubMedCrossRefGoogle Scholar
  20. 20.
    Haley EC, Kassell NF, Torner JC (1988) Failure of heparin to prevent progression in progressing ischemic infarction. Stroke 19: 10–14PubMedCrossRefGoogle Scholar
  21. 21.
    Miller VT, Hart RG (1988) Heparin anticoagulation in acute brain ischemia. Stroke 19: 403–406PubMedCrossRefGoogle Scholar
  22. 22.
    Phillips SJ (1989) An alternative view of heparin anticoagulation in acute focal brain ischemia. Stroke 20: 295–298PubMedCrossRefGoogle Scholar
  23. 23.
    Scheinberg P (1989) Heparin anticoagulation. Stroke 20: 173–174PubMedCrossRefGoogle Scholar
  24. 24.
    von Kummer R, Hacke W (1992) Safety and efficacy of intravenous tissue plasminogen activator and heparin in acute middle cerebral artery stroke. Stroke 23: 646–652CrossRefGoogle Scholar
  25. 25.
    del Zoppo GJ, Ferbert A, Otis S, Brückmann H, Hacke W, Zyroff J, Harker L, Zeumer H (1988) Local intraarterial fibrinolytic therapy in acute carotid territory stroke. A pilot study. Stroke 19: 307–313PubMedCrossRefGoogle Scholar
  26. 26.
    Mori E, Tabuchi M, Yoshida T, Yamadori A (1988) Intracarotid urokinase with thromboembolic occlusion of the middle cerebral artery. Stroke 19: 802–812PubMedCrossRefGoogle Scholar
  27. 27.
    del Zoppo GJ, Furlan A, Hacke W (1990) Treatment of acute stroke. Ann Intern Med 112: 713PubMedGoogle Scholar
  28. 28.
    Yamaguchi T, Hayakawa T, Kikuchi H (1993) Intravenous tissue plasminogen activator in acute thromboembolic stroke: a placebo-contolled double-blind trial. In: del Zoppo GJ, Mori E Hacke W (eds) Thrombolytic therapy in acute ischemic stroke, II. Springer, Berlin, pp 59–65CrossRefGoogle Scholar
  29. 29.
    Krieger D, Adams H, Rieke K, Schwarz S, Forsting M, Hacke W (1992) Prospective evaluation of the prognostic significance of evoked potentials in acute basilar occlusion. Crit Care Med 21 (8): 1169–1174CrossRefGoogle Scholar
  30. 30.
    Goetting MG, Preston G (1991) Jugular bulb catheterization does not increase intracranial pressure. Intensive Care Med 17: 195–198PubMedCrossRefGoogle Scholar
  31. 31.
    Nau R, Dreyhaupt T, Kolenda H, Prange HW (1992) Low blood-to-cerebrospinal fluid passage of sorbitol after intravenous infusion. Stroke 23: 1276–1279PubMedCrossRefGoogle Scholar
  32. 32.
    Nau R, Prins FJ, Kolenda H, Prange HW (1992) Temporary reversal of serum to cerebrospinal fluid glycerol concentration gradient after intravenous infusion of glycerol. Eur J Clin Pharmacol 42: 181–185PubMedCrossRefGoogle Scholar
  33. 33.
    Bayer AJ, Pathy MS, Newcombe R (1987) Double-blind randomised trial of intravenous glycerol in acute stroke. Lancet 1: 405–408PubMedCrossRefGoogle Scholar
  34. 34.
    Frank MS, Nahata MC, Hilty MD (1981) Glycerol: a review of its pharmacology, pharmacokinetics, adverse reactions, and clinical use. Pharmacotherapy 1: 147–160PubMedGoogle Scholar
  35. 35.
    Wolf AL, Levi L, Marmarou A, Ward JD, Muizelaar PJ, Choi S, Young H, Rigamonti D, Robinson WL (1993) Effect of THAM upon outcome in severe head insury: a randomizad prospective clinical trial. J Neurosurg 78: 54–59PubMedCrossRefGoogle Scholar
  36. 36.
    Winer JW, Rosenwasser RH, Jimenez F (1991) Electroencephalographic activity and serum and cerebrospinal fluid pentobarbital levels in determing the therapeutic endpoint during barbiturate coma. Neurosurgery 29: 739–742PubMedCrossRefGoogle Scholar
  37. 37.
    Metz S, Slogoff S (1990) Thiopental sodium by single bolus dose compared to infusion for cerebral protection during cardiopulmonary bypass. J Clin Anesth 2: 226–231PubMedCrossRefGoogle Scholar
  38. 38.
    Delashaw JB, Broaddus WC, Kassell NF, Haley EC, Penddleto GA, Vollmer DG, Maggio WW, Grady MS (1990) Treatment of right hemispheric cerebral infarction by hemicraniectomy. Stroke 21: 874–881PubMedCrossRefGoogle Scholar
  39. 39.
    Greenwood JJ (1968) Acute brain infarctions with high intracranial pressure: surgical indications. Johns Hopkins Med J 122: 254–260PubMedGoogle Scholar
  40. 40.
    Ivamoto HS, Numoto M, Donaghy R (1974) Surgical decompression for cerebral and cerebellar infarcts. Stroke 5: 365–370PubMedCrossRefGoogle Scholar
  41. 41.
    Rieke K, Krieger D, von Kummer R, Aschoff A, Hacke W (in press) Decompressive surgery in space occupying hemispheric infarction. Critical Care MedGoogle Scholar

Copyright information

© Springer-Verlag Tokyo 1995

Authors and Affiliations

  • W. Hacke
    • 1
  • M. Spranger
    • 1
  • Th. Steiner
    • 1
  1. 1.Department of NeurologyUniversity of HeidelbergHeidelbergGermany

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