Management of Acute Ischaemic Stroke: Recommended Practice Guidelines as a Component of Disease Management
Soren Paaske Johnsen
Steen Elkjaer Husted
Stroke is a leading cause of death and disability and continues to have a great public health impact worldwide. Management of patients with acute ischaemic stroke (IS) has been, until recently, primarily supportive care. A better understanding of the mechanisms of stroke has stimulated a far more aggressive and active treatment strategy, and stroke is now considered a state of medical emergency. Evidence-based protocols for the management of patients with stroke should be implemented in all hospital departments involved in the diagnosis and treatment of such individuals. These protocols should include assessment, investigation, immediate treatment and rehabilitation, as well as secondary prevention and risk factor management strategies. Specialised stroke units are well documented initiatives for optimising the management of patients with stroke and are central to the future of acute stroke management. Establishment of stroke units should receive top priority in strategic planning within the area of stroke management. Immediate and precise evaluation of patients with assumed stroke, including a computerised tomography scan of the brain followed by close monitoring, are essential for preventing medical and neurological complications and for achieving the optimal outcome. Primary treatment of acute IS with thrombolysis is a therapy with substantial risks, but at present is essentially the only available therapy for reversing or reducing effects of acute IS. Antiplatelet therapy with aspirin (acetylsalicylic acid) in the acute phase of IS also has a small but significant effect. Anticoagulant therapy with heparin has not yet proven any net long term benefit in the treatment of acute IS. Likewise, there are currently no convincing data on the efficacy of neuroprotective drugs in a clinical setting. Every patient should have disability needs assessed as soon as possible and a well conceived rehabilitation plan should be made based on the patient's own goals. To reduce the incidence of a subsequent stroke, secondary prevention is essential. Prevention should primarily focus on detection and management of risk factors for stroke, which in many cases influence both the risk of ischaemic and haemorrhagic stroke. These risk factors include hypertension, atrial fibrillation, smoking, diabetes mellitus, alcohol abuse and hyperlipidaemia. In patients with IS, secondary prevention also includes antiplatelet therapy with aspirin and dipyridamole or clopidogrel and the possibility of carotid endarterectomy.
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