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Challenges in the Anesthetic and Intensive Care Management of Acute Ischemic Stroke

Kirkman, Matthew A. MBBS, MRCS, MEd; Lambden, Simon MBBS; Smith, Martin MBBS, FRCA, FFICM

Journal of Neurosurgical Anesthesiology: July 2016 - Volume 28 - Issue 3 - p 214–232
doi: 10.1097/ANA.0000000000000225
Review Articles

Acute ischemic stroke (AIS) is a devastating condition with high morbidity and mortality. In the past 2 decades, the treatment of AIS has been revolutionized by the introduction of several interventions supported by class I evidence—care on a stroke unit, intravenous tissue plasminogen activator within 4.5 hours of stroke onset, aspirin commenced within 48 hours of stroke onset, and decompressive craniectomy for supratentorial malignant hemispheric cerebral infarction. There is new class I evidence also demonstrating benefits of endovascular therapy on functional outcomes in those with anterior circulation stroke. In addition, the importance of the careful management of key systemic physiological variables, including oxygenation, blood pressure, temperature, and serum glucose, has been appreciated. In line with this, the role of anesthesiologists and intensivists in managing AIS has increased. This review highlights the main challenges in the endovascular and intensive care management of AIS that, in part, result from the paucity of research focused on these areas. It also provides guidelines for the management of AIS based upon current evidence, and identifies areas for further research.

*Neurocritical Care Unit, The National Hospital for Neurology and Neurosurgery, University College London Hospitals

NIHR University College London Hospitals Biomedical Research Centre, London, UK

M.A.K. is a UK National Institute for Health Research (NIHR) Academic Clinical Fellow in Neurosurgery. M.S. is partly funded by the Department of Health’s NIHR funding scheme via the UCLH/UCL Biomedical Research Centre.

M.A.K. is a member of the Editorial Board of the Journal of Neurosurgical Anesthesiology. M.S. is Reviews Section Editor of the Journal of Neurosurgical Anesthesiology. The other author has no conflicts of interest to disclose.

Reprints: Matthew A. Kirkman, MBBS, MRCS, MEd, Neurocritical Care Unit, The National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK (e-mail:

Received April 7, 2015

Accepted August 4, 2015

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