OPTIMIZING INTENSIVE-CARE IN STROKE - A EUROPEAN PERSPECTIVE

The concept of critical care in stroke is a controversial issue. The q uestion of whether full-scale critical care management of stroke impro ves patient outcome is still open and probably depends on the definiti on adopted for critical care. At a second meeting of the European Ad H oc Consensus Group, the following recommendations for optimal critical care management of stroke patients were made. Emergency stroke Care: Public and professional education programmes and an active policy shou ld be implemented to reduce the time from stroke symptom onset to init iation of therapy, in order to optimize care for all patients and allo w selection of a maximum number of patients eligible for specific acut e therapy. The prehospital care services should be made full partners in acute stroke care. As in any other medical emergency, urgent evalua tion is paramount; evaluation by the family physician could result in unnecessary delays. It is essential that a stroke patient be urgently referred by the first examining physician to the hospital best equippe d to provide the most appropriate acute stroke care. Certain subgroups of patients, including those with large hemispheric infarctions, basi lar or vertebral artery occlusion, coma, lower cranial nerve palsy, or systemic complications, e.g. aspiration or concomitant myocardial inf arction, may benefit from intensive care if they are identified rapidl y. Multihospital networks following standard protocols may enlarge the catchment area for stroke units and ensure consistency and continuity of stroke care. Rapid response systems should be developed in individ ual hospitals to shorten in-hospital treatment delays. Diagnostic dela ys should be avoided by ensuring that the necessary personnel and equi pment are available at all times. A neurologist in attendance or on ca ll should be an integral member of any emergency department that admit s acute stroke patients. Intensive Stroke Care: Organized stroke care can reduce mortality and improve functional outcome in acute stroke pa tients. New techniques for treating stroke subtypes with a poor progno sis require intensive care unit (ICU) facilities and can reduce mortal ity. The essential elements of stroke intensive care consist of 24-hou r availability of third- or fourth-generation computed tomography scan ning, Doppler ultrasonography, a neurologist, a neurosurgeon, a neuror adiologist, monitoring (including invasive monitoring) and laboratory services, and optional ventilation capacity. A written protocol, suppo rted by explicit checklists, is necessary to ensure that patient care is standardized. The use of such a protocol can significantly improve outcome and reduce the incidence of complications, the length of hospi tal stay, and costs. The issues that must be addressed in a protocol f or acute stroke care include suppert of vital functions, detailed diag nostic studies, prevention of deterioration and complications, use of specific acute therapies for appropriate patients, risk factor correct ion, early and late rehabilitation, and secondary prevention. Specific Problems of Stroke Intensive Care: All patients with moderate to seve re acute stroke should be monitored carefully with respect to general and cerebral functions. EGG, oxygen saturation, blood pressure and tem perature should ideally be monitored continuously during the first 24 h. Other functions, including blood glucose levels, should be monitore d intermittently but frequently. Stroke patients considered at risk of cardiac complications and possible cardiac arrest should be cardiac-m onitored preferably for 2-3 days. Routine intracranial pressure (ICP) monitoring should not be performed.Elevation of the head and upper bod y, combined with osmotherapy and mild hyperventilation if indicated, i s recommended as basic treatment for oedema and mass effect in acute i schaemic stroke. Hypertension should not be routinely treated in the a cute phase of stroke. Antihypertensive agents may be used with caution , however, in patients with markedly elevated blood pressure at 2 cons ecutive measurements [systolic blood pressure > 220 mm Hg, or mean art erial blood pressure (MABP) > 140 mm Hg]. As a general guide, MABP sho uld be lowered by decrements no larger than 15 mm Hg. Antihypertensive agents should be chosen appropriately to avoid increases in cerebrova scular blood volume or ICP. An antipyretic and/or an antibiotic should be given immediately for raised temperature, possibly with a cooling blanket, and subcutaneous or intravenous insulin should be used for ma rkedly elevated blood glucose levels. Prophylaxis against deep vein th rombosis and pulmonary embolism is indicated in all acute stroke patie nts, but anticoagulation should be avoided in those with large intracr anial haemorrhage and in selected neurosurgical patients. Physiotherap y as well as speech and occupational therapy should be started as earl y as possible. The Need for Neurological Intensive Care: Neurological ICUs can improve the survival and outcome of those acute stroke patien ts who require intensive care. Aggressive approaches to acute stroke t herapy, e.g. hypervolaemic-hypertensive therapy, ventricular drainage, decompressive surgery, or experimental use of thrombolytic agents, re quire management in a specialized neurological ICU. About 10% of hospi talized acute stroke patients require ICU care, which is best provided by staff with specialized training in neurological care. The minimum requirements for optimal neurological intensive care are a 24-hour neu rologist or neurointensivist shift sei-vice, 1 nurse per patient in at tendance at all times, and facilities for advanced haemodynamic, neuro logical and ICP monitoring.