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  • Print publication year: 2009
  • Online publication date: May 2010

17 - Management of acute ischemic stroke and its complications

from Section IV - Therapeutic strategies and neurorehabilitation

Summary

General management of elevated blood pressure, blood glucose and body temperature

Monitoring the blood pressure (BP), glucose levels and temperature in acute stroke patients is an often neglected matter although it may have an important impact upon the patients' outcome. In the Tel Aviv stroke register, recorded between the years 2001 and 2003, 32% of acute stroke patients in the emergency room had glucose levels higher than 150 mg/dl, higher systolic BP than 140 mmHg was found in 77% of the patients and 17% of patients had temperatures above 37°C on admission. These numbers are representative of other centers as well. This chapter will summarize the current knowledge regarding the management of the above.

Hypertensive blood pressure values in acute ischemic stroke

Several observations have demonstrated spontaneous elevation of blood pressure in the first 24–48 hrs after stroke onset with a significant spontaneous decline after a few days [1–3]. Several mechanisms may be responsible for the increased blood pressure, including stress, pain, urinary retention, Cushing effect due to increased intracranial pressure and the activation of the sympathetic, renin–angiotensin and ACTH– cortisol pathways. Despite the increased prevalence of hypertension following stroke, optimal management has not been yet established. Several arguments speak for lowering the elevated BP: risks of hemorrhagic transformation, cerebral edema, recurrence of stroke and hypertensive encephalopathy.

References
Wallace, JD, Levy, LL. Blood pressure after stroke. JAMA 1981; 13; 246(19):2177–80.
Carlberg, B, Asplund, K, Hägg, E. Factors influencing admission blood pressure levels in patients with acute stroke. Stroke 1991; 22:527–30.
Urrutia, VC, Wityk, RJ. Blood pressure management in acute stroke. Crit Care Clin 2006; 22(4):695–711.
Leonardi-Bee, J, Bath, PM, Phillips, SJ, Sandercock, PA. IST Collaborative Group. Blood pressure and clinical outcomes in the International Stroke Trial. Stroke 2002; 33:1315–20.
Vemmos, KN, Tsivgoulis, G, Spengos, K, Zakopoulos, N, Synetos, A, Manios, E, et al. U-shaped relationship between mortality and admission blood pressure in patients with acute stroke. J Intern Med 2004; 255:257–65.
Aslanyan, S, Fazekas, F, Weir, CJ, Horner, S, Lees, KR; GAIN International Steering Committee and Investigators. Effect of blood pressure during the acute period of ischemic stroke on stroke outcome: a tertiary analysis of the GAIN International Trial. Stroke 2003; 34:2420–5.
Willmot, M, Leonardi-Bee, J, Bath, PM. High blood pressure in acute stroke and subsequent outcome: a systematic review. Hypertension 2004; 43(1):18–24.
Brott, T, Lu, M, Kothari, R, Fagan, SC, Frankel, M, Grotta, JC, et al. Hypertension and its treatment in the NINDS rt-PA Stroke Trial. Stroke 1998; 29:1504–9.
Chamorro, A, Vila, N, Ascaso, C, Elices, E, Schonewille, W, Blanc, R. Blood pressure and functional recovery in acute ischemic stroke. Stroke 1998; 29:1850–3.
Carlberg, B, Asplund, K, Hägg, E. The prognostic value of admission blood pressure in patients with acute stroke. Stroke 1993; 24:1372–5.
Mattle, HP, Kappeler, L, Arnold, M, Fischer, U, Nedeltchev, K, Remonda, L, et al. Blood pressure and vessel recanalization in the first hours after ischemic stroke. Stroke 2005; 36:264–8.
Shin, HK, Nishimura, M, Jones, PB, Ay, H, Boas, DA, Moskowitz, MA, et al. Mild induced hypertension improves blood flow and oxygen metabolism in transient focal cerebral ischemia. Stroke 2008; 39:1548–55.
Rordorf, G, Koroshetz, WJ, Ezzeddine, MA, Segal, AZ, Buonanno, FS. A pilot study of drug-induced hypertension for treatment of acute stroke. Neurology 2001; 56:1210–3.
Marzan, AS, Hungerbühler, HJ, Studer, A, Baumgartner, RW, Georgiadis, D. Feasibility and safety of norepinephrine-induced arterial hypertension in acute ischemic stroke. Neurology 2004; 62:1193–5.
Hillis, AE, Ulatowski, JA, Barker, PB, Torbey, M, Ziai, W, Beauchamp, NJ, et al. A pilot randomized trial of induced blood pressure elevation: effects on function and focal perfusion in acute and subacute stroke. Cerebrovasc Dis 2003; 16:236–46.
Olsen, TS, Larsen, B, Herning, M, Skriver, EB, Lassen, NA. Blood flow and vascular reactivity in collaterally perfused brain tissue. Evidence of an ischemic penumbra in patients with acute stroke. Stroke 1983; 14:332–41.
Mistri, AK, Robinson, TG, Potter, JF. Pressor therapy in acute ischemic stroke: systematic review. Stroke 2006; 37(6):1565–71.
Schrader, J, Lüders, S, Kulschewski, A, Berger, J, Zidek, W, Treib, J, et al. Acute Candesartan Cilexetil Therapy in Stroke Survivors Study Group. The ACCESS Study: evaluation of Acute Candesartan Cilexetil Therapy in Stroke Survivors. Stroke 2003; 34:1699–703.
Potter, JF, Robinson, TG, Ford, GA, James, M, Chernova, J, Jagger, C. Controlling hypertension and hypotension immediately post-stroke (CHHIPS): a randomised, placebo-controlled, double-blind pilot trial. Lancet Neurol 2009; 8:48–56.
,The European Stroke Organisation (ESO) Executive Committee and the ESO Writing Committee. Guidelines for Management of Ischaemic Stroke and Transient Ischaemic Attack 2008. Cerebrovasc Dis 2008; 25:457–507.
Adams, HP, del Zoppo, G, Alberts, MJ, Bhatt, DL, Brass, L, Furlan, A, et al. American Heart Association; American Stroke Association Stroke Council; Clinical Cardiology Council; Cardiovascular Radiology and Intervention Council; Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke 2007; 38:1655–711.
Vázquez-Cruz, J, Martí-Vilalta, JL, Ferrer, I, Pérez-Gallofré, A, Folch, J. Progressing cerebral infarction in relation to plasma glucose in gerbils. Stroke 1990; 21(11):1621–4.
Martín, A, Rojas, S, Chamorro, A, Falcón, C, Bargalló, N, Planas, AM. Why does acute hyperglycemia worsen the outcome of transient focal cerebral ischemia? Role of corticosteroids, inflammation, and protein O-glycosylation. Stroke 2006; 37(5):1288–95. Epub 2006 Apr 6.
Kiers, L, Davis, SM, Larkins, R, Hopper, J, Tress, B, Rossiter, SC, et al. Stroke topography and outcome in relation to hyperglycaemia and diabetes. J Neurol Neurosurg Psychiatry 1992; 55:263–70.
Matz, K, Keresztes, K, Tatschl, C, Nowotny, M, Dachenhausen, A, Brainin, M, et al. Disorders of glucose metabolism in acute stroke patients: an underrecognized problem. Diabetes Care 2006; 29:792–7.
Capes, SE, Hunt, D, Malmberg, K, Pathak, P, Gerstein, HC. Stress hyperglycemia and prognosis of stroke in nondiabetic and diabetic patients: a systematic overview. Stroke 2001; 32:2426–32.
Alvarez-Sabín, J, Molina, CA, Montaner, J, Arenillas, JF, Huertas, R, Ribo, M, et al. Effects of admission hyperglycemia on stroke outcome in reperfused tissue plasminogen activator-treated patients. Stroke 2003; 34:1235–41.
Parsons, MW, Barber, PA, Desmond, PM, Baird, TA, Darby, DG, Byrnes, G, et al. Acute hyperglycemia adversely affects stroke outcome: a magnetic resonance imaging and spectroscopy study. Ann Neurol 2002; 52(1):20–8.
Allport, , Butcher, KS, Baird, TA, MacGregor, L, Desmond, PM, Tress, BM, et al. Insular cortical ischemia is independently associated with acute stress hyperglycemia. Stroke 2004; 35:1886–91.
Berghe, G, Wouters, P, Weekers, F, Verwaest, C, Bruyninckx, F, Schetz, M, et al. Intensive insulin therapy in critically ill patients. N Engl J Med 2001; 345(19):1359–67.
Malmberg, K. Prospective randomized study of intensive insulin treatment on long term survival after acute myocardial infarction in patients with diabetes mellitus. DIGAMI (Diabetes Mellitus, Insulin Glucose Infusion in Acute Myocardial Infarction) Study Group. BMJ 1997; 24; 314:1512–5.
Gray, CS, Hildreth, AJ, Sandercock, PA, O'Connell, JE, Johnston, , Cartlidge, NE, et al. GIST Trialists Collaboration. Glucose-potassium-insulin infusions in the management of post-stroke hyperglycaemia: the UK Glucose Insulin in Stroke Trial (GIST-UK). Lancet Neurol 2007; 6:397–406.
McCormick, MT, Muir, KW, Gray, C, Walters, MR. Management of hyperglycemia in acute stroke: how, when, and for whom?Stroke 2008; 39(7):2177–85.
,Glucose Regulation in Acute Stroke Patients Trial (GRASP). The internet stroke center. American Stroke Association. 2008.
Bruno, A, Kent, TA, Coull, BM, Shankar, RR, Saha, C, Becker, KJ, et al. Treatment of hyperglycemia in ischemic stroke (THIS): a randomized pilot trial. Stroke 2008; 39(2):384–9. Epub 2007 Dec 20.
Memezawa, H, Zhao, Q, Smith, ML, Siesjö, BK. Hyperthermia nullifies the ameliorating effect of dizocilpine maleate (MK-801) in focal cerebral ischemia. Brain Res 1995; 670(1):48–52.
Wass, CT, Lanier, WL, Hofer, RE, Scheithauer, BW, Andrews, AG. Temperature changes of > or = 1 degree C alter functional neurologic outcome and histopathology in a canine model of complete cerebral ischemia. Anesthesiology 1995; 83:325–35.
Reith, J, Jørgensen, HS, Pedersen, PM, Nakayama, H, Raaschou, HO, Jeppesen, LL, et al. Body temperature in acute stroke: relation to stroke severity, infarct size, mortality, and outcome. Lancet 1996; 347:422–5.
Castillo, J, Dávalos, A, Marrugat, J, Noya, M. Timing for fever-related brain damage in acute ischemic stroke. Stroke 1998; 29(12):2455–60.
Varon, J, Acosta, P. Therapeutic hypothermia: past, present, and future. Chest 2008; 133:1267–74.
,Hypothermia After Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurological outcome after cardiac arrest. N Engl J Med 2002; 346:549–56.
Clifton, GL, Miller, ER, Choi, SC, Levin, HS, McCauley, S, Smith, KR, et al. Lack of effect of induction of hypothermia after acute brain injury. N Engl J Med 2001; 344:556–63.
Kasner, SE, Wein, T, Piriyawat, P, Villar-Cordova, CE, Chalela, JA, Krieger, DW, et al. Acetaminophen for altering body temperature in acute stroke: a randomized clinical trial. Stroke 2002; 33:130–4.
Dippel, DW, Breda, EJ, Gemert, HM, Worp, HB, Meijer, RJ, Kappelle, LJ, et al. Effect of paracetamol (acetaminophen) on body temperature in acute ischemic stroke: a double-blind, randomized phase II clinical trial. Stroke 2001; 32:1607–12.
Schwab, S, Schwarz, S, Spranger, M, Keller, E, Bertram, M, Hacke, W. Moderate hypothermia in the treatment of patients with severe middle cerebral artery infarction. Stroke 1998; 29:2461–6.
Guluma, KZ, Oh, H, Yu, SW, Meyer, BC, Rapp, K, Lyden, PD. Effect of endovascular hypothermia on acute ischemic edema: morphometric analysis of the ICTuS trial. Neurocrit Care 2008; 8(1):42–7.
Olsen, TS, Weber, UJ, Kammersgaard, LP, et al. Therapeutic hypothermia for acute stroke. Lancet Neurol 2003; 2:410–6.
Georgia, MA, Krieger, DW, Abou-Chebl, A, Devlin, TG, Jauss, M, Davis, SM, et al. Cooling for Acute Ischemic Brain Damage (COOL AID): a feasibility trial of endovascular cooling. Neurology. 2004; 63(2):312–7.
Forsgren, L, Bucht, G, Eriksson, S, Bergmark, L. Incidence and clinical characterization of unprovoked seizures in adults: a prospective population-based study. Epilepsia 1996; 37:224–9.
Bladin, CF, Alexandrov, AV, Bellavance, A, Bornstein, N, Chambers, B, Coté, R, et al. Seizures after stroke: a prospective multicenter study. Arch Neurol 2000; 57:1617–22.
Lesser, RP, Luders, H, Dinner, DS, Morris, HH. Epileptic seizures due to thrombotic and embolic cerebrovascular disease in older patients. Epilepsia 1985; 26:622–30.
So, EL, Annegers, JF, Hauser, WA, O'Brien, PC, Whisnant, JP. Population-based study of seizure disorders after cerebral infarction. Neurology 1996; 46:350–5.
Kilpatrick, CJ, Davis, SM, Tress, BM, Rossiter, SC, Hopper, JL, Vandendriesen, ML. Epileptic seizures in acute stroke. Arch Neurol 1990; 47:157–60.
Shinton, RA, Gill, JS, Melnick, AK. The frequency, characteristics, and prognosis of epileptic seizures at the onset of stroke. J Neurol Neurosurg Psychiatry 1988; 51:273–276.
Arboix, A, Garcia-Eroles, L, Massons, JB, Oliveres, M, Comes, E. Predictive factors of early seizures after acute cerebrovascular disease. Stroke 1997; 28:1590–4.
Reith, J, Jørgensen, HS, Nakayama, H, Raaschou, HO, Olsen, TS. Seizures in acute stroke: the Copenhagen Stroke Study. Stroke 1997; 28:1585–9.
Giroud, M, Gras, P, Fayolle, H, André, N, Soichot, P, Dumas, R. Early seizures after stroke: a study of 1,640 cases. Epilepsia 1994; 35:959–64.
Olsen, TS. Post-stroke epilepsy. Curr Atheroscler Rep 2001; 3(4):340–4. Review.
Benbir, G, Ince, B, Bozluolcay, M. The epidemiology of post-stroke epilepsy according to stroke sub types. Acta Neurol Scand 2006; 114:8–12.
Myint, PK, Staufenberg, EF, Sabanathan, K. Post-stroke seizure and post-stroke epilepsy. Postgrad Med J 2006; 82:568–72.
Cordonnier, C, Hénon, H, Derambure, P, Pasquier, F, Leys, D. Influence of pre-existing dementia on the risk of post-stroke epileptic seizures. J Neurol Neurosurg Psychiatry 2005; 76:1649–53.
Reuck, J, Proot, P, Maele, G. Chronic obstructive pulmonary disease as a risk factor for stroke-related seizures. Eur J Neurol 2007; 14:989–92.
Sun, DA, Sombati, S, DeLorenzo, RJ. Glutamate injury-induced epileptogenesis in hippocampal neurons: an in vitro model of stroke-induced “epilepsy”. Stroke 2001; 32:2344–50.
Stroemer, RP, Kent, TA, Hulsebosch, CE. Neocortical neural sprouting, synaptogenesis, and behavioral recovery after neocortical infarction in rats. Stroke 1995; 26:2135–44.
Gilad, R, Lampl, Y, Eschel, Y, Sadeh, M. Antiepileptic treatment in patients with early postischemic stroke seizures: a retrospective study. Cerebrovas Dis 2001; 12:39–43.
Ryvlin, P, Montavont, A, Nighoghossian, N. Optimizing therapy of seizures in stroke patients. Neurology 2006 26; 67(12 Suppl 4):S3–9.
Alvarez-Sabín, J, Montaner, J, Padró, L, Molina, CA, Rovira, R, Codina, A. Gabapentin in late-onset poststroke seizures. Neurology 2002; 59(12):1991–3.
Gilad, R, Sadeh, M, Rapoport, A, Dabby, R, Boaz, M, Lampl, Y. Monotherapy of lamotrigine versus carbamazepine in patients with poststroke seizure. Clin Neuropharmacol 2007; 30:189–95.
Hackett, ML, Yapa, C, Parag, V, Anderson, CS. Frequency of depression after stroke: a systematic review of observational studies. Stroke 2005; 36:1330–4.
Paolucci, S, Gandolfo, C, Provinciali, L, Torta, R, Toso, V. DESTRO Study Group. The Italian multicenter observational study on post-stroke depression (DESTRO). J Neurol 2006; 253:556–62.
Morris, PL, Robinson, RG, Samuels, J. Depression, introversion and mortality following stroke. Aust N Z J Psychiatry 1993; 27:443–9.
Gainotti, G, Marra, C. Determinants and consequences of post-stroke depression. Curr Opin Neurol 2002; 15(1):85–9.
Narushima, K, Kosier, JT, Robinson, RG. A reappraisal of poststroke depression, intra- and inter-hemispheric lesion location using meta-analysis. J Neuropsychiatry Clin Neurosci 2003; 15:422–30.
Bhogal, SK, Teasell, R, Foley, N, Speechley, M. Lesion location and poststroke depression: systematic review of the methodological limitations in the literature. Stroke 2004; 35:794–802.
Gaete, JM, Bogousslavsky, J. Post-stroke depression. Expert Rev Neurother 2008; 8:75–92.
Brodaty, H, Withball, A, Sachdev, PS. Rates of depression at 3 and 15 months poststroke and their relationship with cognitive decline: the Sydney Stroke Study. Am J Geriatr Psychiatry 2007; 15:477–486.
Robinson, RG, Jorge, RE, Moser, DJ, Acion, L, Solodkin, A, Small, SL, et al. Escitalopram and problem-solving therapy for prevention of poststroke depression: a randomized controlled trial. JAMA 2008; 299:2391–400.
Román, GC, Tatemichi, TK, Erkinjuntti, T, Cummings, JL, Masdeu, JC, Garcia, JH, et al. Vascular dementia: diagnostic criteria for research studies. Report of the NINDS-AIREN International Workshop. Neurology 1993; 43(2):250–60.
Diagnostic and Statistical Manual of mental disorders (DSM-4), 4th ed. Washington DC: American Psychiatric Association; 1994.
Wetterling, T, Kanitz, RD, Borgis, KJ. Comparison of different diagnostic criteria for vascular dementia (ADDTC, DSM-IV, ICD-10, NINDS-AIREN). Stroke 1996; 27:30–6.
Dubois, MF, Hébert, R. The incidence of vascular dementia in Canada: a comparison with Europe and East Asia. Neuroepidemiology 2001; 20(3):179–87.
Hénon, H, Durieu, I, Guerouaou, D, Lebert, F, Pasquier, F, Leys, D. Poststroke dementia: incidence and relationship to prestroke cognitive decline. Neurology 2001; 57:1216–22.
Ince, PG, Fernando, MS. Neuropathology of vascular cognitive impairment and vascular dementia. Int Psychogeriatr 2003; 15 Suppl 1:71–5.
Jellinger, KA. Pathology and pathophysiology of vascular cognitive impairment. A critical update. Panminerva Med 2004; 46(4):217–21.
Skoog, I. Status of risk factors for vascular dementia. Neuroepidemiology 1998; 17(1):2–9.
Bornstein, NM, Gur, AY, Treves, TA, Reider-Groswasser, I, Aronovich, BD, Klimovitzky, SS, et al. Do silent brain infarctions predict the development of dementia after first ischemic stroke?Stroke 1996; 27:904–5.
Longstreth, WT, Manolio, TA, Arnold, A, Burke, GL, Bryan, N, Jungreis, CA, et al. Clinical correlates of white matter findings on cranial magnetic resonance imaging of 3301 elderly people. The Cardiovascular Health Study. Stroke 1996; 27:1274–82.
Gur, AY, Neufeld, MY, Treves, TA, Aronovich, BD, Bornstein, NM, Korczyn, AD. EEG as predictor of dementia following first ischemic stroke. Acta Neurol Scand 1994; 90(4):263–5.
Snowdon, DA, Greiner, LH, Mortimer, JA, Riley, KP, Greiner, PA, Markesbery, WR. Brain infarction and the clinical expression of Alzheimer disease. The Nun Study. JAMA 1997; 277:813–7.
Kavirajan, H, Schneider, LS. Efficacy and adverse effects of cholinesterase inhibitors and memantine in vascular dementia: a meta-analysis of randomised controlled trials. Lancet Neurol 2007; 6:782–92.
Ingles, JL, Eskes, GA, Phillips, SJ. Fatigue after stroke. Arch Phys Med Rehabil 1999; 80(2):173–8.
Staub, F, Bogousslavsky, J. Fatigue after stroke: a major but neglected issue. Cerebrovasc Dis 2001; 12:75–81.
Fisk, JD, Pontefract, A, Ritvo, PG, Archibald, CJ, Murray, TJ. The impact of fatigue on patients with multiple sclerosis. Can J Neurol Sci 1994; 21:9–14.
Rose, L, Pugh, LC, Lears, K, Gordon, DL. The fatigue experience: persons with HIV infection. J Adv Nurs 1998; 28:295–304.
Riemsma, RP, Rasker, JJ, Taal, E, Griep, EN, Wouters, JM, Wiegman, O. Fatigue in rheumatoid arthritis: the role of self-efficacy and problematic social support. Br J Rheumatol 1998; 37:1042–6.
Zwarts, MJ, Bleijenberg, G, Engelen, BG. Clinical neurophysiology of fatigue. Clin Neurophysiol 2008; 119:2–10.
Werf, SP, Broek, HL, Anten, HW, Bleijenberg, G. Experience of severe fatigue long after stroke and its relation to depressive symptoms and disease characteristics. Eur Neurol 2001; 45:28–33.
Glader, EL, Stegmayr, B, Asplund, K. Poststroke fatigue: a 2-year follow-up study of stroke patients in Sweden. Stroke 2002; 33:1327–33.