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Over recent decades the early management of acute stroke has changed dramatically and the early post-stroke period has been the focus of much research. With advances in pharmacotherapeutics, and on the basis of many randomized controlled trials, the potential interventions now available within the first 24–48 hours following acute stroke are numerous.
This chapter will present the evidence and best practice guidance for interventions during the first 24–48 hours following stroke, based upon the European Stroke Organisation Guidelines 2008 and the European Stroke Initiative recommendations for the management of intracranial hemorrhage [1,2]. For the purposes of this chapter, the interventions discussed will generally be limited to the initial 48 hours following ictus. Access to some of these therapies may not be universal and may be dictated by local availability at individual stroke units. As with other aspects of stroke care, however, close cooperation and inter-disciplinary communication are essential.
In respect of acute interventions, one of the most significant advances during the last two decades has been the introduction of intravenous thrombolysis as a standard therapy for a well-selected population of patients with acute ischemic stroke. At present, the only thrombolytic agent licensed in Europe for the treatment of ischemic stroke is recombinant-tissue plasminogen activator (rtPA), alteplase.
This chapter focuses on the epidemiology of oral anticoagulant therapy (OAT)-associated ICH, its pathophysiology, and treatment options based on the currently available data. One of the most common indications for OAT is to prevent stroke in patients with atrial fibrillation. Intracerebral hemorrhage is the deadliest form of stroke, with a mortality rate between 30% and 55%. The incidence and dynamics of hematoma expansion in OAT-ICH remain to be established. Current data suggest that the natural course of hematoma expansion in this group of patients is more prolonged as compared to spontaneous ICH. This may provide a longer time window for treatment of OAT-ICH. However, in OAT-ICH the underlying coagulopathy prolongs the time course of bleeding or rebleeding, and repeated dosing or a higher dose might be essential. The risk of thromboembolism that is associated with current hemostatic treatment strategies which aim to normalize coagulation is unknown.
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