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Severe acute ischemic stroke (AIS) has been recognized as deserving management in the neurocritical care unit (NCCU) and considerable progress in its understanding and management has been made over the last 10 years. The results of older studies had put into question the usefulness of giving patients with severe AIS access to NCCU treatment and mechanical ventilation, based on a very poor reported prognosis with mortality rates between 50 and 80% [1–4]. Today, however, treatment options such as endovascular thrombectomy, decompressive surgery, or targeted temperature management have changed the perspective of these patients, and they require rapid, adequately aggressive, and consequent emergency and critical care. This chapter addresses, in fairly chronological order, the step-wise management of severe ischemic stroke, i.e. the acute assessment, stabilization, and recanalizing treatment in the emergency room (ER), the general aspects of care for ischemic stroke patients in the NCCU, and finally specific treatment aspects associated with different types of ischemic stroke. Other features of stroke care, such as recognition and prehospital management, general stroke unit management, and secondary stroke prophylaxis, will not be covered.
The airway management and mechanical ventilation of patients with neurological disease requires continuous attention to the effects of respiration on neurophysiology. Brain-injured patients frequently lack compensatory reserves and are therefore vulnerable to “minor” physiologic changes to which we may pay little attention – an intubation during which the bed is left flat, ventilation interrupted, light analgosedation administered, and prolonged direct laryngoscopy performed may precipitate brain herniation in a patient with a mass lesion or elevated intracranial pressure (ICP). Yet it takes little effort to minimize the time the head is down, to see that ventilation is not interrupted, and to provide adequate analgosedation – possibly leading to a very different outcome.
The advent of neuroimaging has allowed clinicians to improve clinico-anatomical correlations in stroke patients. Arterial trunks supplying the brainstem include: the vertebral artery, basilar artery, anterior and posterior spinal arteries, posterior inferior cerebellar artery, anterior inferior cerebellar artery, superior cerebellar artery, posterior cerebral artery, and anterior choroidal artery. The arterial supply of the medulla oblongata comes from the vertebral arteries that form the middle rami of the lateral medullary fossa, the posterior inferior cerebellar artery that gives rise to the inferior rami of the lateral medullary fossa, and the anterior and posterior spinal arteries. Different arterial trunks supply blood to the pons, including the vertebral arteries, anterior inferior cerebellar artery, superior cerebellar artery, and basilar artery. The leptomeningeal arteries consist of the terminal branches of the anterior, middle, and posterior cerebral arteries forming an anastomotic network on the surface of the hemispheres.