Department of Neurology, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Emory Faculty Office Building, 80 Jessee Hill Jr Drive, SE Room 398, Atlanta, GA, 30303, USA.
Curr Treat Options Neurol. 2013 Apr;15(2):113-24. doi: 10.1007/s11940-012-0216-3.
Acute ischemic stroke carries high morbidity and mortality. The advent of intravenous thrombolysis and endovascular reperfusion techniques have helped improve clinical outcomes for patients with large vessel acute ischemic stroke. The care of the post-endovascular stroke patient is complex and encompasses almost all aspects of medicine. Hemodynamics should be optimized post procedure to ensure adequate cerebral perfusion and strict hemodynamic parameters must be adhered to minimize reperfusion injury. Though no studies have specifically examined hemodynamic goals, our practice is to maintain a mean arterial pressure (MAP) > 70 and systolic blood pressure (SBP) < 140 for patients following successful recanalization. Early anti-thrombotic therapy is indicated in patients with stent placement. It remains less clear which patients may benefit from additional anticoagulation or therapy with IIb/IIIa inhibitors. Careful consideration must be paid to volume status to reduce risk of contrast nephropathy and maximize cerebral perfusion. Oral care and attention to dysphagia are key in preventing aspiration pneumonia. Glycemic control should be optimized to avoid excessive hyper and hypoglycemia. In the absence of data to guide treatment of anemia, our practice is to transfuse asymptomatic anemia when Hgb < 7 mg/dL, or if the patient is symptomatic or hemodynamically unstable. Neuro-protective strategies should be considered in the context of clinical trials until further studies are complete. At a minimum, fever should be treated aggressively. Young patients with good pre-morbid functional status who continue to have large volume infarcts may benefit from decompressive hemicraniectomy. When appropriate, aggressive and early mobilization is recommended to prepare patients for acute rehabilitation. Because randomized prospective data is lacking, patients should be encouraged to enroll in clinical trials to optimize care of this growing patient population.
急性缺血性脑卒中具有较高的发病率和死亡率。静脉溶栓和血管内再灌注技术的出现有助于改善大血管急性缺血性脑卒中患者的临床转归。血管内治疗后脑卒中患者的护理非常复杂，几乎涵盖了医学的各个方面。血管内治疗后应优化血液动力学，以确保足够的脑灌注，并严格遵循血液动力学参数，以最大限度地减少再灌注损伤。尽管没有专门研究血液动力学目标，但我们的做法是，对于成功再通的患者，保持平均动脉压（MAP）>70mmHg 和收缩压（SBP）<140mmHg。对于支架置入的患者，早期进行抗血栓治疗是指征。对于哪些患者可能受益于额外的抗凝治疗或 IIb/IIIa 抑制剂治疗，目前仍不清楚。必须仔细考虑容量状态，以降低造影剂肾病的风险并最大限度地提高脑灌注。口腔护理和注意吞咽困难是预防吸入性肺炎的关键。应优化血糖控制，避免过度高血糖和低血糖。在缺乏数据指导贫血治疗的情况下，我们的做法是在 Hgb <7mg/dL 时对无症状贫血进行输血，或当患者出现症状或血液动力学不稳定时进行输血。在完成进一步研究之前，应在临床试验背景下考虑神经保护策略。至少应积极治疗发热。对于有良好的基础功能状态且持续存在大梗死体积的年轻患者，可能会从减压性颅骨切除术获益。在适当情况下，推荐积极和早期的活动，为急性康复做好准备。由于缺乏随机前瞻性数据，应鼓励患者参加临床试验，以优化对这一不断增长的患者群体的护理。
