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J Emerg Trauma Shock. 2010 Jul-Sep; 3(3): 307.
PMCID: PMC2938527

Management of acute ischemic stroke

Sir,

We read the otherwise brilliant review on emergency care for cerebrovascular accidents.[1] We have few observations regarding the management of acute ischemic stroke.

Recently, the recommendation regarding administration of tissue plasminogen activator in acute ischemic stroke has been modified and has been increased from 3 to 4.5 h on the basis of the findings of the third European Cooperative Acute Stroke Study (ECASS-3).[2] While the review correctly recommends the use of computed tomography as the initial rapid study, it is important to realise the importance of magnetic resonance imaging (MRI) in the diagnosis of acute ischemia as also excluding mimics. MRI has not only become more readily available but is also quicker to perform than before. The ability of diffusion-weighted imaging to identify acute infarction and of fluid-attenuated inversion recovery sequence and gradient echo in detecting hemorrhage argue for a greater role of MRI in acute stroke. Recent recommendations have indicated that MRI can be utilized in the first 3 h if it does not delay administration of thrombolytic therapy.[3] Also, the review does not mention the need to control hyperglycemia in acute ischemic stroke, which may have some benefit in improving the outcome.[4]

REFERENCES

1. Birenbaum D. Emergency neurological care of strokes and bleeds. J Emerg Trauma Shock. 2010;3:52–61. [PMC free article] [PubMed]
2. del Zoppo GJ, Saver JL, Jauch EC, Adams HP., Jr American Heart Association Stroke Council. Expansion of the time window for treatment of acute ischemic stroke with intravenous tissue plasminogen activator: a science advisory from the American Heart Association/American Stroke Association. Stroke. 2009;40:2945–8. [PMC free article] [PubMed]
3. Latchaw RE, Alberts MJ, Lev MH, Connors JJ, Harbaugh RE, Higashida RT, et al. Recommendations for imaging of acute ischemic stroke: a scientific statement from the American Heart Association. Stroke. 2009;40:3646–78. [PubMed]
4. Adams HP, Jr, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, et al. 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. [PubMed]

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