Ver el código de «Ischemic stroke»

==Background==
[[File:Gehirn, lateral - Lobi + Stammhirn + Cerebellum eng.svg|thumb|Sagital view of the brain.]]
[[File:Circle of Willis en.png|thumb|Circulation within the Circle of Willis]]
[[File:23-Sensory-Homonculus.png|thumb|Sensory Homonculus - courtesy AnatomyZone.com]]
{{Ischemic Stroke Cause}}

==Clinical Features==
{{Stroke Syndromes}}

==Differential Diagnosis==
{{ Stroke DDX}}

==Evaluation==
[[File:StrokeMCA overlay.png|thumb|A CT showing early signs of a middle cerebral artery stroke with loss of definition of the gyri and grey white boundary]]
[[File:Left MCA Stroke.png|thumb|12-lead ECG of a patient with acute stroke, showing large deeply inverted T-waves.]]
{{Stroke workup}}

==Management==
To differentiate between [[tPA]] and non-tPA candidates see [[Thrombolysis in Acute Ischemic Stroke (tPA)]]
===Both tPA AND non-tPA candidates===
*Prevent dehydration
*Maintain SpO2 > 92%
*Maintain blood glucose between 140 and 180 mg/dL
*Prevent fever 
*HOB > 30°

===tPA Candidate===
*tPA
**See [[Thrombolysis in Acute Ischemic Stroke (tPA)]]
*[[Hypertension]]
**Lower SBP to < 185, DBP to < 110
**Goal MAP < 130
**Options:
***[[Labetalol]] 10–20 mg IV over 1–2 min; may repeat x1 '''OR'''
***[[Nitroglycerin]] paste, 1–2 in. to skin '''OR'''
***[[Nicardipine]] 5 mg/hr, titrate up by 2.5 mg/hr at 5-15 min intervals; max dose 15 mg/hr
****When desired blood pressure attained reduce to 3 mg/hr

===Non-tPA Candidate===
*Hypertension
**Allow permissive hypertension 
**If SBP > 220 or DBP > 120, lower by 25% over 24 hrs (drug of choice is [[nicardipine]])<ref>Zha AM, et al. Recommendations for management of large hemispheric infarction. Curr Opin Crit Care. 2015; 21(2):91-8.</ref>
**Goal MAP for non-thrombolyzed, MAP < 150, per AHA guidelines<ref>Anton Helman. Emergency Medicine Cases. Episode 17 Part 1: Emergency Stroke Controversies. September 2011. https://emergencymedicinecases.com/episode-17-part-1-emergency-stroke-controversies/</ref>
*[[Aspirin]] 325mg (within 24-48hr)
*[[Clopidogrel]] 600 mg load (followed by 75 mg daily for 30-90 days)
**prevents 15 strokes out of 1000 patients at a cost of 5 additional major noncerebral hemorrhages. <ref>[https://www.jwatch.org/na46776/2018/05/17/clopidogrel-plus-aspirin-has-benefits-tia-or-minor-stroke Journal Watch May 17, 2018 Clopidogrel plus Aspirin Has Benefits for TIA or Minor Stroke]</ref><ref>Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA [https://www.nejm.org/doi/full/10.1056/NEJMoa1800410 N Engl J Med 2018; 379:215-225]</ref>
*[[Anticoagulation]] not recommended for acute stroke (even for A-fib)

===Endovascular Therapy===
*Mechanical clot removal for large vessel occlusions (e.g. M1 occlusion, basilar artery occlusion)
*Early trials MR RESCUE, SYNTHESIS, and IMSIII showed no benefit and potential harm
*[[MR CLEAN]] Trial show promising outcomes<ref>Berkhemer OA, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. NEJM. 2015; 372(1):11-20.</ref>
**Participants had proximal intracranial artery occlusions
**Intervention was conducted within 6 hrs
**Functional independence of 32.6% with endovascular treatment and 19.1% with typical therapy
*AHA guidelines say the following patients are eligible for mechanical thrombectomy:
** 0-6 hours: pre-stroke mRS 01, ICA or M1 occlusion, age > 18, NIHSS > 5, puncture < 6 hours
** 0-6 hours: May also be reasonable in carefully selected patients with M2 or M3 occlusions
** 6-16 hours: anterior circulation LVO who meet DAWN or DEFUSE 3 criteria
** 16-24 hours: anterior circulation LVO who meet DAWN criteria 
*May require careful patient selection based on last known normal, ICA/prox MCA occlusion, and additional diagnostic studies such as CT perfusion study, Rapid [[brain MRI|MRI]], etc<ref>Thrombectomy For Stroke At 6 To 16 Hours With Selection By Perfusion Imaging Albers, G.W., et al, N Engl J Med 378(8):708, February 22, 2018</ref>
*Goal SBP <160 after endovascular therapy <ref>Smith M, Reddy U, Robba C, et al. Acute ischaemic stroke: challenges for the intensivist. Intensive Care Med. 2019</ref>

===Cerebellar===
*Early neurosurgical consultation is needed ([[herniation Syndromes|herniation]] may lead to rapid deterioration)
*See [[Cerebellar Stroke]]

===[[Corticosteroids]]===
*Cochrane review showed no benefit in mortality or functional outcomes<ref>Sandercock PA and Soane T. Corticosteroids for acute ischaemic stroke. Cochrane Database Syst Rev. 2011 Sep 7;(9):CD000064.</ref>

==Disposition==
*Admit all acute and subacute ischemic strokes

==See Also==
*[[Transient Ischemic Attack (TIA)]]
*[[Thrombolysis in Acute Ischemic Stroke (tPA)]]
*[[CVA (Post-tPA Hemorrhage)]]
*[[Intracerebral Hemorrhage]]
*[[Subarachnoid Hemorrhage (SAH)]]
*[[Cervical Artery Dissection]]
*[[NIH Stroke Scale]]
*[[Cerebellar Stroke]]
*[[Stroke (main)]]
*[[Alteplase]]

==External Links==
*[http://www.mdcalc.com/modified-nih-stroke-scale-score-mnihss/ MDCalc - NIH Stroke Scale/Score]

==References==
<references/>

[[Category:Neurology]]