We discussed an informative and interesting review article on stroke management in October’s Critical Care Minifellowship meeting.
This article highlights some important points (that shed light on how complicated the brain truly is) and touches upon some interesting neurological trials. A few points to mention are:
– The idea of “time is brain” is being questioned. Studies show that time of symptom onset and time of vascular occlusion is not the same. You can have some pretty extensive vascular occlusions with collateral flow that has developed, leading to no ischemia or asymptomatic ischemic lesions. Time of symptom onset, in fact, usually correlates with time of collateral failure.
– Neuroprotective strategies are being studied to freeze/protect the penumbra, one example: the FAST-MAG trial that looked at Magnesium in the prehospital setting (Note: after this paper came out, results from the study were published and showed that giving Mag had no effect on the modified Rankin score at 90 days)
– Revascularization/thrombolysis is unpredictable. In one German study, initiating revascularization as early as possible within the first hour, showed no improvement in outcomes, whereas the ECASS III showed results leading to extension of the thrombolysis window to 4.5 hours.
Long story short: nice review article, lots more to learn in the realm of stroke management, now that we have more detailed imaging modalities, I’m sure that we will see a lot more research in this field.
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