Continuum, Acute Ischemic Stroke, December 2008, Volume 14, Issue 6

Patients with suspected stroke require urgent evaluation in order to identify those who may be eligible for time-sensitive therapies. A focused and systematic approach to diagnosis improves the likelihood of identifying patients with probable ischemic stroke and minimizes the chances of exposing patients with alternate diagnoses to potentially harmful treatment. This chapter emphasizes the historical, examination, and neuroimaging findings useful in the rapid evaluation and diagnosis of patients with suspected ischemic stroke. Other entities that may present with strokelike symptoms will also be discussed.(C) 2008 American Academy of Neurology

Despite the emergence of many promising therapies for use in acute ischemic stroke, IV recombinant tissue-type plasminogen activator (rt-PA) within 3 hours of stroke onset is currently the only available therapy proven to lead to better patient outcomes. Rapid thrombolytic therapy can substantially limit brain injury, and early rehabilitation can improve recovery after acute ischemic stroke. This chapter emphasizes the mechanics of emergent evaluation and administration of IV rt-PA. Acute rehabilitative interventions are also outlined.(C) 2008 American Academy of Neurology

Acute stroke therapies are evolving gradually. The heterogeneity of stroke has made it difficult to achieve success in large randomized trials. There appears to be "no shoe that fits all" in stroke treatment other than early systemic thrombolysis using recombinant tissue-type plasminogen activator (rt-PA), which succeeds by achieving early recanalization, thereby limiting infarct extent. Many lessons have been learned that have refined our approach to developing new treatments. Emerging therapies for stroke can be classified into a few basic themes. In ischemic stroke, promising therapies are aimed at optimizing arterial recanalization through combined systemic drugs, ultrasound-enhanced treatment, or the use of interventional techniques, such as intraarterial tissue plasminogen activator, Merci(R) catheter, or a combined systemic/interventional approach. Neuroprotection treatment remains elusive, although strategies to initiate ultra-early (ambulance-based) neuroprotection appear justified. Collateral flow augmentation techniques appear promising in improvement of cerebral blood flow via this backdoor approach. The extension of treatment windows beyond the first 3 hours is reliant on neurovascular imaging techniques such as CT perfusion and multimodal MRI to detect significant penumbra.(C) 2008 American Academy of Neurology

Clinical stroke research is typically performed within the domain of large academic medical centers led by stroke specialists generally well versed in clinical trial methodology and performance. Practitioners who see and treat patients with stroke on a regular basis, either as inpatients acutely or as outpatients after the acute hospitalization, have the opportunity to help advance stroke care by testing the same new and promising therapies that are being employed at academic medical centers. This chapter provides an overview of clinical trial structure and implementation that we hope will provide impetus to the practitioner to consider becoming involved in stroke clinical trials. The benefits to practitioners include providing the same promising treatments that patients receive at tertiary care stroke centers, greater patient satisfaction in knowing they are getting state-of-the-art care, enhanced referral patterns, and financial remuneration, among others. Topics covered include resources needed, relationship to academic medical centers, ethical and institutional review board issues, patient perspective, budget, recruitment, informed consent, data collection and management, safety, outcome measures, and lessons from other diseases.(C) 2008 American Academy of Neurology