Critical Care Management of Subarachnoid Hemorrhage and Ischemic Stroke
Section snippets
Epidemiology
Ischemic cerebral infarction accounts for 80% of all stroke in the United States,14 but most patients will not require ICU admission. SAH is a generally more morbid disease, with a 30% to 50% overall mortality rate,15 and virtually all patients at least briefly require ICU admission. Therefore, intensivists are likely to care for similar numbers of patients with ischemic stroke and SAH.
Catastrophic ischemic stroke syndromes are listed in Table 1. Typically, life-threatening ischemic strokes
General considerations
Like all critical illnesses, the management of stroke begins with assessment of the airway, breathing, and circulation. Many patients present with an acute decrease in level of arousal, poor tone in the posterior pharynx, and dulling of airway protective reflexes. These patients are at immediate risk for aspiration, hypoventilation, hypoxia, and respiratory failure. Patients in the acute phase of neurologic decline with moderate to severe respiratory compromise should be intubated without
Aneurysmal subarachnoid hemorrhage
Hunt and Hess grades 1 to 3 (Table 2) carry a favorable prognosis, and almost always warrant aggressive treatment. Although patients may suffer complications such as hydrocephalus, vasospasm, or delayed cerebral ischemia (DCI), the outcome of their care is expected to be good, with most patients experiencing good or complete neurologic recovery.29 Conversely, “poor-grade” subarachnoid hemorrhage is a catastrophic disease, and without aggressive neurosurgical and medical therapy, most patients
Ischemic stroke
Ischemic stroke is a heterogeneous group of diseases with extremely variable prognosis, acute management, and critical care concerns. Intensivists must rapidly distinguish between potentially catastrophic large vessel or posterior circulation strokes, and smaller lacunar or embolic events. The intensive care of patients with large or critical ischemic strokes is based on four goals: (1) reperfusion; (2) the prevention of infarct expansion, recurrence, or hemorrhagic conversion; (3) the
Summary
Patients with severe brain injury from SAH and ischemic stroke have seen an improvement in survival and long-term neurologic outcome over the past decade when aggressive surgical and medical neuroprotective measures are used. Many patients once considered to have a fatal brain injury can now be treated with the prospect of an acceptable recovery. The critical care management of these patients relies on rapid evaluation and surgical triage, early and aggressive monitoring, and treatment of both
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