Targeted temperature management in patients with intracerebral haemorrhage, subarachnoid haemorrhage, or acute ischaemic stroke: consensus recommendations

Targeted temperature control following traumatic brain injury: ESICM/NACCS best practice consensus recommendations

AIMS AND SCOPE

The aim of this panel was to develop consensus recommendations on targeted temperature control (TTC) in patients with severe traumatic brain injury (TBI) and in patients with moderate TBI who deteriorate and require admission to the intensive care unit for intracranial pressure (ICP) management.

METHODS

A group of 18 international neuro-intensive care experts in the acute management of TBI participated in a modified Delphi process. An online anonymised survey based on a systematic literature review was completed ahead of the meeting, before the group convened to explore the level of consensus on TTC following TBI. Outputs from the meeting were combined into a further anonymous online survey round to finalise recommendations. Thresholds of ≥ 16 out of 18 panel members in agreement (≥ 88%) for strong consensus and ≥ 14 out of 18 (≥ 78%) for moderate consensus were prospectively set for all statements.

RESULTS

Strong consensus was reached on TTC being essential for high-quality TBI care. It was recommended that temperature should be monitored continuously, and that fever should be promptly identified and managed in patients perceived to be at risk of secondary brain injury. Controlled normothermia (36.0-37.5 °C) was strongly recommended as a therapeutic option to be considered in tier 1 and 2 of the Seattle International Severe Traumatic Brain Injury Consensus Conference ICP management protocol. Temperature control targets should be individualised based on the perceived risk of secondary brain injury and fever aetiology.

CONCLUSIONS

Based on a modified Delphi expert consensus process, this report aims to inform on best practices for TTC delivery for patients following TBI, and to highlight areas of need for further research to improve clinical guidelines in this setting.

Vitreoretinal Surgery with Temperature Management: A Preliminary Study in Rabbits

The present study aimed to evaluate the structure of the rabbit retina after vitreoretinal surgery using prolonged irrigation with solutions of different temperatures. Thirty-six rabbits (72 eyes) were included in this study and randomly divided into 3 equal groups according to the temperature of the intraocular irrigating fluid they received during vitrectomy. Vitreoretinal surgery was performed with a 5°C irrigation solution in group 1 (12 rabbits, 24 eyes), a 22°C irrigation solution in group 2 (12 rabbits, 24 eyes), and a 36°C irrigation solution in group 3 (12 rabbits, 24 eyes). In each group of animals, the mean irrigation/aspiration time was 30 minutes for left eyes and 60 minutes for right eyes. Histological examination of the retina was performed 1, 7, and 30 days after surgery. During surgery, the temperature in the vitreous cavity of the eyes of rabbits of groups 1, 2, and 3 dropped by 26.0°C, 11.2°C (deep hypothermia), and 1.0°C (mild hypothermia), respectively. The highest rewarming rate was detected in group 1 (0.9°C/min) compared with group 2 (0.7°C/min) and group 3 (0.2°C/min). After 60 minutes of irrigation, retinal structural changes were detected in the animals of groups 1 and 2 (in contrast to the animals of group 3). After surgery with irrigation lasting 30 minutes, no retinal structural changes were observed. This study showed that temperature management, avoidance of intraoperative deep hypothermia, and prevention of rapid uncontrolled rewarming may protect the retinal morphology and increase the safety of prolonged vitreoretinal surgery.

Low-intensity pulsed ultrasound ameliorates glia-mediated inflammation and neuronal damage in experimental intracerebral hemorrhage conditions

BACKGROUND

Intracerebral hemorrhage (ICH) is a condition associated with high morbidity and mortality, and glia-mediated inflammation is a major contributor to neurological deficits. However, there is currently no proven effective treatment for clinical ICH. Recently, low-intensity pulsed ultrasound (LIPUS), a non-invasive method, has shown potential for neuroprotection in neurodegenerative diseases. This study aimed to investigate the neuroprotective effects and potential mechanisms of LIPUS on glia-mediated inflammation in ICH.

METHODS

This study used 289 mice to investigate the effects of LIPUS on ICH. ICH was induced by injecting bacterial collagenase (type VII-S; 0.0375 U) into the striatum of the mice. LIPUS was applied noninvasively for 3 days, including a 2-h-delayed intervention to mimic clinical usage. The study evaluated neurological function, histology, brain water content, hemoglobin content, MRI, and protein expression of neurotrophic factors, inflammatory molecules, and apoptosis. In vitro studies investigated glia-mediated inflammation by adding thrombin (10 U/mL) or conditioned media to primary and cell line cultures. The PI3K inhibitor LY294002 was used to confirm the effects of PI3K/Akt signaling after LIPUS treatment.

RESULTS

LIPUS treatment improved neurological deficits and reduced tissue loss, edema, and neurodegeneration after ICH. The protective effects of LIPUS resulted from decreased glia-mediated inflammation by inhibiting PI3K/Akt-NF-κB signaling, which reduced cytokine expression and attenuated microglial activation-induced neuronal damage in vitro.

CONCLUSIONS

LIPUS treatment improved neurological outcomes and reduced glia-mediated inflammation by inhibiting PI3K/Akt-NF-κB signaling after ICH. LIPUS may provide a non-invasive potential management strategy for ICH.

Targeted temperature management in patients with intracerebral haemorrhage, subarachnoid haemorrhage, or acute ischaemic stroke: updated consensus guideline recommendations by the Neuroprotective Therapy Consensus Review (NTCR) group

BACKGROUND

There is a lack of consistent, evidence-based guidelines for the management of patients with fever after brain injury. The aim was to update previously published consensus recommendations on targeted temperature management after intracerebral haemorrhage, aneurysmal subarachnoid haemorrhage, and acute ischaemic stroke in patients who require admission to critical care.

METHODS

A modified Delphi consensus, the Neuroprotective Therapy Consensus Review (NTCR), included 19 international neuro-intensive care experts with a subspecialty interest in the acute management of intracerebral haemorrhage, aneurysmal subarachnoid haemorrhage, and acute ischaemic stroke. An online, anonymised survey was completed ahead of the meeting before the group came together to consolidate consensus and finalise recommendations on targeted temperature management. A threshold of ≥80% for consensus was set for all statements.

RESULTS

Recommendations were formulated based on existing evidence, literature review, and consensus. After intracerebral haemorrhage, aneurysmal subarachnoid haemorrhage, and acute ischaemic stroke in patients who require critical care admission, core temperature should ideally be monitored continuously and maintained between 36.0°C and 37.5°C using automated feedback-controlled devices, where possible. Targeted temperature management should be commenced within 1 h of first fever identification with appropriate diagnosis and treatment of infection, maintained for as long as the brain remains at risk of secondary injury, and rewarming should be controlled. Shivering should be monitored and managed to limit risk of secondary injury. Following a single protocol for targeted temperature management across intracerebral haemorrhage, aneurysmal subarachnoid haemorrhage, and acute ischaemic stroke is desirable.

CONCLUSIONS

Based on a modified Delphi expert consensus process, these guidelines aim to improve the quality of targeted temperature management for patients after intracerebral haemorrhage, aneurysmal subarachnoid haemorrhage, and acute ischaemic stroke in critical care, highlighting the need for further research to improve clinical guidelines in this setting.

Posterior circulation ischaemic stroke diagnosis and management

This narrative review provides an overview of the posterior circulation and the clinical features of common posterior circulation stroke (PCS) syndromes in the posterior arterial territories and how to distinguish them from mimics. We outline the hyperacute management of patients with suspected PCS with emphasis on how to identify those who are likely to benefit from intervention based on imaging findings. Finally, we review advances in treatment options, including developments in endovascular thrombectomy (EVT) and intravenous thrombolysis (IVT), and the principles of medical management and indications for neurosurgery. Observational and randomised clinical trial data have been equivocal regarding EVT in PCS, but more recent studies strongly support its efficacy. There have been concomitant advances in imaging of posterior stroke to guide optimal patient selection for thrombectomy. Recent evidence suggests that clinicians should have a heightened suspicion of posterior circulation events with the resultant implementation of timely, evidence-based management.

An Ambiguous Role for Fever in Worsening Outcome After Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) accounts for 10-15% of all strokes and leaves most survivors with impairments. Fever, a rise in the thermoregulatory set point, complicates ICH. This review summarizes ICH fever studies and employs meta-analytic techniques to explore the relationship between fever and ICH. We discuss methodological considerations for future studies and provide an overview of mechanisms by which fever, and its treatment, may impact ICH. We searched the PubMed database using the following terms: ((fever OR hyperthermia) AND (intracerebral hemorrhage OR intraparenchymal hemorrhage OR intracerebral haemorrhage OR intraparenchymal haemorrhage)). Our search returned 727 studies, of which 21 were included in our final analysis, consisting of 19 clinical, and two preclinical, studies. We conducted a meta-analysis on the clinical data to quantify how fever is related to mortality, functional outcomes, and intraventricular hemorrhage. Analysis of clinical studies suggested that fever causes an increased risk of mortality but does not appear to be associated with poor outcomes among survivors, making it difficult to ascertain the extent of harm caused by post-ICH fever or the benefits of its treatment. Perhaps these inconsistencies stem from variable fever definitions, and temperature measurement and fever treatment protocols. Additionally, the lack of mechanistic data in clinical studies coupled with preclinical studies showing no harmful effects of moderate bouts of hyperthermia raise concerns about the direct contribution of hyperthermia and fever in post ICH outcome. Overall, the significance of temperature increases after ICH is unclear, making this an important area for future research.

Nursing Management of Temperature in a Patient with Stroke

Fever is common in patients with stroke and is associated with worse outcomes. Studies in brain injury informed interventions commonly termed therapeutic temperature management (TTM) to improve the monitoring and management of fever. While the role and benefit of TTM in stroke patients has not been well studied, the nurse and healthcare team must extrapolate existing data to determine how to best monitor and apply TTM after stroke. Nurses should be knowledgeable about interventions to monitor and manage complications of TTM (eg, shivering), the studies underway to quantify the impact of fever treatment and emerging technology expected to improve TTM.

Understanding the Therapeutic Approaches for Neuroprotection

The term "neurodegenerative disorders" refers to a group of illnesses in which deterioration of nerve structure and function is a prominent feature. Cognitive capacities such as memory and decision-making deteriorate as a result of neuronal damage. The primary difficulty that remains is safeguarding neurons since they do not proliferate or regenerate spontaneously and are therefore not substituted by the body after they have been damaged. Millions of individuals throughout the world suffer from neurodegenerative diseases. Various pathways lead to neurodegeneration, including endoplasmic reticulum stress, calcium ion overload, mitochondrial dysfunction, reactive oxygen species generation, and apoptosis. Although different treatments and therapies are available for neuroprotection after a brain injury or damage, the obstacles are inextricably connected. Several studies have revealed the pathogenic effects of hypothermia, different breathed gases, stem cell treatments, mitochondrial transplantation, multi-pharmacological therapy, and other therapies that have improved neurological recovery and survival outcomes after brain damage. The present review highlights the use of therapeutic approaches that can be targeted to develop and understand significant therapies for treating neurodegenerative diseases.

A Case Series of Clinical Limitations to the Clinical Course of Neurogenic Fever

Nurses play a vital role in the care of neurocritical patients. Fever is a common and dangerous occurrence, and there is a substantial lack of consistency in how to maintain normothermia in these patients. We present five cases in which patients were confirmed to have neurogenic fever (NF) and the documented interventions. In all five cases, temperature and interventions were not documented consistently, making it difficult to assess how nurses acted to avoid hyperthermia in these patients. Additional research is needed to determine interventions, processes, procedures, and documentation of NF in neurocritical patients.

Computational modeling of targeted temperature management in post-cardiac arrest patients

Our core body temperature is held around [Formula: see text]C by an effective internal thermoregulatory system. However, various clinical scenarios have a more favorable outcome under external temperature regulation. Therapeutic hypothermia, for example, was found beneficial for the outcome of resuscitated cardiac arrest patients due to its protection against cerebral ischemia. Nonetheless, practice shows that outcomes of targeted temperature management vary considerably in dependence on individual tissue damage levels and differences in therapeutic strategies and protocols. Here, we address these differences in detail by means of computational modeling. We develop a multi-segment and multi-node thermoregulatory model that takes into account details related to specific post-cardiac arrest-related conditions, such as thermal imbalances due to sedation and anesthesia, increased metabolic rates induced by inflammatory processes, and various external cooling techniques. In our simulations, we track the evolution of the body temperature in patients subjected to post-resuscitation care, with particular emphasis on temperature regulation via an esophageal heat transfer device, on the examination of the alternative gastric cooling with ice slurry, and on how anesthesia and the level of inflammatory response influence thermal behavior. Our research provides a better understanding of the heat transfer processes and therapies used in post-cardiac arrest patients.

Fever management in acute brain injury

PURPOSE OF REVIEW

Fever is common after acute brain injury and is associated with poor prognosis in this setting.

RECENT FINDINGS

Achieving normothermia is feasible in patients with ischemic or hemorrhagic stroke, subarachnoid hemorrhage and traumatic brain injury. Pharmacological strategies (i.e. paracetamol or nonsteroidal anti-inflammatory drugs) are frequently ineffective and physical (i.e. cooling devices) therapies are often required. There are no good quality data supporting any benefit from therapeutic strategies aiming at normothermia in all brain injured patients when compared with standard of care, where mild-to-moderate fever is tolerated. However, recent guidelines recommended fever control in this setting.

SUMMARY

As fever is considered a clinically relevant secondary brain damage, we have provided an individualized therapeutic approach to treat it in brain injured patients, which deserved further validation in the clinical setting.

Construction of a nomogram to reveal the prognostic benefit of spontaneous intracranial hemorrhage among Chinese adults: a population-based study

BACKGROUND AND PURPOSE

We aimed to build a nomogram, based on patients with spontaneous intracerebral hemorrhage (SICH), to predict the probability of mortality and morbidity at 7 days and 90 days, respectively.

METHODS

We performed a retrospective study, with patients at less than 6 h from ictus admitted to the department of neurosurgery in a single institute, from January 2011 to December 2018. A total of 1036 patients with SICH were included, 486 patients (46.9%) were 47-66 years old at diagnosis, and 711 patients (68.6%) were male. The least absolute shrinkage and section operator method was performed to identify the key adverse factors predicting the outcomes in patients with SICH, and multivariate logistic regression analysis was built on these variables, and then the results were visualized by a nomogram. The discrimination of the prognostic models was measured and compared by means of Harrell's concordance index (C-index), calibration curve, area under the curve (AUC), and decision curve analysis (DCA).

RESULTS

Multivariate logistic regression analysis revealed that factors affecting 7-day mortality, including the following: age, therapy, Glasgow Coma Scale (GCS) admission, location, ventricle involved, hematoma volume, white blood cell (WBC), uric acid (UA), and L-lactic dehydrogenase (LDH); and factors affecting 90-day mortality, including temperature, therapy, GCS admission, ventricle involved, WBC, international normalized ratio, UA, LDH, and systolic blood pressure. The C-index for the 7-day mortality and 90-day mortality prediction nomogram was 0.9239 (95% CI = 0.9061-0.9416) and 0.9241 (95% CI = 0.9064-0.9418), respectively. The AUC of 7-day mortality was 92.4, as is true of 90-day mortality. The calibration curve and DCA indicated that nomograms in our study had a good prediction ability. For 90-day morbidity, age, marital status, and GCS at 7-day remained statistically significant in multivariate analysis. The C-index for the prediction nomogram was 0.6898 (95% CI = 0.6511-0.7285), and the calibration curve, AUC as well as DCA curve indicated that the nomogram for the prediction of good outcome demonstrated good agreement in this cohort.

CONCLUSIONS

Nomograms in this study revealed many novel prognostic demographic and laboratory factors, and the individualized quantitative risk estimation by this model would be more practical for treatment management and patient counseling.

Intracerebral Hemorrhage

PURPOSE OF REVIEW

Nontraumatic intracerebral hemorrhage (ICH) is the second most common type of stroke. This article summarizes the basic pathophysiology, classification, and management of ICH and discusses the available evidence on therapy for hematoma, hematoma expansion, and perihematomal edema.

RECENT FINDINGS

Current available data on potential therapeutic options for ICH are promising, although none of the trials have shown improvement in mortality rate. The literature available on reversal of anticoagulation and antiplatelet agents after an ICH and resumption of these medications is also increasing.

SUMMARY

ICH continues to have high morbidity and mortality. Advances in therapeutic options to target secondary brain injury from the hematoma, hematoma expansion, and perihematomal edema are increasing. Data on reversal therapy for anticoagulant-associated or antiplatelet-associated ICH and resumption of these medications are evolving.

Effects of Hyperthermia on Intracranial Pressure and Cerebral Autoregulation in Patients with an Acute Brain Injury

Hyperthermia is a common detrimental condition in patients with an acute brain injury (ABI), which can worsen their prognosis and outcome. The aim of this study was to evaluate the effects of hyperthermia on intracranial pressure (ICP) and cerebral autoregulation (CA).Eight patients with ABI were studied. CA was assessed on the basis of the pressure reactivity index (PRx) coefficient. The ICP, cerebral perfusion pressure (CPP), and PRx were compared before and during development of hyperthermia. Hyperthermia was defined as an increase in cerebral temperature above 38.3 °C.Thirty-three episodes of hyperthermia were analyzed: 25 of these occurred on a background of initially normal ICP whereas 8 occurred on a background of initially elevated ICP, and 17 of the 33 episodes occurred on a background of initially intact autoregulation whereas 16 occurred on a background of initially impaired autoregulation.During hyperthermia, elevated ICP was found in 52% of instances where it was initially normal, and further progression of intracranial hypertension occurred in 100% of instances where ICP was initially elevated. The median ICP during hyperthermia was 24 [range quartiles 22-28] mmHg in instances where it was initially normal and 31 [quartiles 27-32] mmHg in instances where it was initially elevated (p < 0.01). The correlation coefficient between the brain temperature and ICP was 0.11 (p < 0.01). During hyperthermia, the number of episodes of ICP >20 mmHg increased by 41% in instances with intact autoregulation but ICP was above 20 mmHg and by 38% (p > 0.05) in instances with impaired autoregulation and ICP was 20 mmHg. The cerebral hyperthermia-associated increase in ICP was not associated with impaired autoregulation.

[Influence of cerebral hyperthermia on intracranial pressure and autoregulation of cerebral circulation in patients with acute brain injury]

Background. Hyperthermia is a common symptom in ICU patients with brain injury.

OBJECTIVE

To study the effect of hyperthermia on intracranial pressure (ICP) and cerebral autoregulation (Prx).

MATERIAL AND METHODS

There were 8 patients with acute brain injury, signs of brain edema and intracranial hypertension. Cerebral autoregulation was assessed by using of PRx. ICP, CPP, BP, PRx were measured before and during hyperthermia. We have analyzed 33 episodes of cerebral hyperthermia over 38.30 C. Statistica 10.0 (StatSoft) was used for statistical analysis.

RESULTS

Only ICP was significantly increased by 6 [3; 11] mm Hg (p<0.01). In patients with initially normal ICP, hyperthermia resulted increase of ICP in 48% of cases (median 24 [22; 28] mm Hg). In patients with baseline intracranial hypertension, progression of hypertension was noted in 100% cases (median 31 [27; 32] mm Hg) (p<0.01). Hyperthermia resulted intracranial hypertension regardless brain autoregulation status.

CONCLUSION

Cerebral hyperthermia in patients with initially normal ICP results intracranial hypertension in 48% of cases. In case of elevated ICP, further progression of intracranial hypertension occurs in 100% of cases. Cerebral hyperthermia is followed by ICP elevation in both intact and impaired cerebral autoregulation.

Intensive Care Admission and Management of Patients With Acute Ischemic Stroke: A Cross-sectional Survey of the European Society of Intensive Care Medicine

BACKGROUND

No specific recommendations are available regarding the intensive care management of critically ill acute ischemic stroke (AIS) patients, and questions remain regarding optimal ventilatory, hemodynamic, and general intensive care unit (ICU) therapeutic targets in this population. We performed an international survey to investigate ICU admission criteria and management of AIS patients.

METHODS

An electronic questionnaire including 25 items divided into 3 sections was available on the European Society of Intensive Care Medicine Web site between November 1, 2019 and March 30, 2020 and advertised through the neurointensive care (NIC) section newsletter. This survey was emailed directly to the NIC members and was endorsed by the European Society of Intensive Care Medicine.

RESULTS

There were 214 respondents from 198 centers, with response rate of 16.5% of total membership (214/1296). In most centers (67%), the number of AIS patients admitted to respondents' hospitals in 2019 was between 100 and 300, and, among them, fewer than 50 required ICU admission per hospital. The most widely accepted indication for ICU admission criteria was a requirement for intubation and mechanical ventilation. A standard protocol for arterial blood pressure (ABP) management was utilized by 88 (58%) of the respondents. For patients eligible for intravenous thrombolysis, the most common ABP target was <185/110 mm Hg (n=77 [51%]), whereas for patients undergoing mechanical thrombectomy it was ≤160/90 mm Hg (n=79 [54%]). The preferred drug for reducing ABP was labetalol (n=84 [55.6%]). Other frequently used therapeutic targets included: blood glucose 140 to 180 mg/dL (n=65 [43%]) maintained with intravenous insulin infusion in most institutions (n=110 [72.4%]); enteral feeding initiated within 2 to 3 days from stroke onset (n=142 [93.4%]); oxygen saturation (SpO2) >95% (n=80 [53%]), and tidal volume 6 to 8 mL/kg of predicted body weight (n=135 [89%]).

CONCLUSIONS

The ICU management of AIS, including therapeutic targets and clinical practice strategies, importantly varies between centers. Our findings may be helpful to define future studies and create a research agenda regarding the ICU therapeutic targets for AIS patients.

Temperature management in acute brain injury: A systematic review of clinical evidence

Temperature alterations in neurocritical care settings are common and have a striking effect on brain metabolism leading to or exacerbating neuronal injury. Hyperthermia worsens acute brain injury (ABI) patients outcome. However conclusive evidence linking control of temperature to improved outcome is still lacking. This review article report an update -results from clinical studies published between March 2006 and March 2020- on the relationship between hyperthermia or Target Temperature Management and functional outcome or mortality in ABI patients.

MATERIALS AND METHODS

A systematic search of articles in PubMed and EMBASE database was accomplished. Only complete studies, published in English in peer-reviewed journals were included.

RESULTS

A total of 63 articles into 5 subchapters are presented: acute ischemic stroke (17), subarachnoid hemorrhage (14), brain trauma (14), intracranial hemorrhage (8), and mixed acute brain injury (10). This evidence confirm and extend the negative impact of hyperthermia in ABI patients on worse functional outcome and higher mortality. In particular "early hyperthermia" in AIS patients seems to have a protective role have as promoting factor of clot lysis but no conclusive evidence is available. Normothermic TTM seems to have a positive effect on TBI patients in a reduced mortality rate compared to hypothermic TTM.

CONCLUSIONS

Hyperthermia in ABI patients is associated with worse functional outcome and higher mortality. The use of normothermic TTM has an established indication only in TBI; further studies are needed to define the role and the indications of normothermic TTM in ABI patients.

Management of the Patient with Malignant Hemispheric Stroke

Malignant hemispheric stroke occurs in 10% of ischemic strokes and has one of the highest mortality and morbidity rates. This stroke, also known as malignant middle cerebral artery stroke, may cause ischemia to an entire hemisphere causing edema, herniation, and death. A collaborative interdisciplinary team approach is needed to manage these complex stroke patients. The nurse plays a vital role in bedside management and support of the patient and family through this complex course of care. This article discusses malignant middle cerebral artery stroke pathophysiology, techniques to predict patients at risk for herniation, collaborative care strategies, and nursing care.

Priority Nursing Interventions Caring for the Stroke Patient

Nearly 20% of all patients with ischemic stroke will require care in an intensive care unit (ICU), particularly those who have received intravenous alteplase or endovascular therapy. Prioritizing nursing intervention and intensive care monitoring can improve patient outcomes and reduce disability. A collaborative interdisciplinary team approach best facilitates the ICU care of an acute stroke patient.

WSES consensus conference guidelines: monitoring and management of severe adult traumatic brain injury patients with polytrauma in the first 24 hours

The acute phase management of patients with severe traumatic brain injury (TBI) and polytrauma represents a major challenge. Guidelines for the care of these complex patients are lacking, and worldwide variability in clinical practice has been documented in recent studies. Consequently, the World Society of Emergency Surgery (WSES) decided to organize an international consensus conference regarding the monitoring and management of severe adult TBI polytrauma patients during the first 24 hours after injury. A modified Delphi approach was adopted, with an agreement cut-off of 70%. Forty experts in this field (emergency surgeons, neurosurgeons, and intensivists) participated in the online consensus process. Sixteen recommendations were generated, with the aim of promoting rational care in this difficult setting.

How to manage fever in brain-injured patients

Fever represents a frequent and dangerous secondary insult for the injured brain and is often associated with worsened neurological outcomes. The identification of fever in the Neuro-Intensive Care Unit requires careful monitoring and rapid and effective treatment. The main objective of this article was to provide practical information regarding temperature monitoring, triggers for intervention and fever management in brain injured patients.

Acute ischaemic stroke: challenges for the intensivist

PURPOSE

To provide an update about the rapidly developing changes in the critical care management of acute ischaemic stroke patients.

METHODS

A narrative review was conducted in five general areas of acute ischaemic stroke management: reperfusion strategies, anesthesia for endovascular thrombectomy, intensive care unit management, intracranial complications, and ethical considerations.

RESULTS

The introduction of effective reperfusion strategies, including IV thrombolysis and endovascular thrombectomy, has revolutionized the management of acute ischaemic stroke and transformed outcomes for patients. Acute therapeutic efforts are targeted to restoring blood flow to the ischaemic penumbra before irreversible tissue injury has occurred. To optimize patient outcomes, secondary insults, such as hypotension, hyperthermia, or hyperglycaemia, that can extend the penumbral area must also be prevented or corrected. The ICU management of acute ischaemic stroke patients, therefore, focuses on the optimization of systemic physiological homeostasis, management of intracranial complications, and neurological and haemodynamic monitoring after reperfusion therapies. Meticulous blood pressure management is of central importance in improving outcomes, particularly in patients that have undergone reperfusion therapies.

CONCLUSIONS

While consensus guidelines are available to guide clinical decision making after acute ischaemic stroke, there is limited high-quality evidence for many of the recommended interventions. However, a bundle of medical, endovascular, and surgical strategies, when applied in a timely and consistent manner, can improve long-term stroke outcomes.