Aims of treatment

• To protect the penumbra with close attention to oxygenation, hydration, glycaemic control, and avoidance of pyrexia.

• Blood pressure control is needed for severe hypertension (e.g. >200/120 mmHg) and hypotension.

• Drug therapy including thrombolysis and aspirin. The evidence for anticoagulation remains contentious as there is an increased risk of bleeding and no consistent subgroup benefit has been shown. Early anticoagulation is probably beneficial for intracranial stenosis, a stroke-in-evolution, complete vessel occlusion with minimal deficit and in low risk patients with a high probability of recurrence (secondary prevention).

• For thrombolysis the extent of reperfusion depends on the aetiology with basilar > middle cerebral artery > internal carotid, and embolic > thrombotic. Pooled studies with rt-PA (0.9 mg/kg) given within 3 h of stroke onset (and tight blood pressure control) showed a favourable outcome. However, there was a 6-fold increase in haemorrhage (to 5.9%), of whom 60% died. This was more common in the elderly, and with more severe stroke.

• Neurosurgical intervention may be considered for cerebellar haematoma, cerebellar infarction and the malignant middle cerebral artery syndrome (for massive infarction on the non-dominant side).

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