Advances in Critical Care and Emergency Medicine

Abstract

In 2008, there were clinical trial advances in 3 areas that will impact on the way stroke care is practiced in the emergency department and intensive care unit (ICU). These include (1) the positive results of the European Cooperative Acute Stroke Study (ECASS) III trial, extending the time window for intravenous thrombolytic therapy for acute ischemic stroke; (2) the negative results of 2 trials investigating the use of intensive insulin therapy in the ICU; and (3) new data from the Phase 2 Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT), investigating the role of intensive blood pressure (BP) control after intracerebral hemorrhage (ICH). Intravenous thrombolysis with alteplase is still the only approved treatment for acute ischemic stroke. However, the time window for applying this therapy, which significantly reduces morbidity but not mortality, up to now has been restricted to 3 hours after symptom onset.1 Various stroke trials trying to expand this strict time window, selecting patients based on CT or MRI perfusion, and using thrombolytic agents other than recombinant tissue plasminogen activator (rtPA), have up until now failed to prove efficacy regarding clinical end points.2–5 After a couple of years without any positive stroke trials, ECASS III adds on to the encouraging results of the pooled analyses of the ECASS and National Institute of Neurological Diseases and Stroke trials,6 now expanding the time window for CT-based treatment of acute ischemic stroke up to 4.5 hours.7 The ECASS III trial randomly assigned 821 patients either to receive 0.9 mg rtPA per kilogram body weight or placebo. After ruling out intracranial hemorrhage using CT, thrombolysis was administered between 3 and 4.5 hours (median, 4 hours). The dichotomized primary end point of recovery with no disability after 90 days (modified …