From the Guidelines
Lidocaine is not recommended for routine use in acute stroke management. The most recent and highest quality study, 1, provides guidelines for the early management of patients with ischemic stroke, emphasizing the importance of urgent evaluation and treatment, including measures to protect the airway, breathing, and circulation, and the use of intravenous rtPA for carefully selected patients. However, this study does not mention lidocaine as a recommended treatment for acute ischemic stroke. Some key points to consider in the management of acute ischemic stroke include:
- Urgent evaluation and treatment to determine the cause of symptoms and eligibility for intravenous rtPA
- Measures to protect the airway, breathing, and circulation, especially among seriously ill or comatose patients
- Intravenous administration of rtPA for carefully selected patients who can receive the medication within 3 hours of onset of stroke
- Comprehensive stroke unit care, including comprehensive rehabilitation, for a broad spectrum of patients
- Subsequent treatment to prevent or treat medical or neurological complications of stroke, and institution of medical or surgical therapies to lessen the risk of recurrent stroke. As noted in the guidelines, 1, no medication with putative neuroprotective effects, including lidocaine, has yet been shown to be useful for treatment of patients with acute ischemic stroke. Therefore, the focus should be on established treatments that improve outcomes, such as rtPA and comprehensive stroke unit care, rather than on unproven neuroprotective agents like lidocaine.
From the Research
Lidocaine and Stroke
- Lidocaine has been used to treat ventricular arrhythmias for over 50 years, but its use can be associated with neurologic dysfunction, which can be misinterpreted as a stroke 2.
- Stroke is a clinically defined syndrome of acute, focal neurological deficit attributed to vascular injury, and it is not a single disease but can be caused by a wide range of risk factors, disease processes, and mechanisms 3.
- Lidocaine is classified as a class Ib anti-arrhythmic that blocks voltage- and pH-dependent sodium channels, and it has been used to treat ventricular arrhythmias, but its use has been pushed into the background in the era of amiodarone and modern electric device therapy 4.
Lidocaine as a Treatment for Post-Stroke Pain
- Lidocaine has been used to relieve central pain after a stroke, and it has been shown to reduce post-stroke pain in some patients 5.
- A study found that four patients responded to an intravenous lidocaine infusion for relief of central pain after a stroke, and two of them continued to take mexiletine, an oral congener of lidocaine, and reported excellent relief at 12 months' follow-up 5.
Acute Stroke Management
- Acute stroke management is moving from a universal time window approach to a concept of tissue preservation, and it involves preserving cerebral blood flow, the penumbra, and reducing the risk of a second event 6.
- Recent updates in acute ischemic stroke management include the use of mechanical thrombectomy and thrombolytics, such as tenecteplase, and individualizing treatment to patients 6.