From the Guidelines
Ischemic encephalopathy requires immediate medical attention, and the initial management should focus on ensuring adequate oxygenation, maintaining blood pressure, and correcting metabolic abnormalities, with thrombolytic therapy considered within 4.5 hours of symptom onset if the cause is thrombotic 1.
Key Considerations
- The brain imaging study should be interpreted within 45 minutes of patient arrival in the ED by a physician with expertise in reading CT and MRI studies of the brain parenchyma 1.
- Either NECT or MRI is recommended before intravenous rtPA administration to exclude ICH and to determine whether CT hypodensity or MRI hyperintensity of ischemia is present 1.
- Neuroprotective measures, such as therapeutic hypothermia, may be considered in post-cardiac arrest patients to reduce metabolic demands and inflammation.
- Anticonvulsants, such as levetiracetam or phenytoin, are used to manage seizures, which are common complications.
Management
- Initial management includes ensuring adequate oxygenation, maintaining blood pressure, and correcting metabolic abnormalities.
- In acute cases, thrombolytic therapy with tissue plasminogen activator (tPA) may be administered within 4.5 hours of symptom onset if the cause is thrombotic 1.
- Rehabilitation, including physical, occupational, and speech therapy, should begin as soon as the patient is stable.
Prognosis
- The prognosis varies widely depending on the severity, duration of oxygen deprivation, patient age, and comorbidities.
- Early intervention is crucial as brain tissue rapidly dies when deprived of oxygen, with irreversible damage occurring within minutes of severe hypoxia.
Additional Considerations
- A noninvasive intracranial vascular study is strongly recommended during the initial imaging evaluation of the acute stroke patient if either intra-arterial fibrinolysis or mechanical thrombectomy is contemplated for management 1.
- CT perfusion and MRI perfusion and diffusion imaging may be considered for the selection of patients for acute reperfusion therapy beyond the time windows for intravenous fibrinolysis 1.
From the Research
Ischaemia Encephalopathy
- Ischaemia encephalopathy is a condition that occurs when there is a lack of blood flow to the brain, resulting in damage to brain tissue 2.
- The primary cerebral injury due to acute ischaemic stroke occurs in the first hours, and early reperfusion importantly impacts on patient outcome 2.
- Therapeutic strategies for acute ischaemic stroke consist of restoration of blood flow and a bundle of medical, endovascular, and surgical strategies 2.
Treatment Options
- Intravenous recombinant tissue plasminogen activator (IV alteplase) is currently the only proven effective medication for the treatment of acute ischaemic stroke 3.
- Antiplatelet agents, such as aspirin, produce a small but worthwhile benefit in long-term functional outcome and survival, and have become standard treatment for acute ischaemic stroke 4.
- Anticoagulants, such as unfractionated heparin and low molecular-weight heparin, have been compared to antiplatelet agents in clinical trials, but have not shown net advantages over antiplatelet agents in acute ischaemic stroke 4.
- Dual-antiplatelet therapy with aspirin and clopidogrel has been shown to be superior to alteplase for achieving a better functional outcome in acute minor ischemic stroke 5.
Complications and Risks
- Symptomatic intracranial haemorrhage (SICH) is a significant risk associated with the use of anticoagulants and thrombolytic agents, such as alteplase 6, 4.
- Early administration of intravenous aspirin in patients with acute ischaemic stroke treated with alteplase does not improve outcome at 3 months and increases the risk of SICH 6.
- The combination of low-dose unfractionated heparin and aspirin may be associated with net benefits compared with aspirin alone, but this requires further research 4.