Medical approaches to the treatment of acute focal cerebral ischemia1

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Acute focal cerebral ischemia is a common entity which has been intensively studied both experimentally and clinically. With the accumulation of knowledge, a framework for reducing tissue injury and improving neurological outcome has evolved. It has been clearly established that treatment must be initiated before irreversible damage occurs. The two basic, interdependent approaches are (1) to improve blood flow to the ischemic zone and (2) to increase the resistance of cerebral tissue to metabolic injury. Optimization of blood viscosity and maintenance of systemic arterial blood pressure are important factors in enhancing circulation. Agents such as mannitol and low-molecular-weight dextran have proved beneficial, whereas prostacyclin and calcium-entry blockers have not. Elevation of blood glucose levels before the ischemic event has been shown to have a deleterious effect upon circulation and metabolism in the ischemic zone. Barbiturate coma, although difficult to use in the usual clinical setting, has been shown to reduce ischemic injury. The rationale and application of the various therapeutic approaches are discussed.



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