Clinical Guidelines for Acute Stroke Management - Living on the EDge

4.3.2 Oxygen therapy
Section 4 <strong>Acute</strong> Medical & Surgical <strong>Management</strong>
One systematic review of hyperbaric oxygen
therapy concluded that there is insufficient evidence to
demonstrate clear benefits. 188 One preliminary study of
normobaric oxygen therapy found short term
improvements in stroke severity scales but no
difference in patient outcomes at 3 months. 189
Many centres represented in the stroke unit trials data
had management policies <strong>for</strong> oxygen therapy 18 and
until further evidence is available there is consensus
that in patients found to be hypoxic oxygen therapy
should be provided.
4.3.2 OXYGEN THERAPY GRADE LEVEL
Patients who are hypoxic should be given oxygen supplementation. ✓ –
4.3.3 Glycaemic control
Hyperglycaemia after stroke is a commonly found in 1/3
of patients although reported prevalence varies between
8-83% depending on the cohort and definition. 190
Observational data indicates that hyperglycaemia
fluctuates in the first 72 hours in non diabetic as well as
diabetic patients even with current best practice. 191
Observational data also demonstrates poorer outcomes
<strong>for</strong> non diabetic patients with hyperglycaemia 190 and
the prevalence of undetected diabetes ranges from
16-24% of patients. 192, 193 Patients with glucose
intolerance after stroke is also common (approximately
25%) 193, 194 and linked to higher stroke recurrence
(see section 7.6). 195 Given these facts, acute monitoring
and management appear important although evidence is
scarce. Two pilot studies found glucose infusion to be
safe and feasible. 196, 197 However, a recent large follow up
of one study investigating aggressive maintenance of
euglycaemia via glucose-potassium-insulin infusion failed
to demonstrate benefits. 198 There is consensus that
management should be commenced in patients with
hyperglycaemia, however, further data are needed to
determine the most appropriate management strategies.
4.3.3 GLYCAEMIC CONTROL GRADE LEVEL
a) Patients with hyperglycaemia should have their blood glucose level monitored ✓ –
and appropriate glycaemic therapy instituted to ensure euglycaemia, especially
if the patient is diabetic. Hypoglycaemia should be avoided.
b) Intensive, early maintenance of euglycaemia is currently not recommended. B Level II 198
4.3.4 Neuroprotective agents
A large number of neuroprotective agents have been
studied in clinical trials, however, none have
demonstrated clear robust benefits and hence cannot be
recommended <strong>for</strong> routine use. 199-202 One robust RCT of
NXY-059 was found to have some benefits (reduced
disability at 90 days), but it did not significantly improve
other outcome measures (e.g. neurological functioning as
measured by the NIHSS score). 203 The follow up trial has
not been published in full, however, the summary of
results was released and failed to confirm the beneficial
effects seen in the earlier trial. At this stage, NXY-059
cannot be recommended <strong>for</strong> routine use.
Other groups of agents including colony stimulating
factors (including erythropoietin, granulocyte colony
stimulating factor and analogues), 204, 205 theophylline,
aminophylline, caffeine and analogues, 206 have too few
data and further trials are required be<strong>for</strong>e clear
conclusions can be made.
A number of trials have found potential benefits from initial
small trials, <strong>for</strong> example albumin, 207 Edaravone 208 and
arundic acid (ONO2506) 209 but larger trials are required
to confirm the preliminary study results. Similarly, a large
number of mainly lower level studies have assessed the
feasibility of reducing body temperature (via physical
cooling or acetaminophen) as an acute intervention and
while physical cooling looks promising, larger RCTs are
needed be<strong>for</strong>e such interventions can be
recommended.
210, 211, 212-215
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