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acetaminophen might lower body temperature by a mean of 0.26°C within 4 hours of starting treatment.210 In another clinical trial, Dippel et al210 compared the effects of placebo, ibuprofen, or acetaminophen on body temperature in 75 patients with recent stroke. Although treating fever after stroke makes intuitive sense, no data demonstrate that the use of medications to lower body temperature among either febrile or afebrile patients improves neurological outcomes after stroke. Seeking and treating the source of fever are reasonable. Hypothermia has been shown to be neuroprotective in experimental and focal hypoxic brain injury models. Hypothermia may delay depletion of energy reserves, lessen intracellular acidosis, slow influx of calcium into ischemic cells, suppress production of oxygen free radicals, and lessen the impact of excitatory amino acids.211 Deep hypothermia often is administered to protect the brain in major operative procedures. Mild to moderate hypothermia is associated with improved neurological outcomes among patients with cardiac arrest.212–214 Conversely, a multicenter clinical trial found that mild hypothermia administered during surgery for treatment of a ruptured intracranial aneurysm did not improve outcomes after subarachnoid hemorrhage.215 Several small clinical studies have evaluated the feasibility of inducing modest hypothermia for treatment of patients with acute ischemic stroke.216–223 Two small studies evaluated the utility of hypothermia in treating patients with malignant cerebral infarctions; results were mixed.224,225 Potential side effects of therapeutic hypothermia include hypotension, cardiac arrhythmias, and pneumonia.226 In a systematic review of available data, Correia et al227 could find no evidence that physical cooling would improve outcomes after stroke. Although strong experimental and clinical evidence indicates that induced hypothermia can protect the brain in the presence of hypoxia or ischemia, including after cardiac arrest, data about the utility of induced hypothermia for treatment of patients with stroke are not yet available. Hypothermia is discussed in more detail in the neuroprotection section of this statement. C. Cardiac Monitoring and Treatment Although patients with heart disease are at high risk for ischemic stroke, both myocardial ischemia and cardiac arrhythmias are potential complications of acute cerebrovascular diseases.228,229 Patients with infarctions of the right hemisphere, particularly those involving the insula, may have an increased risk of cardiac complications, presumably secondary to disturbances in autonomic nervous system function.78,230–234 ECG changes secondary to stroke include ST-segment depression, QT dispersion, inverted T waves, and prominent U waves.235–237 Elevations in blood levels of enzymes attributable to injury to myocardial muscle also may be found.79 The most common arrhythmia detected in the setting of stroke is atrial fibrillation, which either may be related to the cause of stroke or may be a complication. Other potentially life-threatening cardiac arrhythmias are relatively uncommon, but sudden death may occur.77,238 No clinical trials have tested the utility of cardiac monitoring for most patients with ischemic stroke or the use of cardiac protective agents or medications to prevent serious cardiac arrhythmias. Still, general consensus exists that patients with acute ischemic stroke should have cardiac monitoring for at least the first 24 hours and that any serious cardiac arrhythmia should be treated. The utility of prophylactic administration of medications to prevent cardiac arrhythmias among patients with stroke is not known. D. Arterial Hypertension An elevated blood pressure is often detected in the first hours after stroke. Elevations in blood pressure >160 mm Hg are detected in >60% of patients with acute stroke.239 Both elevated and low blood pressures are associated with poor outcome after stroke.240 For every 10-mm Hg increase >180 mm Hg, the risk of neurological deterioration increased by 40% and the risk of poor outcome increased by 23%. The elevation in blood pressure may be secondary to the stress of the
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