Accident vasculaire cérébral ischémique

Ischemic stroke (IS) is the first cause of disability in western countries. A benefit of intensive care management is obvious in some instances, as treatment of epilepsy, management of sepsis, decreased consciousness due to the development of ischemic edema in patients with a good recovery profile. On the contrary, intensive care is futile in most elderly patients in deep coma due to IS. Recently, aggressive treatments have demonstrated efficacy for reducing mortality or long-term disability. Thrombolysis or thrombectomy have clear indications, increasing every year. General anesthesia for thrombectomy is potentially harmful, probably mostly related to arterial hypotension. General anesthesia using a well-standardized protocol is not deleterious in the short-term and may be beneficial in the long-term. A decrease in mortality has been demonstrated with surgical treatments (cerebrospinal fluid drainage, decompressive craniectomy). Thus, it is mandatory to create networks between neurosurgical centers and community hospitals to select the appropriate indications. These new treatment options ask ethical questions to intensivists and anesthesiologists. They have to avoid fatalism giving rise to self-fulfilling prophecies but also avoid futile treatments leading to very severe disability in elderly patients with its societal burden and family suffering.