Optimising homeostasis

There is a wealth of experimental and clinical information showing that hypertension, hyperglycaemia, hyperthermia and intracranial hypertension are each independent indicators of a poor prognosis after stroke, but there is an astonishing lack of evidence from randomised controlled trials to tell us how to manage these problems, bearing in mind their frequency in stroke patients. The therapeutic options will, in most cases, not involve patented drugs, and financial support for running the necessary randomised controlled trials will have to come from government or charity sponsors rather than from the pharmaceutical industry. It is vital that academic researchers now devise studies of appropriate design and size to answer these important questions. In the absence of randomised data, severe hyperglycaemia and pyrexia should be treated, whilst acute hypertension is probably best left untreated unless very severe or complicated by other medical conditions. The management of cerebral oedema remains an enigma.