No scholar, historian, or policy-maker wishes to dispute the role that power plays in foreign affairs. From Thucydides to modern international politics, the power of a state has influenced its position and success in dealing with other countries. But the calculus of “power” is not the be-all and end-all of national policy in international relations. Countries are prompted to act as a result of their economic circumstances, their moral codes, and their institutional setting (reinforced by domestic politics) as much as by their position in the power hierarchy. Leaders frequently have ambitions that range beyond the limits that power technically permits. Sometimes, decision-makers also minimize their involvements owing to the pressures of internal factors. Sustained by such pressures, international institutions, ideologies, and recognized legitimacies temper and channel the pursuit of influence. Sometimes leaders strive to protect their own position against domestic opponents, even when their country might lose a war in consequence. The definition of the state's situation in foreign affairs also conditions outcomes: is the state rising or declining? Does action have to be taken to prevent further decline? In regard to each of these factors, the authors of this volume have shown in case after case that countries do not restrict their policies to what their “power line” apparently mandates – the relative position they occupy vis-à-vis other major nations in the power hierarchy. Instead they chart their own course – influenced by external pressures, but not determined by them.

Introduction

When a major power acts aggressively and unpredictably, opponents often are nonplussed. The targets of aggressive action first interpret the move as a deliberate challenge, and are tempted to adopt an offensive response. But, they hesitate to respond until they understand why the opponent felt impelled to issue the challenge. Chairman Nikita Khrushchev of the Soviet Union placed “offensive” missiles in Cuba, although President John F. Kennedy had explicitly warned him not to do so. When the missiles were detected and the president informed on October 16, 1962, JFK reacted explosively. “He can't do this to me,” Kennedy said (in more graphic terms than reproduced here). Kennedy's advisers initially interpreted Khrushchev's move as a completely illegitimate and unparalleled action in terms of Soviet foreign policy. No Soviet leader had ever placed such missiles in the Eastern European satellite countries – how could they station them ninety miles off the coast of the United States? From Khrushchev's point of view, however, while the placement was abrupt and unprecedented, it was also a symmetrical response to American stationing of Jupiter missiles in Turkey near the southern border of the Soviet Union. The Soviet missiles were also sent in reaction to US threats to Cuba which were even more compelling than any Russian pressure on Turkey. “What was sauce for the goose was sauce for the gander,” Khrushchev reasoned.

Introduction

Over recent decades the early management of acute stroke has changed dramatically and the early post-stroke period has been the focus of much research. With advances in pharmacotherapeutics, and on the basis of many randomized controlled trials, the potential interventions now available within the first 24–48 hours following acute stroke are numerous.

This chapter will present the evidence and best practice guidance for interventions during the first 24–48 hours following stroke, based upon the European Stroke Organisation Guidelines 2008 and the European Stroke Initiative recommendations for the management of intracranial hemorrhage [1,2]. For the purposes of this chapter, the interventions discussed will generally be limited to the initial 48 hours following ictus. Access to some of these therapies may not be universal and may be dictated by local availability at individual stroke units. As with other aspects of stroke care, however, close cooperation and inter-disciplinary communication are essential.

Thrombolysis

In respect of acute interventions, one of the most significant advances during the last two decades has been the introduction of intravenous thrombolysis as a standard therapy for a well-selected population of patients with acute ischemic stroke. At present, the only thrombolytic agent licensed in Europe for the treatment of ischemic stroke is recombinant-tissue plasminogen activator (rtPA), alteplase.