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Responding to a crisis: A call to action

Introduction As coronavirus disease 2019 (COVID-19) escalated into a global pandemic, health system scrambled to prepare for surge conditions. Patient loads increased exponentially, and state governmental agencies advised hospitals to double their capacity while simultaneously reducing their non-COVID-19 patient populations. As an additional measure to free up bed capacity, nonemergent medical procedures were severely restricted. The pressure to prepare and the pressure to perform changed how…

Decompressive Craniectomy for Infarction and Intracranial Hemorrhages

Key Points Patients with subtotal or complete infarction of the middle cerebral artery (MCA) territory are at high risk for space-occupying edema formation and increased intracranial pressure (ICP). The diagnosis of malignant MCA infarction is based on clinical and radiologic criteria. Patients who present with a severe hemispheric syndrome, deterioration of consciousness with reduced ventilator drive, and definite infarction on neuroimaging of at least two-thirds of…

Extracranial–Intracranial Bypass for Cerebral Ischemia

Key Points Extracranial-intracranial bypass is effective in augmenting blood flow to the middle cerebral artery. Although extracranial-intracranial bypass was originally developed as a strategy for treating cerebral ischemia related to atherosclerotic cerebrovascular occlusive disease (e.g., carotid occlusion), prospective randomized trials have failed to demonstrate an overall reduction in stroke risk in such patients. Bypass is still selectively considered for patients with atherosclerotic cerebrovascular occlusive disease who…

Indications for Carotid Endarterectomy in Patients With Asymptomatic and Symptomatic Carotid Stenosis

Key Points Extracranial carotid artery stenosis is the cause of approximately 8% of ischemic strokes. Modalities for diagnosing extracranial carotid artery stenosis include carotid artery duplex Doppler ultrasound, magnetic resonance angiography, computed tomography angiography, and conventional angiography. Each modality has certain advantages and disadvantages, and, as such, often two modalities are used for confirmatory testing. Medical management of extracranial carotid artery stenosis includes aspirin, statins, blood…

Surgical Management of Cavernous Malformations and Venous Anomalies

Key Points Cerebral cavernous malformations (CCMs) are “mulberry-like” lesions without intervening brain tissue. CCMs present most frequently with seizure, hemorrhage, or neurologic deficit. Three gene loci have been implicated in the pathogenesis of CCMs: chromosomal arms 7q CCM1 (KRIT1), 7p CCM2 (MGC4607, OSM, Malcavernin), and 3q CCM3 (PDCD10, TFAR15). Sporadic lesions or CCM1 genotype have a more benign natural history than familial lesions or CCM3 genotype.…

Surgical Management of Cranial and Spinal Arteriovenous Malformations

Key Points Review of the pathophysiology, natural history, and clinical presentation of cerebral arteriovenous malformations (AVMs). Discussion of cerebral AVM classification schemes and their impact on surgical decision-making. Consideration of the unique features of cerebellar AVMs. Technical nuances for the microsurgical resection of cerebral AVMs. Classification and treatment recommendations for spinal AVMs. Acknowledgments The authors thank the staff of Neuroscience Publications at Barrow Neurological Institute for…

Management of Intraventricular Hemorrhage

Key Points Spontaneous intraventricular hemorrhages (IVHs) occur most commonly as extensions of parenchymal/deep hypertensive hemorrhages. Other causes can include aneurysmal rupture extension, most commonly from anterior communicating artery locations and fourth ventricular hemorrhages for posterior circulation aneurysmal rupture or arteriovenous malformations (AVMs). IVH is an independent and important clinical problem that can influence outcome. Distended ventricular anatomy with compression of adjacent structures or obstruction of cerebrospinal…

Surgery for Intracerebral Hemorrhage

Key Points Surgery for spontaneous supratentorial intracerebral hemorrhage (ICH) remains controversial. Surgical evacuation of cerebellar ICH is recommended for clots that are large or causing brainstem compression. There is good rationale and strong preclinical data to suggest that surgical evacuation would be beneficial to patients. Studies evaluating minimally invasive evacuation strategies have produced positive results but require further evaluation in well-designed, rigorous randomized clinical trials. The…

Surgery of Anterior and Posterior Aneurysms

Key Points Many aneurysms are not safely or completely treatable by endovascular means. Surgical clipping has a firmly established safety and durability history, with the advantages of lower recurrence and rebleeding rates compared to those associated with endovascular intervention. Surgery remains a significant tool in aneurysm management. Mastery of operative approaches and treatments is an essential component in any comprehensive aneurysm management strategy. The three most…

Dural Arteriovenous Malformations

Key Points Dural arteriovenous malformations or fistulas (DAVM/F) consist of pathologic arteriovenous shunting occurring within the dural leaflet, with secondary involvement of the cerebral venous circulation. The vast majority of these lesions are acquired with possible secondary causes including hypercoagulability, surgery, and trauma. Complete workup should include hematologic assessment for potential hypercoagulable states. DAVM/F typically have arterial supply from branches of the external carotid artery near…

Interventional Therapy of Brain and Spinal Arteriovenous Malformations

Key Points While risk of bleeding of an unruptured brain arteriovenous malformation (AVM) is close to 2%, rupture rate of a previously ruptured AVM is considerably higher; thus, treatment of the latter is in most cases indicated whereas treatment of unruptured aneurysm remains a matter of debate. Brain AVMs may become symptomatic with hemorrhage but also with non-hemorrhagic deficits or symptoms that can be related to…

Endovascular Treatment of Intracranial Aneurysms

Key Points Endovascular therapy has become the main treatment for most ruptured and unruptured intracranial aneurysms. Various endovascular treatment modalities and devices with high safety and efficacy have been developed. Endovascular treatment has shown to be safer and comparably effective to surgical clipping for ruptured intracranial aneurysms. All unruptured aneurysms of the posterior circulation and anterior circulation aneurysms greater than 7 mm should be treated. Endovascular…

Endovascular Treatment of Acute Ischemic Stroke

Key Points Large vessel occlusion (LVO) acute ischemic stroke (AIS) is a major cause of disability and mortality. Intravenous (IV) tissue plasminogen activator (tPA), approved nearly two decades ago for the treatment of AIS, has low rates of recanalization for the treatment of LVO-AIS. In five major randomized trials, endovascular treatment of LVO-AIS showed an overwhelmingly superior benefit over IV tPA alone when endovascular mechanical thrombectomy…

Endovascular Therapy of Extracranial and Intracranial Occlusive Disease

Key Points The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) demonstrated higher risk of stroke with carotid angioplasty and stenting (CAS) and higher risk of myocardial infarction with carotid endarterectomy (CEA). Age, sex, lesion morphology, lesion location, and aortic arch anatomy influence outcomes after CAS. Embolic protection devices have become the standard of care in both investigational trials and routine clinical practice. In most patients with…

Design of Stroke-Related Clinical Trials

Key Points A trial can be conducted only when there is equipoise. Phase 2 trials can reduce the number of ineffective treatments taken to phase 3 in stroke research. Common outcome measures are the National Institutes of Health stroke scale and modified Rankin scale. Properly planned adaptive designs can allow midcourse modifications to the study design while maintaining validity and integrity of study data. No single…

Secondary Prevention of Cardioembolic Stroke

Key Points Cardioembolic stroke is a major etiology accounting for one-fifth of all ischemic strokes. Recent advances in technology have enabled us to monitor heart rhythm remotely and detect paroxysmal atrial fibrillation. Atrial cardiopathy is an area of further investigation as a risk factor for cardioembolic stroke, especially in patients with cryptogenic stroke. CLOSE, Gore-REDUCE, DEFENSE-PFO, and RESPECT trials have shown that device closure of patent…

Antiplatelet Therapy for Secondary Prevention of Stroke

Key Points Antiplatelet agents are the gold standard for secondary prevention of non-cardioembolic stroke. Aspirin, aspirin plus dipyridamole, or clopidogrel, ticagrelor, and possibly cilostazol are acceptable therapeutic alternatives. The combination of aspirin plus clopidogrel should not be used for long-term secondary stroke prevention. For prevention of stroke recurrence early after minor stroke or high-risk transient ischemic attack, the combination of aspirin and clopidogrel or aspirin and…

Enhancing Stroke Recovery With Cellular Therapies

Key Points Over the past 15 years, cell therapies have attracted intense interest in their use as a potential treatment in a multitude of neurologic disorders including stroke. A large number of preclinical studies have provided important information on the mechanisms, efficacy, and potential clinical application of cell therapies to enhance recovery after stroke. Cell therapies can be obtained from a variety of sources ranging from…