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Interventions to Improve Recovery After Stroke

Key Points Neural repair is a therapeutic strategy distinct from acute stroke strategies such as reperfusion: biologic targets are different. The goal is to boost function in surviving brain elements, not to salvage threatened tissue, and time windows are measured in days to weeks, not hours. Many classes of therapy are under study in animals and in human trials to improve stroke recovery, including drugs, biologic…

Rehabilitation and Recovery of the Patient With Stroke

Key Points Neurologic rehabilitation is primarily concerned with lessening physical and cognitive impairments and functional disabilities, as well as returning patients to more normal participation in daily life. Rehabilitative strategies draw upon basic mechanisms of post-injury neural adaptations and learning and memory. The reacquisition of skills depends on experience- and training-induced synaptic reorganization, as well as behavioral compensation. Many preventable and reversible medical complications that may…

Medical Therapy of Intracerebral and Intraventricular Hemorrhage

Key Points Patients with intracerebral hemorrhage (ICH) should be cared for in specialized units with a focus on monitoring for deterioration and avoiding medical complications such as fever, hyper- or hypoglycemia, and deep vein thrombosis. Blood pressure lowering after ICH to a target systolic blood pressure less than 140 mm Hg is probably safe but has not been definitively shown to reduce the outcome of death…

Treatment of “Other” Stroke Etiologies

Key Points There are a variety of specific but relatively uncommon causes of stroke, many of which have unique treatment implications. For most uncommon causes of stroke, there are few data from randomized trials, and treatment is based largely on clinical experience. Uncommon causes of stroke are more common in the young and in those without traditional vascular risk factors. Inflammatory and noninflammatory vasculopathies, hematologic disorders,…

Pharmacologic Modification of Acute Cerebral Ischemia

Key Points The ideal cytoprotective agent should be low in cost and complexity to allow access in emergency settings of variable sophistication. Cerebral ischemia provides the potential to modify the process both during and after the event to affect outcome. Challenges in translation of clinical trials in acute ischemic stroke include standardization of stroke physiology, sample size estimation, optimal time to treatment, coupling cytoprotection with reperfusion,…

Critical Care of the Patient With Acute Stroke

Key Points Mechanical ventilation and sedation. Brain edema and increased intracranial pressure. Blood pressure and blood glucose management. Neuromonitoring. Targeted temperature management. Large middle cerebral artery stroke. Basilar artery occlusion. Large cerebellar infarction. Intracerebral hemorrhage. Cerebral venous thrombosis. We are indebted to the authors of a previous version of this chapter, Silvia Schönenberger and Marek Sykora, for having provided the grounds for this current version. General…

General Stroke Management and Stroke Units

Key Points All stroke patients should be admitted to hospitals that offer 24/7 specialized stroke care with access to stroke unit care. Multiprofessional stroke unit care reduces significantly mortality, dependency, and need for long-term institutional care, independent of patients’ age and gender or subtype and severity of stroke. Each stroke patient should undergo a full investigation, including clinical, laboratory, and imaging examinations that ascertain diagnosis, subtype,…

Antithrombotic Therapy for Treatment of Acute Ischemic Stroke

Key Points Aspirin therapy (initial dose of 325 mg and subsequently 81 mg a day) should be initiated to patients within 24–48 hours after acute ischemic stroke. Patients receiving thrombolytic therapy should delay treatment until after 24 hours. Antiplatelet agents remain the preferred antithrombotic therapy for most patients with stroke not secondary to cardioembolism and should be initiated prior to discharge from the hospital. A 21-day…

Intravenous Thrombolysis

Key Points Intravenous (IV) recombinant tissue plasminogen activator (t-PA), commercially known as alteplase, remains the most commonly used therapy that is effective and safe for acute ischemic stroke. Pivotal trials in the 1990s demonstrated the beneficial effect of t-PA; subsequent trials have confirmed the initial results and extended the evidence of benefit to include key subgroups such as the very old and patients with very mild…

Prehospital and Emergency Department Care of the Patient With Acute Stroke

Key Points Prehospital and emergency department care of the stroke patient must be focused on identification of potential stroke victims, rapid assessment, and prompt initiation of treatment for eligible individuals. Time from initiation of symptoms to first medical contact represents a significant source of delay in care of the stroke patient. Outreach efforts to educate the lay public on stroke symptoms and immediate activation of emergency…

Stroke Systems of Care and Impact on Acute Stroke Treatment

Key Points Rates of thrombolysis and thrombectomy remain low relative to the clinical burden of stroke worldwide and remain challenging for rural, limited resource communities. Use of thrombolytic therapy and triage for thrombectomy has expanded in the pre-hospital setting through Mobile Stroke Units and telemedicine. Integrated stroke systems of care have developed within hub and spoke networks, including drip-and-ship and trip-and-treat protocols to improve access to…

OMICs in Stroke: Insight Into Stroke Through Epigenomics, Transcriptomics, Proteomics, Lipidomics, and Metabolomics

Key Points OMICs-based technologies are identifying novel molecules and pathways associated with stroke. Markers identified through an OMICs-based approach may have utility as biomarkers to aid in the diagnosis of stroke, prediction of stroke risk, and assessment of stroke complications and stroke outcome. OMICs approaches include epigenetics, transcriptomics, proteomics, metabolomics, and lipidomics. Stroke is a complex disease. Broad assessment at the whole genome, proteome, metabolome, and…

Cerebral Angiography

Key Points The technique of cerebral angiography emanates from before the advent of noninvasive imaging, yet this approach serves a unique role in the management of patients with cerebrovascular disorders. The risks and benefits of cerebral angiography include morbidity due to vascular injury with the advantage of exquisite spatial and temporal resolution to diagnose and treat numerous vascular lesions. Common indications include ischemic or hemorrhagic stroke,…

Magnetic Resonance Imaging of Cerebrovascular Diseases

Key Points The magnetic resonance imaging (MRI) acute stroke protocol includes T2-weighted imaging, fluid attenuated inversion recovery, gradient recalled echo, MR angiography, diffusion-weighted imaging, and perfusion-weighted imaging and can be acquired in 15–20 minutes. Diffusion-weighted MRI is an excellent tool to detect acute cerebral infarcts and to distinguish these from chronic infarcts, in patients with stroke or transient ischemic attack. MRI is an effective tool to…

Computed Tomography-Based Evaluation of Cerebrovascular Disease

Key Points Noncontrast computed tomography (CT) is the standard diagnostic modality for acute stroke patients. It reliably differentiates hemorrhagic from ischemic stroke, enables rapid thrombolysis, and thereby improves stroke recovery. On noncontrast CT, different types of “early ischemic changes” can be found: hypodensity, isolated cortical swelling, and hyperdense arteries. Patients with extensive hypodensity do not appear to benefit from thrombolysis, whereas isolated cortical swelling or hyperdense…

Ultrasonography

Key Points Extracranial ultrasound assessment of the cervical arteries provides real-time, bedside evaluation of blood flow and vessel walls. Ultrasound examination is a non-invasive imaging modality of atherosclerosis in the extracranial arteries. For better yield of microembolic signals, power motion Doppler (PMD) is superior to single-channel transcranial Doppler ultrasonography (TCD). TCD yields good-to-excellent results in detecting steno-occlusive intracranial lesions in the setting of acute cerebral ischemia…

Cerebral Venous Thrombosis

Key Points A high suspicion rate is needed to identify cerebral venous thrombosis (CVT). CVT rarely presents as a stroke syndrome, i.e., as the sudden onset of focal symptoms and signs in a patient with classical vascular risk factors. Confirmation of the diagnosis of CVT requires magnetic resonance (MR) imaging and MR venography or computed tomography (CT) and CT venography. The more frequent risk factors for…

Cryptogenic Stroke

Key Points In a percentage of patients, a defined etiology of ischemic stroke is not identified. These patients are categorized as cryptogenic (unknown cause) ischemic stroke. The estimated percentage of ischemic strokes that are cryptogenic varies from 15% to 35%, reflecting the lack of a standardized definition for cryptogenic ischemic stroke, inconsistency of the extent and quality of etiologic diagnostic testing, variable types of populations included…

Migraine and Stroke

Key Points Migraine and particularly migraine with aura are associated with increased risk of ischemic and hemorrhagic stroke and other vascular events. In few cases does migraine directly result in a stroke. Treatment of stroke in patients with migraine is generally similar to patients without. However, several treatment options to treat or prevent migraine attacks are contraindicated after stroke. Distinction between migraine aura and a transient…

Hematologic Disorders and Stroke

Key Points Patients with hematologic disorders, such as hereditary thrombophilias, are at higher risk for venous thrombosis than ischemic stroke, but these disorders account for a small, but important, percentage of stroke patients. The hereditary causes of protein S, protein C, and antithrombin III deficiencies, in addition to antiphospholipid antibody syndrome, are considered to be very high risk for recurrent thromboembolic events. There are no clinical…