Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Magnetic and Direct Current Stimulation for Stroke

Introduction There has been a recent surge in literature regarding noninvasive techniques that stimulate the brain to better understand plastic changes following stroke, and to modulate neuroplasticity to enhance post-stroke motor recovery. Noninvasive brain stimulation (NIBS) can be broadly categorized into transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS) ( Table 169.1 ). The theory behind magnetic and direct current stimulation is that neuronal…

Rehabilitation for Disabling Stroke

Rehabilitation after stroke concentrates on reducing physical and cognitive impairments and the disabilities they induce so as to return patients to more independently managed self-care, mobility, communication, and daily activities. Care goals include prevention of the complications of immobility, dysphagia, pain, bowel and bladder dysfunction, sleep and mood disorders, as well as treatment of risk factors for cardiovascular disease and stroke. Optimal management to provide retraining…

Anticoagulants in Stroke Treatment

Funding Information Supported by NIH NS20989. Introduction Anticoagulants continue to play a central role in the prevention of stroke. Unlike thrombolytics, anticoagulants do not degrade clot; rather, they prevent thrombus formation and propagation by reduction of fibrin formation. Anticoagulants act on different steps of the intrinsic and extrinsic coagulation pathways. Unfractionated heparin, low-molecular-weight heparins (LMWHs) and heparinoids are parenteral anticoagulants of rapid onset that act by…

Antiplatelet Agents: Mechanisms and Their Role in Stroke Prevention

Introduction Ischemic stroke presents several opportunities for medical intervention, distinguished by their relative timing: 1. primary prevention of a stroke; 2. control of tissue damage in the acute ischemic stroke setting; 3. secondary prevention following a transient ischemic attack (TIA) or stroke. Considering the high morbidity and mortality associated with stroke, primary and secondary prevention are paramount. Traditionally, antiplatelets are used in this third setting, to…

Management of Lipid Metabolism

Introduction Recent studies have demonstrated that elevated low-density lipoprotein (LDL) cholesterol and total cholesterol (TC) levels and decreased levels of high-density lipoprotein (HDL) cholesterol are particularly significant risk factors for ischemic cerebrovascular disease—is the second leading cause of death after ischemic heart disease (IHD) . The pathophysiological basis of both diseases refers to atherosclerosis. Other determinants, such as diabetes mellitus (DM), arterial hypertension, cigarette smoking, and…

Prevention of Ischemic Stroke

Introduction Stroke is well suited for prevention as it has a high prevalence, a number of modifiable factors proven to reduce stroke risk, and a high societal economic and disability burden . An international observational study, INTERSTROKE, showed that 10 relatively common factors are associated with about 90% of stroke risk . Hypertension accounted for almost 35% of the risk. Approaches to stroke prevention include the…

Surgical Aspects of Moyamoya Disease

Moyamoya disease (MMD) is a rare cerebrovascular disorder characterized by unilateral or bilateral steno-occlusion of the main trunks of the circle of Willis and the development of basal collateral channels, including hypertrophy of the lenticulostriate and thalamoperforating arteries, which results in the characteristic appearance of moyamoya vessels. Takeuchi first described the disease in 1957 as hypoplasia of the bilateral internal carotid arteries . In 1969, Suzuki…

Extracranial–Intracranial Bypass Procedures

Introduction Extracranial–intracranial (EC–IC) bypass procedures have played an important role in the treatment of cerebrovascular disease since their development in the 1960s. They serve two main purposes : (1) flow replacement when managing challenging aneurysms or tumors requiring cerebral vessel sacrifice and (2) flow augmentation to treat cerebral ischemia mainly in the setting of atherosclerotic occlusive disease and moyamoya disease. In both settings, a new conduit…

Surgical and Endovascular Management of Vertebrobasilar Atherosclerosis

Introduction Posterior circulation stroke and transient ischemic attack (TIA) constitute 20% of all cerebrovascular ischemic events, with vertebrobasilar atherosclerosis (VBA), the primary etiology in up to 35% . Aggressive medical therapy may reduce the risk of recurrence; however, 30-day and 1-year recurrent stroke rates may be higher than 30%, and nearly 60% in the setting of hemodynamic insufficiency . Although use of antiplatelet agents and strict…

Surgical and Endovascular Management of Unruptured Arteriovenous Malformations

Introduction Brain arteriovenous malformations (AVMs) are clusters of direct connections of arteries to draining veins without intervening capillary bed . The three main components of an AVM are one or more feeding arteries, the nidus at the site of the arteriovenous shunt, and the draining venous structures. AVMs are high-flow, low-resistant shunts due to a significant pressure difference between the arterial and venous sides. The pressure…

Surgical and Endovascular Management of Acutely Ruptured Arteriovenous Malformations

Introduction A brain arteriovenous malformation (AVM) is a tangle of dysplastic blood vessels characterized by abnormal connections between arteries and veins. Dilated arteries and a nidus drained by arterialized veins without intervening capillaries form a high-flow, low-resistance shunt between the arterial and venous systems. High flow through the feeding arteries, nidus, and draining veins may lead to rupture and intracerebral hemorrhage. AVMs are a leading cause…

Surgical Management of Pituitary Apoplexy

Introduction The term “pituitary apoplexy” (PA) was first described in context of five autopsies in which hemorrhagic necrosis was noted in pituitary adenomas; the studied patients had a history of clinical dyspituitarism and sudden death . This condition is exceptionally rare relative to the frequency of pituitary adenomas; 0.6–9% of adenomas undergo clinical apoplexy while up to 20–25% of the general population may have pituitary tumors…

Surgical and Endovascular Management of Aneurysms in the Pediatric Age Group

Introduction Aneurysms are one of the most common vascular anomalies of the central nervous system but are far less common in children than in adults. These structurally abnormal areas of the arterial wall can cause bleeding, compression of adjacent structures, and concomitant loss of neurologic function. The epidemiology, pathophysiology, presentation, and treatment of pediatric intracranial aneurysms have features distinct from those of adults. Epidemiology and Pathophysiology…

Surgical and Endovascular Management of Patients With Giant Cerebral Aneurysms

Introduction Giant cerebral aneurysms (GCAs) have been defined by convention as aneurysms that are 2.5 cm or greater in diameter. These lesions constitute approximately 5% of intracranial aneurysms and are the result of progressive enlargement of a small aneurysm . Descriptions of aneurysms as large as 8.5 cm in diameter exist in the literature . Despite advances in both surgical and endovascular techniques, the GCA continues…

Surgical and Endovascular Management of Patients With Unruptured Aneurysm

Introduction Intracranial aneurysms are abnormal focal dilations of blood vessels in the brain that result in weakening of the vessel wall making it more prone to rupture. They are common acquired lesions that are usually saccular. Rupture of an intracranial aneurysm results in subarachnoid hemorrhage (SAH), which can have devastating effects with high morbidity and mortality. With the advances in imaging techniques, a large number of…

Surgical and Endovascular Management of Ruptured Posterior Circulation Aneurysms

Introduction Nearly 30,000 Americans suffer from aneurysmal subarachnoid hemorrhage (SAH) every year, and the overall mortality rate is 40% . About 5–15% of all intracranial aneurysms are located in the posterior circulation . The posterior circulation provides the blood supply to the medulla, pons, midbrain, cerebellum, occipital lobes, and posterior parietal and posteroinferior temporal watershed zones. A comprehensive review of the posterior circulation vasculature is beyond…

Management of Cerebellar Hematomas and Infarcts

Cerebellar hemorrhage and cerebellar infarction are two clinical entities with entirely different pathophysiologies, although the clinical syndromes are quite similar and the surgical management and operative considerations are nearly identical. For this reason, surgical treatment of either cerebellar hemorrhage or cerebellar infarction should be listed under the rather broader category of management of vascular-related mass effect in the posterior fossa. Cerebellar Hemorrhage Cerebellar hemorrhage is most…

Management of Asymptomatic Extracranial Carotid Artery Disease

Introduction The stroke risk and management principles for symptomatic internal carotid artery (ICA) stenosis are relatively well established and have a wide consensus among practicing clinicians, discussed in Chapter 80 . The same, however, cannot be said for management of asymptomatic carotid stenosis (ACS), which is a more complex and challenging issue. An extensive in-depth analysis exceeds the scope of this chapter, but we will present…

Carotid Endarterectomy and Carotid Angioplasty and Stenting

Introduction Large-vessel arteriosclerotic disease and stenosis, most commonly of the extracranial carotid artery bifurcation and simply referred to as carotid stenosis, accounts for 15–20% of cerebral ischemic events. The two main mechanisms for these events are hemodynamic compromise, as the internal carotid artery (ICA) diameter is reduced by at least 70%, and artery-to-artery embolization from an ulcerated plaque. The carotid bifurcation is prone to arteriosclerotic plaque…

Surgery for Ischemic Infarcts

Introduction The first surgical procedures on patients with massive infarctions were performed to alleviate severe brain swelling often erroneously attributed to a tumor. With the common use of computed tomography (CT) and magnetic resonance imaging (MRI), the pathophysiologic cause of severe brain swelling is now rarely in question. Although anatomic imaging studies may not show signs of massive hemispheric or cerebellar infarction for the first few…