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Endovascular Therapy for the Treatment of Cerebrovascular Disease

Abbreviations 3D three dimensional ACoA anterior communicating artery ADAPT a direct aspiration first-pass technique AP anteroposterior AVM arteriovenous malformation CT computed tomographic CTA CT angiography DMSO dimethyl sulfoxide DSA digital subtraction angiography FRED Flow redirection endoluminal device IA intracranial aneurysm ISAT International Subarachnoid Aneurysm Trial ISUIA International Study of Unruptured Intracranial Aneurysms IVH intraventricular hemorrhage LVIS Low-profile visualized intraluminal support MCA middle cerebral artery NBCA N-butylcyanoacrylate…

Treatment of Vasculitis

Introduction Vasculitis, in general, is the inflammation of blood vessels. However, not all cases of vasculitis are identical. Vasculitis can vary based on a number of characteristics such as size of blood vessel involved, target organs, etiology, and the underlying pathogenesis which can range from infectious, malignant to connective tissue disease. When involving the central nervous or peripheral nervous system, diagnosis and treatment can be difficult…

Depression, Psychosis, and Agitation in Stroke

Introduction Every year, stroke affects more than 15 million patients worldwide, resulting in death in 5.7 million patients and disability in another 5 million . Neuropsychiatric disorders are common after stroke, including depression, anxiety, agitation, mania, apathy, emotional lability, psychosis, and fatigue ( Table 147.1 ). Noncognitive neuropsychiatric disorders are distressing to patients, families, and caregivers in the poststroke period, and can significantly interfere with rehabilitation…

Management of Atrial Fibrillation

Frequency and Pathogenesis Nonvalvular atrial fibrillation (AF) is a potent predictor of first and recurrent stroke, affecting more than 2.7 million Americans. An estimated 14–38% of patients with ischemic stroke have AF . The frequency of ischemic stroke events in patients with AF is directly proportional to the mean age of populations studied. Of note, this data may be an underestimation due to the difficulty of…

Management of Diabetes in Stroke

Introduction Diabetes mellitus is a global health problem. About 350 million people worldwide are affected and this number is expected to increase by a staggering 50% in the next decade because of increases in the prevalence of obesity and inactivity . Type 1 diabetes mellitus, which accounts for about 10% of all cases, is an autoimmune disease where there is immune destruction of the insulin-producing pancreatic…

Management of Hypertension in Stroke

Introduction Chronic hypertension is a known risk factor for acute ischemic as well as hemorrhagic strokes. There is an independent, graded relationship between the two, and hypertension is therefore aggressively treated in the outpatient environment in order to reduce future stroke risks . Ischemic strokes comprise the majority of all strokes. Although they can present in a myriad of manifestations, patients will usually have a focal…

Cardiac Complications and ECG Abnormalities After Stroke

Introduction A significant overlap exists between cerebrovascular disease and cardiac disease. Cardiac disease is frequent in stroke patients, and cardiac abnormalities are also common following stroke. The most serious events include acute myocardial infarction (MI), heart failure, arrhythmias such as ventricular tachycardia, ventricular fibrillation, or atrial fibrillation, and cardiac arrest. Patients with cerebral atherosclerosis often have coronary artery disease (CAD) or peripheral vascular disease (PVD). Conversely,…

Clinical Status of Neuroprotection in Cerebral Ischemia

Introduction Cerebral ischemia, resulting in neuronal death, is seen in a wide range of conditions. Most often, it results from arterial occlusion secondary to thromboembolic or atherosclerotic diseases. Trauma is also a common cause of ischemic disease. In other instances, it can be iatrogenic in the setting of interventional treatments, such as those for carotid artery stenosis or cerebral aneurysms. Neuroprotective strategies in clinical practice fall…

Management of Cerebral Edema/Intracranial Pressure in Ischemic Stroke

Introduction Stroke is the fifth leading cause of death in the United States, resulting in greater than 125,000 deaths annually . Large brain infarctions are associated with edema and, in severe cases, shift of intracranial contents and elevation of intracranial pressure (ICP). Depression of consciousness and other signs of brainstem compression represent symptoms concerning for severe cerebral edema and can be correlated to imaging findings of…

Hypertensive Encephalopathy

Introduction Hypertensive encephalopathy is an acute syndrome characterized by acute hypertension (HTN) associated with various neurological symptoms and characteristic neuroimaging findings. The common clinical signs and symptoms of the condition include encephalopathy, seizures, headache, visual disturbances, and focal neurological deficits . Hypertensive encephalopathy is an important clinical syndrome to recognize since early recognition and treatment can lead to good clinical outcomes. We now have an ever-increasing…

Physiological Monitoring of Stroke in the Intensive Care Setting

Physiological monitoring is the cornerstone of critical care; it allows for identifying hemodynamic instability and assessing response to therapy. Utility of most hemodynamic monitoring remains unproven and rather serves as a trigger for detection of cardiorespiratory instability. Some have argued that utility can only be proven if linked to a treatment protocol improving outcome . Noninvasive physiological monitoring includes ​electrocardiogram (ECG), pulse oximetry, and arterial blood…

General Treatment of Stroke in Intensive Care Setting

Introduction Meticulous critical care is key to achieve the best possible outcome after stroke. There has been considerable evolution in our approach to critically ill patients over the recent years, including the establishment of standardized protocols that cover both general critical care and neurocritical care. This chapter provides an overview of the treatment of critically ill patients with ischemic and hemorrhagic stroke in the intensive care…

Thrombolysis for Acute Ischemic Stroke

In 1996, the FDA approved the use of intravenous alteplase for the treatment of acute ischemic stroke after publication of the National Institute of Neurological Disorders and Stroke (NINDS) trial. There were five randomized controlled trials that laid the groundwork for this initial approval and paved the path for thrombolytic therapy for acute stroke . Over the next 20 years, significant advances have occurred in the…

Ultrasound Examination of the Aortic Arch in Stroke

Introduction The presence of protruding or ulcerated atheromas in the proximal segment of the aorta is associated with an increased frequency of peripheral or cerebral embolic events . The association, initially recognized in pathology studies , was confirmed in vivo with the introduction of transesophageal echocardiography (TEE), which rapidly became the diagnostic test of choice for detecting proximal aortic atheromas. TEE has allowed an accurate visualization of…

Conventional Cerebral Arteriography

Introduction Cerebral angiography was introduced and expanded by the Portuguese neurologist Egas Moniz close to a century ago . Significant morbidity and mortality in the first procedures lead to a transition to iodinated solution as contrast media, leading to satisfactory technical results. Despite the original “distrust” and controversy regarding this method and its future , cerebral angiography not only remains the gold standard for the diagnosis…

Transcranial and Cervical Ultrasound in Stroke

Introduction Transcranial Doppler ultrasound (TCD), or transcranial color-coded sonography (TCCS) and duplex ultrasound of extracranial brain supplying vessels are noninvasive methods that can be used at bedside for neurovascular examination ( Fig. 133.1 ). Ultrasound is the safest vessel imaging method that also allows repeated assessments and real-time monitoring. Brightness-mode (B-mode) display has been in clinical use for over four decades to evaluate the vessel wall…

MRI and MRA of Ischemic Stroke

Introduction We image patients with stroke syndromes to establish a diagnosis and to guide patient management, especially when there is a reasonable likelihood of intervention improving outcomes. Computed tomography (CT)- and magnetic resonance imaging (MRI)-based imaging, often in combination, are commonly used. With recent major advances in the treatment of the severe ischemic stroke caused by occlusions of the major cerebral arteries, a critical assessment is…

CT, CT-Angiography, and Perfusion-CT Evaluation of Stroke

Introduction A stroke is a sudden loss of neurological function due to brain parenchyma damage caused by a cerebrovascular disorder. It can be caused either by the sudden loss or significant decrease of blood flow to a specific brain region (ischemic stroke), or by the rupture of blood vessels in the brain (hemorrhagic stroke). Together, stroke is the second most common cause of death worldwide, accounting…

Overview of Neuroimaging of Stroke

Introduction Stroke incurs ischemic or hemorrhagic injury in the brain, typically associated with alterations in the cerebral circulation, including a variety of disorders that affect arteries, capillaries, and venous components. Imaging provides detailed information on brain tissue and vascular anatomy for clinicians to corroborate their clinical history and examination findings in acute stroke cases. The significance of imaging in stroke depends on unraveling the pathophysiology of…