Chapter 48B: Critical Care of Cerebrovascular Disease

KEY POINTS

1. Stroke is the leading cause of disability and fourth cause of death in the United States. Of the 800,000 annual strokes in the United States, 85% are acute ischemic strokes (AIS).

2. Intensive care issues pertinent to the care of AIS include the recognition and diagnosis of stroke, the provision of fibrinolytics and/or endovascular management, as well the medical management in the 24 hours posttreatment, and management of cerebellar or large hemispheric infarcts (LHIs).

3. Clinical symptoms of stroke are highly heterogeneous and variable and are objectively scored using the National Institutes of Health Stroke Scale (NIHSS).

4. Intravenous recombinant tissue plasminogen activator (IV-rtPA) should be administered as soon as possible to all patients with AIS who meet inclusion/exclusion criteria.

5. Endovascular treatment (EVT) is recommended in AIS patients with an internal carotid artery (ICA) or M1 occlusion who are more than 17 years of age, receiving IV-rtPA and have a prestoke modified Rankin Score (mRS) of 0 to 1, NIHSS greater than 5, and Alberta stroke program early computed tomography score (ASPECTS) greater than 5, and who can have EVT initiated (ie, groin puncture) within 6 hours of their last known well time.

6. During and after the administration of reperfusion therapy (IV-rtPA or endovascular), blood pressure (BP) parameters must be vigilantly maintained (< 180/105 mm Hg). All antiplatelet and anticoagulant medications are held for at least the first 24 hours. Aspirin should be provided 24 hours after IV-rtPA or EVT if the patient is neurologically stable and neuroimaging does not demonstrate hemorrhagic conversion of the infarct.

7. The management of LHI includes therapies aimed to minimize the development of cerebral edema and identifying candidates for decompressive hemicraniectomy (DC).

8. Surgical options in the management of intracerebral hemorrhage (ICH) include craniotomy with or without clot evacuation and, in the setting of obstructive hydrocephalus due to intraventricular hemorrhage, the placement of an intraventricular catheter.

9. Treatment goals for patients with subarachnoid hemorrhage in the first 6 hours include BP control, cardiopulmonary stability, correction of symptomatic hydrocephalus, treatment of intracranial hypertension, reversal of herniation syndromes, and consideration of antifibrinolytics.