CHAPTER 86: Cerebrovascular Disease

KEY POINTS

• Acute Ischemic Stroke

  • With a high probability of acute ischemic stroke based on clinical presentation, CT imaging to exclude intracranial hemorrhage should be performed rapidly.

  • Acute reperfusion therapy is an option if the last time normal (Last Known Normal) is less than 24 hours. The two options are intravenous thrombolysis and mechanical thrombectomy. If eligible, treatment should be initiated as rapidly as possible.

  • Antiplatelet therapy should be given to those not eligible for acute reperfusion therapy. Therapeutic anticoagulation within 48 hours does not improve death or disability compared to aspirin or placebo, even with atrial fibrillation.

  • For patients ≤60 years with large unilateral hemispheric infarctions and decreased consciousness within 48 hours, decompressive craniectomy reduces mortality by 50%; 20% are independent with activities of daily living (ADLs). For those 60 and older, mortality reduction is similar, but <10% are independent.

  • For those with BP <220/120 mm Hg who are not given acute reperfusion therapy, treating hypertension does not improve death or dependency. With BP > 220/120 mm Hg, the benefit of hypertension management is uncertain.

• Acute Intracerebral Hemorrhage

  • No RCTs of intracerebral hemorrhage (ICH) have shown improvement in outcome. Recommendations are based observational studies, inferred pathophysiology, extrapolation from other diseases and expert opinion.

  • Guidelines for a target SBP < 180 mm Hg are derived from expert opinion only. In a subgroup analysis of 228 subjects with initial SBP > 220 mm Hg, similar neutral outcome results were observed at 3 months

  • Coagulopathy must be queried by appropriate laboratory tests and history of medication use, since routinely available tests do not reliably identify coagulopathy due to direct acting oral anticoagulants. Coagulopathies must be corrected as rapidly as possible with appropriate specific agents.

  • Craniotomy with clot evacuation is not beneficial, based on RCTs. Clot removal by minimally invasive procedures shows some benefit, though trials have generally been of poor quality.

  • Continuous EEG monitoring imparts no benefit for patients with ICH

• Acute Subarachnoid Hemorrhage due to Ruptured Intracranial Aneurysm

  • With aneurysmal subarachnoid hemorrhage (SAH), elevated BP should be treated before the onset of vasospasm, with one important exception—comatose patients in whom CT shows marked hydrocephalus. Here, BP should be reduced very cautiously with short-acting agents until the ICP is known. In patients who present several days after hemorrhage and are at risk for vasospasm, the appropriate management of hypertension is less clear. The benefit of preventing rebleeding must be weighed against the risk of worsening neurologic symptoms by lowering BP in the presence of vasospasm.

  • An early short (<72 hours) course of antifibrinolytic therapy may reduce the risk of rebleeding by up to 11%.

  • Nimodipine reduces the incidence and severity of delayed ischemic deficits and improves outcome in SAH.

  • Early aneurysm treatment by clipping or coiling generally occurs 1 to 3 days after rupture for those with grade I to III on the Hunt-Hess scale. The timing of procedures in poor-grade patients (Hunt-Hess grades IV or V) remains controversial.

  • Cerebral vasospasm generally occurs several ...