Acute Ischemic Stroke. Medical, Endovascular, and Surgical Techniques

Description

Preface Contents Part 1: Basics 1: Pathophysiology of Ischemic Stroke 1.1 Classification of Ischemic Stroke 1.1.1 Stroke Data Bank Subtype Classification 1.1.2 Oxfordshire Community Stroke Project Subtype Classification 1.1.3 Trial of ORG 10172 in Acute Stroke Treatment (TOAST) Subtype Classification 1.1.4 The Path of Stroke Classification 1.2 Thrombus Formation According to the Stroke Etiology 1.2.1 Formation of Platelet Thrombus 1.2.1.1 Two Independent Pathways for Platelet Activation 1.2.1.2 Propagation of Thrombi Composed of Platelets 1.2.2 Blood Coagulation 1.2.2.1 Contact Activation Pathway (Intrinsic Pathway) 1.2.2.2 TF Pathway (Extrinsic Pathway) 1.2.2.3 Common Pathway 1.2.2.4 Cofactor and Modulator Cofactor Modulator 1.3 Mechanism of Vascular Occlusion Causing Ischemic Stroke 1.3.1 Mechanism of Occlusion in Large-Artery Atherosclerosis 1.3.1.1 Classification of Atherosclerotic Plaque 1.3.1.2 Plaque Rupture 1.3.1.3 Plaque Erosion 1.3.1.4 Calcified Nodule 1.3.2 Mechanism of Occlusion in Small-Vessel Occlusion 1.3.3 Mechanism of Occlusion in Cardioembolism 1.3.3.1 Structural Consideration of the Left Atrium 1.3.3.2 Abnormal Blood Pooling in Atrial Fibrillation 1.3.3.3 Hypercoagulation Status of the Blood 1.4 Changes in Brain Tissues According to Cerebral Ischemia 1.4.1 Mechanism for Regulating the Normal Cerebral Blood Flow 1.4.1.1 Cerebral Blood Flow 1.4.1.2 Cerebral Autoregulation 1.4.2 Structural Factors Involved in the Regulation of the Cerebral Blood Flow 1.4.2.1 Regulation by the Nervous System and the Neurovascular Unit 1.4.2.2 Vascular Endothelial Cell 1.4.2.3 Astrocyte 1.4.3 Change in the Brain Tissue Caused by Ischemic Stroke 1.4.3.1 Confirmation of the Penumbra Region Through Diagnostic Imaging 1.4.3.2 Penumbra Region Defined with Biochemical Indicators 1.4.3.3 Penumbra Region Defined by the Regeneration Mechanism of the Brain References 2: Pathophysiology of Moyamoya Disease 2.1 Background 2.2 Histopathological Features 2.3 Genetics 2.4 Ring Finger Protein 213 2.5 MicroRNAs 2.6 Molecular Biomarkers 2.7 Vascular Progenitor Cells 2.8 Recent Proteomic and Metabolomic Analyses 2.9 MMD in Association with Thyroid Disease References 3: Radiological Assessment of Ischemic Stroke 3.1 Introduction 3.2 Computed Tomography 3.2.1 Noncontrast Computed Tomography 3.2.1.1 Assessing for Ischemic Infarction 3.2.2 Computed Tomography Angiography 3.2.2.1 Assessment of Vascular Occlusion 3.2.2.2 Assessment of Collateral Vascular Status 3.2.2.3 Detection of Ischemic Change 3.2.3 Computed Tomography Perfusion 3.2.3.1 Assessment of Ischemic Penumbra 3.2.3.2 Techniques of CT Perfusion 3.3 Magnetic Resonance Imaging 3.3.1 Diffusion-Weighted Imaging 3.3.2 Susceptibility-Weighted Imaging 3.3.3 MR Angiography 3.3.4 Fluid-Attenuated Inversion Recovery (FLAIR) Imaging 3.3.5 Magnetic Resonance Perfusion Imaging 3.3.5.1 Dynamic-Susceptibility Contrast MR Perfusion Assessment of Penumbra 3.3.5.2 Arterial Spin Labeling MR Perfusion 3.3.5.3 Basic Principle of ASL Perfusion Imaging 3.4 Summary References 4: Histologic Characteristics of Intracranial Clots Retrieved Using Mechanical Thrombectomy 4.1 Red Versus White Clot 4.2 Histologic Analysis of Retrieved Clots 4.3 Clot Compositions and Stroke Etiology 4.4 Clot Compositions and Imaging Characteristics 4.5 Summary and Recommendations References Part 2: Medical Practices 5: General Management and Intensive Care in Acute Ischemic Stroke 5.1 General Supportive Care 5.1.1 Airway Management and Oxygen Supply 5.1.2 Patient Position 5.1.3 Body Temperature 5.1.4 Cardiac Monitoring 5.1.5 Intravenous Fluid Management 5.1.6 Blood Pressure and Arterial Hypertension 5.1.7 Blood Glucose and Hyperglycemia 5.2 Antithrombotic Therapy in Acute Ischemic Stroke 5.3 Intensive Care 5.3.1 ICP Monitoring 5.3.2 Therapeutic Hypothermia References 6: Cardiac Evaluation and Management After Ischemic Cerebral Stroke 6.1 Background 6.2 Cardiac Evaluation 6.2.1 Electrocardiogram (ECG) 6.2.2 Holter Monitor 6.2.3 Event Recorder 6.2.4 Transthoracic Echocardiography (TTE) 6.2.5 Transesophageal Echocardiography (TEE) 6.3 Management and Prevention of Cardioembolic Stroke 6.3.1 Atrial Fibrillation (AF) 6.3.2 Left Ventricular Thrombus 6.3.3 Mitral Stenosis (MS) 6.3.4 Prosthetic Heart Valve 6.3.5 Atrial Septal Abnormality 6.3.6 Infective Endocarditis (IE) 6.3.7 Aortic Atheroma 6.4 Summary and Recommendations References 7: Intravenous Thrombolytic Therapy 7.1 Introduction 7.2 Mechanism of Thrombus Formation and Thrombolysis 7.3 Drugs for Intravenous Thrombolysis 7.3.1 Tissue Plasminogen Activator (tPA) 7.3.2 Large Clinical Trials on tPA 7.3.2.1 ECASS I 7.3.2.2 NINDS 7.3.2.3 ECASS II 7.3.2.4 ATLANTIS 7.3.2.5 Pooled Analysis of NINDS, ECASS, and ATLANTIS Data 7.3.2.6 ECASS III 7.3.2.7 IST-3 7.3.2.8 SITS-MOST and SITS-NEW 7.3.2.9 Trials for Enhancing the Thrombolytic Activity of tPA 7.3.3 Other Thrombolytic Agents 7.3.3.1 Tenecteplase 7.3.3.2 Desmoteplase 7.3.3.3 Ancrod 7.3.3.4 Glycoprotein IIb/IIIa Antagonist 7.3.3.5 Argatroban 7.4 Practical Use of Intravenous tPA in Acute Ischemic Stroke 7.4.1 Protocols for Intravenous tPA Therapy 7.4.2 Management During and After Thrombolytic Treatment 7.5 Factors Affecting the Outcome of Thrombolysis 7.5.1 Thrombus Location, Composition, and Burden 7.5.2 Hyperglycemia 7.5.3 Blood Pressure and Blood Pressure Variability 7.5.4 Age 7.5.5 Time to Thrombolytic Treatment 7.5.6 Dosage of tPA 7.6 Complications of Thrombolytic Therapy 7.6.1 Thrombolysis-Related Intracranial Bleeding 7.6.2 Systemic Bleeding 7.6.3 Angioedema 7.6.4 Reperfusion Injury 7.7 Combination of Intravenous Thrombolysis and Other Treatment Options 7.8 Intravenous Thrombolysis Followed by Endovascular Mechanical Thrombectomy References 8: Acute Ischemic Stroke in Children 8.1 Background 8.2 Risk Factors of Childhood AIS 8.3 Clinical Presentation 8.4 Diagnostic Approach of Childhood AIS 8.5 Treatment of Childhood AIS 8.6 Rehabilitation of Childhood AIS 8.7 Outcomes 8.8 Summary References Part 3: Endovascular Practices 9: History and Overview of Endovascular Stroke Therapy 9.1 Introduction and Recent Evolution of Acute Stroke Management 9.2 Indications and Considerations for Mechanical Thrombectomy 9.2.1 Clinical Indications 9.2.1.1 Time Window 9.2.1.2 Age 9.2.1.3 National Institute of Health Stroke Scale (NIHSS) Score 9.2.2 Radiologic Considerations 9.2.3 Anatomical Considerations 9.3 Evolution of Endovascular Stroke Therapy 9.3.1 Various Old Techniques 9.3.1.1 Mechanical Clot Disruption 9.3.1.2 Intra-arterial Local Urokinase Infusion 9.3.1.3 Mixed Mechanical Clot Disruption and Intra-arterial Local Urokinase Infusion 9.3.1.4 Percutaneous Balloon Angioplasty 9.3.1.5 Intraluminal Clot Disruption Using Ultrasound 9.3.1.6 Intraluminal Clot Disruption Using Laser Technology 9.3.2 Merci Retriever 9.3.3 Penumbra System 9.3.4 Clot Aspiration Thrombectomy 9.3.5 Stent Retriever Thrombectomy 9.4 Summary References 10: Clot Aspiration Thrombectomy in Acute Ischemic Stroke 10.1 Earlier Attempts Using Clot Aspiration Thrombectomy 10.2 New-Generation Clot Aspiration Techniques: FAST and ADAPT 10.2.1 FAST: Forced Arterial Suction Thrombectomy 10.2.2 ADAPT: A Direct Aspiration First Pass Technique 10.2.3 Difference Between FAST and ADAPT Focusing on the Usage of a Balloon Guide Catheter 10.2.4 Step-by-Step Description of the FAST Technique 10.2.4.1 Step 1: Femoral Arterial Puncture and Sheath Insertion 10.2.4.2 Step 2: Balloon Guiding Catheter Placement 10.2.4.3 Step 3: Advancement of Large-Bore Aspiration Catheter 10.2.4.4 Step 4: Balloon Inflation and Manual Aspiration with a Syringe, Then Catheter Retrieval Maintaining Aspiration Force 10.2.5 Technical Tips to Overcome Tortuous Segment During the FAST 10.2.5.1 Use the Softest Aspiration Catheter on the Practitioner’s Hand and Maximize Guiding Catheter Support 10.2.5.2 Steam Shaping of the Tip of Penumbra Aspiration Catheter: 45°, 90°, and J-Shape 10.2.5.3 Coaxial Advancement Technique of the Penumbra Catheter 10.2.6 Additional Case Examples of the FAST 10.2.6.1 Acute ICA Terminus Occlusion 10.2.6.2 Acute MCA Occlusion at M2 Segment 10.3 Combined Usage of Direct Clot Aspiration and Stent Retriever Thrombectomy: Switching Strategy and Solumbra Technique 10.3.1 What Is the Switching Strategy for Mechanical Thrombectomy? 10.3.2 What Is the Solumbra Technique? 10.4 Role of Clot Aspiration Thrombectomy and FAST in Special Conditions of Acute Ischemic Stroke 10.4.1 Proximal Aspiration Thrombectomy for Clot Burden Reduction for ICA Occlusions 10.4.2 FAST for Vertebrobasilar Artery Occlusions 10.4.3 FAST and Acute Stroke Involving Underlying Intracranial Atherosclerotic Stenosis 10.5 Applications of FAST Technique in Other Neurointerventional Procedures 10.5.1 FAST for Thromboembolism During Coil Embolization of Ruptured Cerebral Aneurysm 10.5.2 FAST for Acute Carotid Stent Thrombosis During Carotid Artery Stenting 10.6 Complications of the FAST Technique 10.6.1 Groin Complication 10.6.2 Dissection and Perforation 10.6.3 Procedure-Related Subarachnoid Hemorrhage 10.6.4 Reperfusion Injury Related to Symptomatic Intracranial Hemorrhage 10.6.5 Thrombus Fragmentation and Distal Embolization to New Territories 10.6.5.1 Are There Any Differences in the Incidence of Distal Embolization According to the Technique Used? 10.6.5.2 Can Using a BGC Reduce the Incidence of Distal Embolization? 10.7 Penumbra Reperfusion Catheter and Other Aspiration Catheters 10.8 Summary References 11: Stent Retriever (Stentriever) Thrombectomy for Acute Ischemic Stroke 11.1 Basic Technique 11.1.1 Guiding Catheter Placement 11.1.2 Microcatheter Navigation and Stentriever Deployment 11.1.3 Retrieval of Stentriever 11.2 Complex Situations 11.2.1 Very Tortuous Cervical and Cavernous Segment 11.2.2 A Large Amount of Clots in the Cervical and/or Cavernous Segment 11.2.3 Acute Stroke due to Cervical Artery Atherosclerotic Occlusion References 12: Refractory Occlusion to Stentriever Thrombectomy: Etiological Considerations and Suggested Solutions 12.1 Etiological Considerations for Refractoriness to Stentriever 12.2 Angiographic Discrimination of Non-embolic from Embolic ILAO 12.3 Suggested Solutions for Refractory ILAO Based on Pathomechanism 12.3.1 Solution for Refractory Occlusion Due to Underlying ICAS 12.3.2 Solution for Refractory Occlusion Due to Embolic Organized (Hard) Clot 12.4 Permanent Stenting for Acute ILAO References Part 4: Surgical Practices 13: Surgical Embolectomy for Acute Ischemic Stroke 13.1 Background 13.1.1 Surgical Embolectomy Revisited 13.1.2 Results of Endovascular Recanalization Therapies 13.2 Interdisciplinary Management for Acute Ischemic Stroke 13.2.1 Overall Strategy 13.2.2 Indications of Surgical Embolectomy 13.3 Presurgical Steps 13.3.1 Presurgical Procedures 13.3.2 Surgical Informed Consent 13.4 Surgical Techniques 13.4.1 Craniotomies 13.4.2 Embolectomy 13.4.3 Repair of Arteriotomy 13.4.4 Minimally Invasive and Rapid Surgical Embolectomy (MIRSE) 13.4.5 Superciliary Keyhole Approach 13.4.6 Intradural Procedures 13.5 Postoperative Course 13.5.1 Surgical Results 13.5.2 Subdural Fluid Collection 13.5.3 Intracranial Hemorrhage 13.5.4 Frontalis Muscle Palsy 13.6 Case Illustrations 13.6.1 Case No. 6 13.6.2 Case No. 8 13.6.3 Case No. 10 References 14: Bypass Surgery 14.1 Background 14.2 Carotid Occlusive Disease 14.3 Moyamoya Disease 14.4 Surgical Steps of Direct Bypass 14.5 Case Illustration References 15: Decompressive Hemicraniectomy for Malignant Hemispheric Infarction 15.1 Background 15.2 Recent Clinical Trials 15.3 Surgical Timing and Indications 15.3.1 Timely Surgery 15.3.2 Early Predictors of Malignant Hemispheric Infarction 15.4 Surgical Technique 15.5 Surgical Results According to Patient Age References Index