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Content Update

August 8, 2019

Endovascular Therapy for Acute Ischemic Stroke, Use Beyond 6 Hours and in Mild Stroke: Endovascular therapy has been shown to have a benefit when used within 6 hours of stroke in patients meeting specific criteria using second generation stent retrievers. The majority of patients receive intravenous (IV) alteplase prior to thrombectomy; however, endovascular therapy may be an option in patients who are not candidates for IV alteplase. The updated 2018 stroke guidelines provide guidance on the use of endovascular therapy beyond 6 hours and in patients with mild stroke. In patients meeting study criteria, functional outcomes were improved with thrombectomy plus standard care with IV alteplase in patients from 6 to 24 hours after symptom onset or patient last known to be well. Endovascular therapy and IV alteplase may have a role in the treatment of patients with mild stroke.

LEARNING OBJECTIVES

LEARNING OBJECTIVES

Upon completion of the chapter, the reader will be able to:

  1. Differentiate types of cerebrovascular disease including transient ischemic attack (TIA), ischemic stroke (cerebral infarction), and hemorrhagic stroke.

  2. Identify modifiable and nonmodifiable risk factors associated with ischemic stroke and hemorrhagic stroke.

  3. Explain the pathophysiology of ischemic stroke and hemorrhagic stroke.

  4. Describe the clinical presentation of TIA, ischemic stroke, and hemorrhagic stroke.

  5. Formulate strategies for primary prevention of acute ischemic stroke.

  6. Evaluate treatment options for acute ischemic stroke.

  7. Determine whether fibrinolytic therapy is indicated in a patient with acute ischemic stroke.

  8. Formulate strategies for secondary prevention of acute ischemic stroke.

  9. Evaluate treatment options for acute hemorrhagic stroke.

INTRODUCTION

Cerebrovascular disease, or stroke, is the second most common cause of death worldwide, and is the fifth leading cause of death in the United States. Stroke can be either ischemic or hemorrhagic and is an acute medical emergency. Rapid treatment dependent on the type of stroke is critical. Treatment of risk factors and preventive measures are also paramount in the management of stroke. Decades of progress in treatment and prevention of stroke have resulted in a decrease in both stroke incidence and stroke case fatality rates.1 Stroke mortality rates are higher in women than men and geographic variability exists, with higher mortality rates observed in the Southeastern United States, termed the “stroke belt.”

EPIDEMIOLOGY

Approximately 795,000 strokes occur in the United States each year. New strokes account for 610,000 of this total; recurrent strokes account for the remaining 185,000. Stroke incidence increases with age, especially after age 55 years, resulting in an increased incidence in the elderly population.2 Stroke is the leading cause of long-term disability in adults, with 90% of survivors having residual deficits. Moderate to severe disability is seen in 70% of survivors and 15% to 30% of stroke ...

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