Acute Ischemic Stroke: Medical, Endovascular, and Surgical Techniques

265 Pages·2017·21.14 MB·English

by  Jaechan Park (eds.)

Jaechan Park
Editor
Acute
Ischemic Stroke
Medical, Endovascular,
and Surgical Techniques
123
Acute Ischemic Stroke
Jaechan Park
Editor
Acute Ischemic Stroke
Medical, Endovascular,
and Surgical Techniques
Editor
Jaechan Park
Department of Neurosurgery
Kyungpook National University Hospital
Daegu
Republic of Korea
ISBN 978-981-10-0964-8 ISBN 978-981-10-0965-5 (eBook)
DOI 10.1007/978-981-10-0965-5
Library of Congress Control Number: 2017936670
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Preface
Many important advances have occurred in the treatment of acute ischemic
stroke for the past two decades. The NINDS clinical trial of thrombolysis
using recombinant tissue-type plasminogen activator (rtPA), which was pub-
lished in 1995, established medical treatment of acute ischemic stroke within
3 h of stroke onset. Ten years later, MERCI clinical trial using a MERCI
mechanical thrombectomy retriever opened the endovascular era for acute
stroke management within 8 h of stroke onset. Since then, the therapeutic
time window for rtPA has been extended to 4.5 h after stroke onset based on
the ECASS III clinical trial, and various catheter-based and stent-based endo-
vascular thrombectomy devices were developed. Currently, interdisciplinary
management including medical, endovascular, and surgical methods is
required to provide the best management for acute ischemic patients.
This book approaches the topic of management of acute ischemic stroke in
an interdisciplinary manner, explaining how best to utilize the methods cur-
rently available for medical, surgical, and endovascular care. After an open-
ing section on basics including pathophysiology and radiological assessment
of ischemic stroke, comprehensive and up-to-date information is provided on
each of the available therapies, techniques, and practices. Special attention is
paid to recent advances in neurointerventional and neurosurgical procedures,
with clear description of important technical details. The book includes plen-
tiful high-quality case illustrations and a wealth of practical information that
will prove of value in emergency rooms, angiography suites, operating rooms,
and intensive care units. It will aid not only neurologists, neurointervention-
ists, and neurosurgeons but also all others who are involved in the manage-
ment of acute ischemic stroke, from radiologists and emergency physicians to
healthcare providers.
I would like to express my appreciation and acknowledge the efforts of all
contributors to this book. The authors hope that their experience in acute
stroke management woven into this book may be of benefit to physicians who
care for ischemic stroke patients. We look forward to a future in which more
stroke patients are treated with the best possible results due to further advances
and innovations in the multidisciplinary management of ischemic stroke.
Daegu, Korea Jaechan Park, MD, PhD
v
Contents
Part 1 Basics
1 Pathophysiology of Ischemic Stroke � � � � � � � � � � � � � � � � � � � � � � � � 3
Seung-Hoon Lee
2 Pathophysiology of Moyamoya Disease � � � � � � � � � � � � � � � � � � � � 27
Jin Pyeong Jeon and Jeong Eun Kim
3 Radiological Assessment of Ischemic Stroke � � � � � � � � � � � � � � � � 35
Chul-Ho Sohn
4 Histologic Characteristics of Intracranial Clots
Retrieved Using Mechanical Thrombectomy � � � � � � � � � � � � � � � � 59
Woong Yoon
Part 2 Medical Practices
5 General Management and Intensive Care
in Acute Ischemic Stroke � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 73
Yang-Ha Hwang and Yong-Won Kim
6 Cardiac Evaluation and Management After
Ischemic Cerebral Stroke � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 85
Se Yong Jang and Dong Heon Yang
7 Intravenous Thrombolytic Therapy � � � � � � � � � � � � � � � � � � � � � � � 99
Man-Seok Park
8 Acute Ischemic Stroke in Children � � � � � � � � � � � � � � � � � � � � � � � 125
Soonhak Kwon
Part 3 Endovascular Practices
9 History and Overview of Endovascular Stroke Therapy � � � � � 139
Dong-Hun Kang
10 Clot Aspiration Thrombectomy in Acute Ischemic Stroke � � � � 155
Dong-Hun Kang
11 Stent Retriever (Stentriever) Thrombectomy
for Acute Ischemic Stroke � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 191
Byung Moon Kim
vii
viii Contents
12 R efractory Occlusion to Stentriever Thrombectomy:
Etiological Considerations and Suggested Solutions � � � � � � � � � 213
Byung Moon Kim
Part 4 Surgical Practices
13 S urgical Embolectomy for Acute Ischemic Stroke � � � � � � � � � � 229
Jaechan Park
14 Bypass Surgery � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 247
Jeong Eun Kim, Jin Pyeong Jeon, and Won-Sang Cho
15 Decompressive Hemicraniectomy for Malignant
Hemispheric Infarction� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 255
Jaechan Park
Index � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 263
Part 1
Basics
1
Pathophysiology of Ischemic
Stroke
Seung-Hoon Lee
Here, the classification and pathophysiology of tant. Most of the stroke registry studies that have
ischemic stroke will be discussed in detail. been conducted so far revealed that 25–40% of all
Ischemic stroke is often classified for academic stroke patients could not find the cause of their
purposes, but there is actually a very practical stroke [1]. The frequency varies depending on the
reason for its classification. Ischemic stroke is a quality, completeness, and examination timing of
clinical syndrome, which develops not with a the diagnostic tests for stroke etiology. The stroke
single cause but with multiple causes. Ischemic whose cause is not known is called “stroke of
stroke with a different cause would have a differ- unknown cause, or cryptogenic stroke.” Moreover,
ent clinical developmental pattern, and more there are many cases where it has more than two
decisively, the medicine and therapy for treat- possible causes and it is difficult to determine
ment and prevention vary. Thus, its proper confir- which of the causes is the real one (e.g., a case
mation would great influence the patient’s accompanied by atrial fibrillation and significant
prognosis. In this chapter, the classification of stenosis of the internal carotid artery associated
ischemic stroke and the latest knowledge on the with the location of cerebral infarction).
pathophysiology related to it will be presented.
1.1.1 Stroke Data Bank Subtype
1.1 Classification of Ischemic Classification
Stroke
A solid classification system for ischemic stroke
Stroke is classified for various purposes. It is often did not exist previously, but since the advent of
classified for academic purposes, to describe the computed tomography (CT) opened an era of
characteristics of the patients included in a clinical neuroimaging, classification methods have been
study or to classify the patient group according to suggested. Stroke Data Bank Subtype
their characteristics, but the clinical purpose of its Classification is a method that was initially
classification—to determine the appropriate treat- derived from the stroke register protocol of
ment plan for a stroke patient—is also very impor- Harvard University and that classifies stroke into
the following five types indicated in the Stroke
Data Bank established by the National Institute
S.-H. Lee, MD, PhD, FAHA of Neurological Disorders and Stroke (NINDS):
Department of Neurology, Seoul National University (1) brain hemorrhage, (2) brain infarction
Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080,
(atherothrombotic and tandem arterial pathologi-
Republic of Korea
cal abnormalities), (3) cardioembolic stroke,
e-mail: [email protected]
© Springer Science+Business Media Singapore 2017 3
J. Park (ed.), Acute Ischemic Stroke, DOI 10.1007/978-981-10-0965-5_1
4 S.-H. Lee
(4) lacunar stroke, and (5) stroke from rare causes of Oxfordshire community (Table 1.1). At the
or with an undetermined etiology. time, the OCSP researchers were forced to exert
The definition of atherothrombotic brain infarc- efforts to meet the standard of diagnostic tests
tion in this classification is more than 90% stenosis available in the British public healthcare system
in the relevant cerebral artery, which is very limited. because all the stroke patients in the UK are
For this reason, the proportion of patients diagnosed treated by primary care physicians. Besides the
with atherothrombotic brain infarction was under- clinical findings, CT is the best examination
estimated, and as such, the cases of stroke with an method among others, and there was no way at
undetermined etiology increased, representing that time to confirm the problem in the brain ves-
approximately 40% of all the stroke cases. In other sel itself or the presence of a heart disease.
words, in this classification method, the etiology of Therefore, the OCSP researchers chose a method
about half of all stroke patients could not be identi- of classifying patients depending on the site and
fied. Additionally, the definition of lacunar stroke size of their ischemic stroke on a clinical basis.
was too broad, based only on the clinical symptoms As the size and location of ischemic stroke are
and signs, which was inevitable because at the time not determined by the cause of stroke, however,
of establishment of such classification method there even a patient whose stroke is classified as lacu-
were no brain imaging techniques such as CT angi- nar stroke has a possibility of having stenosis in
ography or MR angiography that could determine the M1 portion of middle cerebral artery or atrial
the pathology of the intracranial artery. fibrillation, but there is no way to figure this out
in most cases. In early stage of ischemic stroke,
lesions are not clearly shown on the CT image in
1.1.2 Oxfordshire Community many cases, and in such cases, the patients’
Stroke Project Subtype stroke is classified depending only on the clinical
Classification findings. Thus, approximately 20–30% of stroke
cases are known to have been misclassified. This
Oxfordshire Community Stroke Project (OCSP) classification method, however, depends only on
was originally suggested to identify the charac- the location and size of the ischemic stroke based
teristics of the subjects in epidemiology studies simply on the clinical findings and CT; as such, it
Table 1.1 OSCP classification
Type of infarct Diagnosis
Cerebral If a CT scan performed within 28 days of symptom onset shows an area of low attenuation, no
infarction relevant abnormality or an area of irregular high attenuation within a larger area of low attenuation
(i.e., an area of hemorrhagic infarction) or if a necropsy examination shows an area of cerebral
infarction (pale or hemorrhagic) in a region compatible with the clinical signs and symptoms
Lacunar infarct One of the four classic clinical lacunar syndromes. Patients with faciobrachial or brachiocrural
(LACI) deficits are included, but more restricted deficits are not
Total anterior Combination of new higher cerebral dysfunction (e.g., dysphasia, dyscalculia, visuospatial
circulation disorders), homonymous visual field defect, and ipsilateral motor and/or sensory deficit of at least
infarct (TACI) two areas of the face, arm, and leg. If the conscious level is impaired and formal testing of higher
cerebral function or the visual fields is not possible, a deficit is assumed
Partial anterior Only two of the three components of the TACI syndrome, with higher dysfunction alone or with a
circulation motor/sensory deficit more restricted than those classified as LACI (e.g., confined to one limb or to
infarct (PACI) the face and hand but not the whole arm)
Posterior Any of the following: ipsilateral cranial nerve palsy with contralateral motor and/or sensory deficit,
circulation bilateral motor and/or sensory deficit, disorder of conjugate eye movement, cerebellar dysfunction
infarcts (POCI) without ipsilateral long-tract deficit (i.e., ataxic hemiparesis), or isolated homonymous visual field
defect
OCSP Oxfordshire Community Stroke Project