TY  - CHAP
M1  - Book, Section
TI  - Cerebrovascular Disease
A1  - Powers, William J.
A1  - Jordan, J. Dedrick
A2  - Schmidt, Gregory A.
A2  - Kress, John P.
A2  - Douglas, Ivor S.
PY  - 2023
T2  - Hall, Schmidt and Wood’s Principles of Critical Care, 5<sup>th</sup> Edition
AB  - KEY  POINTSAcute  Ischemic  StrokeWith  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    220/120  mm  Hg,  the  benefit  of  hypertension  management  is  uncertain.Acute  Intracerebral  HemorrhageNo  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    220  mm  Hg,  similar  neutral  outcome  results  were  observed  at  3  monthsCoagulopathy  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  ICHAcute  Subarachnoid  Hemorrhage  due  to  Ruptured  Intracranial  AneurysmWith  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  days  after  aneurysm  rupture.  Those  with  Hunt-Hess  grades  III  through  V  and  Fisher  Scale  of  3  and  4  are  at  highest  risk.  If  symptoms  persist  despite  optimal  intravascular  ...
SN  - 
PB  - McGraw Hill
CY  - New York, NY
Y2  - 2024/10/03
UR  - accesssurgery.mhmedical.com/content.aspx?aid=1201807216
ER  -