What are the recommended neurointerventional approaches for managing cerebrovascular disease, including acute ischemic stroke and hemorrhagic stroke?

Neurointerventional Approaches for Managing Cerebrovascular Disease

For acute ischemic stroke, endovascular therapy with mechanical thrombectomy is strongly recommended for patients with large vessel occlusion who can be treated within 24 hours of symptom onset, while intra-arterial thrombolysis is indicated for selected patients with major stroke of 6 hours' duration due to middle cerebral artery occlusion. 1, 2

Initial Assessment and Imaging

• Immediate brain imaging with CT or MRI is essential to distinguish between hemorrhagic and ischemic stroke 1, 3
• Vascular imaging (CTA, MRA, or conventional angiography) should be performed during initial evaluation for patients who are candidates for endovascular therapy 1
• For patients presenting within the thrombolytic window (0-4.5 hours), either noncontrast CT or MRI is recommended to exclude intracranial hemorrhage 1
• For patients outside the standard thrombolytic window (>4.5 hours) or with wake-up stroke, advanced imaging with perfusion studies is required to identify salvageable tissue 2

Acute Ischemic Stroke Management

Intravenous Thrombolysis

• IV tPA (0.9 mg/kg, maximum 90 mg) is first-line therapy for eligible patients within 3-4.5 hours of symptom onset 3
• Blood pressure must be maintained <185/110 mmHg before administration and <180/105 mmHg during and for 24 hours after tPA 3
• Aspirin (325 mg) should be administered within 24-48 hours after stroke onset for patients not receiving thrombolysis 1, 3
• Aspirin should not be administered within 24 hours of tPA administration 1

Endovascular Interventions

1. Mechanical Thrombectomy

   • Indicated for patients with large vessel occlusion who can be treated within 6 hours of symptom onset 1, 2
   • Extended window up to 24 hours for selected patients with favorable imaging (small core infarct with salvageable penumbra) 2
   • Requires immediate access to cerebral angiography and qualified interventionalists 1

2. Intra-arterial Thrombolysis

   • Indicated for selected patients with major stroke of ≤6 hours' duration due to middle cerebral artery occlusion 1
   • Reasonable for patients with contraindications to IV thrombolysis, such as recent surgery 1
   • The availability of intra-arterial thrombolysis should not preclude IV tPA administration in eligible patients 1

3. Combined Approaches

   • "Bridging therapy" (IV thrombolysis followed by endovascular treatment) may achieve higher recanalization rates in eligible patients 1

Management of Hemorrhagic Stroke

• For intracranial hemorrhage, vascular imaging (CTA or MRI) should be performed to assess for underlying vascular pathologies such as aneurysms, arteriovenous malformations, or vasculopathies 1
• Surgical options for cerebellar hemorrhage with neurological deterioration include:
  • Suboccipital decompressive craniectomy
  • External ventricular drainage for hydrocephalus 3

Post-Acute Management and Monitoring

• Close neurological monitoring is essential, particularly for cerebellar infarctions due to risk of edema and brainstem compression 3
• For significant edema with neurological deterioration, consider:
  • Osmotic therapy with mannitol 0.25-0.5 g/kg IV every 6 hours
  • Hyperventilation for temporary relief (target PCO₂ 30-35 mmHg)
  • Surgical decompression for patients deteriorating despite medical therapy 3

Common Pitfalls and Caveats

• Delayed recognition and treatment significantly worsen outcomes - "time is brain" 2, 4
• Failure to perform vascular imaging may miss large vessel occlusions that would benefit from endovascular therapy 1
• Relying solely on time windows without considering tissue status (core infarct vs. penumbra) may exclude patients who could benefit from intervention 2
• The MERCI device for mechanical clot extraction has FDA approval but its clinical efficacy has not been fully established in controlled outcomes trials 1
• Neuroprotective agents have shown disappointing results in clinical trials and are not currently recommended outside research settings 1

Special Considerations

• For cerebellar infarctions, vigilant monitoring is crucial due to risk of edema and brainstem compression 3
• Surgical decompression should be considered for patients with cerebellar infarction who deteriorate neurologically despite medical therapy 3
• EC-IC bypass procedures for acute ischemic stroke have failed to improve outcomes and are associated with high risk of intracranial hemorrhage 1

By following these evidence-based neurointerventional approaches for cerebrovascular disease management, clinicians can significantly improve patient outcomes by reducing mortality and improving functional recovery.