Ischemic Stroke
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Presentation of the Series
Emergency in Neurology: A Practical Approach is a series of
books which deal with the most significant chapters in the
scenario of neurological emergencies, in terms of diagnosis,
differential diagnosis and therapy. One particularity of the
philosophy of all the books is the close integration between
the strictly clinical-scientific aspects and the organizational
elements, which are so important for the efficiency and effec-
tiveness of the treatment.
The main themes of the individual volumes are as follows:
• Ischemic stroke
• Hemorrhagic stroke
• Acute loss of consciousness
• Emergencies in neuromuscular diseases
• Neurological emergency during pregnancy
• Neurological emergency in paediatrics
• Delirium, stupor and coma
• Neurological infections
• Spinal emergencies
• Cerebral hyper/hypotension syndrome
• Diagnostic tools in neurological emergencies
• Emergency medical network in neurological disease
All the volumes are structured in the same way, each con-
taining the following chapters:
A. The first chapter is an overview of the most recent progress
in diagnosis and therapy, including the clinical, instrumental
and therapeutic aspects of the acute pathology under dis-
cussion, focusing specifically on the best clinical practices.
v
vi Presentation of the Series
B. A chapter dedicated to clinical pathways and the associ-
ated organizational elements, following principles which
inspired the international guidelines.
C. A review of clinical cases that are typical of the diverse
clinical situations presented daily to the doctors involved
in managing neurological emergencies. After the presen-
tation of each clinical case, the reader finds a series of
questions and topics regarding the case’s management,
and some observations by the co-ordinator of the series.
D. A section dedicated to the differentiated algorithms used
for decision-making, based on the organizational, struc-
tural and technological features of the hospital receiving
the clinical case. This final section of each book is extremely
important for the day-to-day handling of neurological
emergencies. This chapter aims to supply the reader with
all the elements necessary to apply the guidelines and
send the patient on the best clinical pathway, taking into
consideration the diagnostic and therapeutic opportuni-
ties available.
The aim of this series is to provide the specialist with a
useful tool for improving the outcome for patients with acute
and/or time-dependent neurological pathologies, by choosing
a dedicated clinical pathway according to the best practices
and scenarios of the professional and organizational opportu-
nities offered by the clinical centres.
Elio Agostoni, MD
Department of Neurosciences
ASST Grande Ospedale
Metropolitano Niguarda
Milano, Italy
Preface
The acute phase of ischaemic stroke is a time-dependent neu-
rological emergency. Management of the stroke requires a
complex series of programmes and timely actions which can
assure that the process is efficient and the treatment effective.
Since December 2014, scientific literature regarding acute
stroke has been enriched with new evidence which broadens
the range of treatment offered, from simple thrombolysis to
a combination of the procedures of venous thrombolysis and
mechanical thrombectomy. This scenario makes it ever more
necessary to have a dedicated organization whose objective is
to guarantee the best treatment for patients with acute
stroke, always and everywhere.
This volume aims to provide the specialist with a tool of
reference which will help him to send the acute stroke patient
along the pathway in the most efficient and coherent manner,
taking directions from scientific literature and International
Guidelines. The scope of stroke management is extremely
complex, and its developments are a fundamental point of
reference for directing diagnostic, clinical and instrumental
choices, for selecting the patients who qualify for the best
therapy and for defining the aspects of their prognosis. This
book applies a dynamic methodology to deal with current
diagnostic aspects and the latest directions in the guidelines.
Real clinical cases are introduced which record the various
stages of the problems, the diagnostic-therapeutic decisions
and the patients’ clinical pathways: the decision to include
these cases derived from observing the daily reality, which is
then presented to the reader in a critical way through the
reflections and comments of clinical experts.
vii
viii Preface
The importance of this book lies in its determination to
put the best clinical practices into real-life contexts, without
losing sight of the organizational characteristics of the hospi-
tals receiving the acute stroke victim.
In keeping with this concept, the diagnostic-therapeutic
pathways for acute stroke are differentiated according to the
hospitals’ technical, professional and structural characteris-
tics. The philosophy of this volume places the reader in a real
situation and offers the clinical expert the chance to choose
the best pathway, also considering the functional features of
the hospital where the case is to be handled. This paradigm
facilitates the development of pathological networks and
broadens the concept of the ‘Hub and Spoke’ organization
for accurately managing acute ischaemic stroke as a time-
dependent pathology. Making up for any avoidable delay is
the basic element, and it starts with a good organization
which will help the patient’s clinical outcome. In this scenario,
the structural and organizational characteristics of the clini-
cal centres are used to differentiate the clinical pathways for
patients with acute stroke, thus facilitating the clinical expert
in his choices and highlighting the importance of operative
cooperation between the centres in the network.
Milan, Italy The Series Editor and the Authors
Contents
1 Brief Description of Recent Developments
in Diagnosis and Treatment . . . . . . . . . . . . . . . . . . . . 1
1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2.1 Clinical Neurological Evaluation. . . . . . 2
1.2.2 Neuroradiological Diagnosis . . . . . . . . . 2
1.3 Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
1.3.1 Reperfusion Treatment . . . . . . . . . . . . . . 14
1.3.2 Neuroprotection. . . . . . . . . . . . . . . . . . . . 21
1.3.3 Surgical Treatment . . . . . . . . . . . . . . . . . . 22
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
2 Clinical Cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
2.1 Case Study No. 1 . . . . . . . . . . . . . . . . . . . . . . . . . 35
2.1.1 Topics of Discussion . . . . . . . . . . . . . . . . 37
2.2 Case Study No. 2 . . . . . . . . . . . . . . . . . . . . . . . . . 38
2.2.1 Topics of Discussion . . . . . . . . . . . . . . . . 42
2.3 Case Study No. 3 . . . . . . . . . . . . . . . . . . . . . . . . . 43
2.3.1 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . 45
2.4 Case Study No. 4 . . . . . . . . . . . . . . . . . . . . . . . . . 46
2.4.1 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . 50
2.5 Case Study No. 5 . . . . . . . . . . . . . . . . . . . . . . . . . 50
2.5.1 Topics of Discussion . . . . . . . . . . . . . . . . 53
2.6 Case Study No. 6 . . . . . . . . . . . . . . . . . . . . . . . . . 54
2.6.1 Topics of Discussion . . . . . . . . . . . . . . . . 57
2.7 Case Study No. 7 . . . . . . . . . . . . . . . . . . . . . . . . . 58
2.7.1 Topics for Discussion. . . . . . . . . . . . . . . . 61
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
ix
x Contents
3 Organizational Clinical Pathways . . . . . . . . . . . . . . . 65
3.1 Clinical Evaluation in Emergency. . . . . . . . . . . 66
3.2 Neuroimaging. . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
3.3 Indications for Intravenous
Reperfusion Therapy . . . . . . . . . . . . . . . . . . . . . 69
3.4 Indications for Endovascular Therapy . . . . . . . 75
3.5 Monitoring Vital Signs of the Patient
in the Stroke Unit . . . . . . . . . . . . . . . . . . . . . . . . 77
3.6 Management of Transient Ischaemic
Attack . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
3.7 Management of Acute Complications
of Ischaemic Stroke . . . . . . . . . . . . . . . . . . . . . . 80
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
4 Differentiated Decisional Algorithms. . . . . . . . . . . . 87
Abbreviations
ACA Anterior cerebral artery
ACAS Asymptomatic Carotid Atherosclerosis Trial
ACE Angiotensin-converting enzyme
ADC Apparent diffusion coefficient
AHA American Heart Association
AIFA Italian Drug Agency
AMI Acute myocardial infarct
aPTT Activated partial thromboplastin time
ASA American Stroke Association
ASPECTS Alberta Stroke Program Early CT Score
BP Blood pressure
CBF Cerebral blood flow
CBG Capillary blood glucose
CBV Cerebral blood volume
CCO Contralateral carotid occlusion
CEA Carotid endarterectomy
CI Confidence interval
CT Computerized tomography
CVA Cerebrovascular accident
DWI Diffusion-weighted imaging
ECG Electrocardiogram
EEG Electroencephalography
EMA European Medicines Agency
ESO European Stroke Organization
FDA Food and Drug Administration
GPP Good practice point
GRE Gradient echo
HR Heart rate
ICA Internal carotid artery
xi
xii Abbreviations
ICD Intracardiac device
ICP Intracranial pressure
INR International normalized ratio
ISO Italian Stroke Organization
MCA Middle cerebral artery
MRI Magnetic resonance imaging
mRS modified Rankin Scale
MTT Mean transit time
NASCET North American Symptomatic Carotid
Endarterectomy Trial
NIHSS National Institute of Health Stroke Scale
NMR Nuclear magnetic resonance
NNT Number needed to treat
NOACs New oral anticoagulants
NYHA New York Heart Association
OAT Oral anticoagulant therapy
OR Odds ratio
PT Prothrombin time
PTT Partial thromboplastin time
PWI Perfusion-weighted imaging
rtPA Recombinant tissue-type plasminogen
Activator
SPREAD Stroke Prevention and Educational Awareness
Diffusion
TIA Transient ischaemic attack
TT Thrombin time
WHO World Health Organization
Contributors
Elio Agostoni, MD Division of Neurology and Stroke Unit,
Department of Neuroscience, ASST Grande Ospedale
Metropolitano Niguarda, Milano, Italy
Giuseppe D’Aliberti Department of Neuroscience,
Department of Neurosurgery, ASST Grande Ospedale
Metropolitano Niguarda, Milano, Italy
Marco Longoni Department of Neuroscience, Department
of Neurology and Stroke Unit, ASST Grande Ospedale
Metropolitano Niguarda, Milano, Italy
Cristina Motto Department of Neuroscience, Department
of Neurology and Stroke Unit, ASST Grande Ospedale
Metropolitano Niguarda, Milano, Italy
Valentina Oppo Department of Neuroscience, Department
of Neurology and Stroke Unit, ASST Grande Ospedale
Metropolitano Niguarda, Milano, Italy
Valentina Perini Department of Neuroscience, Department
of Neurology and Stroke Unit, ASST Grande Ospedale
Metropolitano Niguarda, Milano, Italy
Luca Valvassori Department of Neuroscience, Department
of Neuroradiology, ASST Grande Ospedale Metropolitano
Niguarda, Milano, Italy
Simone Vidale Division of Stroke Unit and Neurological
Emergiences, Sant’Anna Hospital, Como, Italy
xiii
Chapter 1
Brief Description of Recent
Developments in Diagnosis
and Treatment
Simone Vidale, Giuseppe D’Aliberti, and Luca Valvassori
1.1 Introduction
World Health Organization (WHO) defines stroke as the
sudden onset of neurological symptoms attributable solely to
a brain disorder and caused by a circulatory disorder lasting
more than 24 h.
In Western countries, stroke is the leading cause of severe
disability in adults and the third cause of death [1].
At present, therefore, the scientific community is commit-
ted to actions dedicated to improving the prognosis in terms
of mortality and residual disability.
1.2 Diagnosis
In order to deliver the best possible treatment, correct
diagnosis is needed in the earliest stages after onset of
symptoms. In this respect, at least three elements are of
vital importance in the early evaluation of patients with
suspected ischaemic stroke: medical history, neurological
examination and neuroimaging. The first factor focuses
mainly on accurately gathering data about the timing of the
onset of symptoms, allowing the medical staff to synthesize
the alleged timing of intracranial arterial occlusion. This
G. D’Aliberti et al., Ischemic Stroke, Emergency Management 1
in Neurology, DOI 10.1007/978-3-319-31705-2_1,
© Springer International Publishing Switzerland 2017
2 Chapter 1. Brief Description of Recent Developments
factor is essential in order to practise the best possible
therapy, as will later be explained.
1.2.1 Clinical Neurological Evaluation
The initial diagnostic classification is not possible without an
objective neurological evaluation. Cerebral ischaemia in dif-
ferent vascular territories can present with specific clinical
syndromes, some of which are already pathognomonic of the
aetiology responsible for the event. Lacunar syndromes are
particularly recognizable, totally or partially affecting the
anterior arterial territory, and syndromes related to posterior
vascular territories. In this regard, the National Institute of
Health proposed in the past a rating scale (National Institute
of Health Stroke Scale – NIHSS), based on the execution of
an objective neurological evaluation, allowing the clinical
severity of the disease at onset to be synthesized in one num-
ber (Table 1.1) [2]. The higher the value, the higher the clini-
cal severity. Today this scale is the most universally used, and
it is also standardized in different languages, so that it can be
applied in different countries. In addition, the value of the
NIHSS is also a criterion for the administration of thrombo-
lytic therapy. Since, as previously mentioned, stroke is the
leading cause of disability in adults, to date the modified
Rankin Scale (mRS, Table 1.2) has been taken into account to
exemplify this condition through a numerical value
(Table 1.1). Conventionally, grades 0–1 express total indepen-
dence, but many trials consider a value on the mRS of
between 0 and 2 (box) as a favourable outcome [3].
1.2.2 Neuroradiological Diagnosis
In the acute phase of stroke, the instrumental techniques of
neuroimaging are intended to exclude pathologies like stroke
(stroke mimics) and to distinguish ischaemic lesions from
haemorrhagic lesions, to assess the volume of damaged brain
1.2 Diagnosis 3
Table 1.1 National Institute of Health Stroke Scale (NIHSS) and
modified Rankin Scale (mRS)
NIH Stroke Scale
1a Level of 0 Alert
consciousness
1 Not alert; but arousable by minor
stimulation
2 Not alert; requires repeated
stimulation
3 Responds only with reflex motor
or autonomic effects or totally
unresponsive
2a LOC 0 Answers both correctly
questions
1 Answers one question correctly
2 Answers neither question correctly
1c LOC 0 Performs both tasks correctly
commands
1 Performs one task correctly
2 Performs neither task correctly
2 Best gaze 0 Normal
1 Partial gaze palsy
2 Forced deviation
3 Visual 0 No visual loss
1 Partial hemianopia
2 Complete hemianopia
3 Bilateral hemianopia
4 Facial palsy 0 Normal
1 Minor paralysis
2 Partial paralysis (near- or total
paralysis low face)
3 Complete paralysis of one or both
sides
4 Chapter 1. Brief Description of Recent Developments
Table 1.1 (continued)
NIH Stroke Scale
5 Motor arm 0 No drift
(a) Left arm 1 Drift
(b) Right arm 2 Some effort against gravity
3 No effort against gravity
4 No movement
UN Amputation
6 Motor leg 0 No drift
(a) Left leg 1 Drift
(b) Right leg 2 Some effort against gravity
3 No effort against gravity
4 No movement
UN Amputation
7 Limb ataxia 0 Absent
1 Present in one limb
2 Present in two limbs
UN Amputation
8 Sensory 0 Normal
1 Mild-to-moderate sensory loss
2 Severe-to-total sensory loss
9 Best language 0 No aphasia
1 Mild-to-moderate aphasia
2 Severe aphasia
3 Mute, global aphasia
(continued)
