Avoiding Hemorrhagic Stroke and Confronting All the Rest

Cerebrovascular Disease p. 281-282 April 2014, Vol.20, No.2 doi: 10.1212/01.CON.0000446100.36679.61
Editor’s Preface

Dr Kelly and his team of vascular neurology experts have assembled a practical and contemporary review of the diagnosis, management, and secondary prevention of the diverse etiologies of ischemic stroke—both arterial and venous—that can occur throughout the lifespan.

When Guest Editor Adam Kelly, MD, and I began planning this issue, we envisioned covering the prevention, evaluation, and management of as wide a variety of cerebrovascular disorders as possible in a single issue. To achieve this aim for our readers while at the same time avoiding unnecessary redundancy with other issues, we decided to defer coverage of the management of hemorrhagic stroke to the upcoming (2015) neurocritical care issue of Continuum, where entities such as intraparenchymal and subarachnoid hemorrhage will be covered extensively.

I hope you will be as pleased with the end result as I am. Within this issue Dr Kelly and his team of vascular neurology experts have assembled a practical and contemporary review of the diagnosis, management, and secondary prevention of the diverse etiologies of ischemic stroke—both arterial and venous—that can occur throughout the lifespan.

The issue begins with a bang with a discussion of the evaluation and management of acute ischemic stroke by Dr Pooja Khatri. Dr Khatri provides a state-of-the-art and remarkably practical review of the emergency evaluation and time-dependent diagnostic and acute reperfusion (eg, IV thrombolysis) therapeutic decisions required for the contemporary management of acute ischemic stroke, including a thoughtful summary and analysis of very recent trials assessing the role of endovascular reperfusion interventions. Next, the issue turns to stroke prevention with an article by Drs Shyam Prabhakaran and Ji Chong on risk factor management. In their extremely thorough review, these authors summarize the current evidence for each of the medical and behavioral stroke risk factors and their management—with a focus on those that are modifiable—that neurologists need to be very knowledgeable about as we provide our secondary preventive stroke risk reduction recommendations to patients who have had a stroke or TIA. Next, Dr Anthony Kim discusses the evaluation and prevention of cardioembolic stroke. In his article, Dr Kim provides a discussion and analysis of the diagnostic evaluation to assess for atrial fibrillation (AF)—a common and preventable cause of recurrent stroke—as a patient’s stroke mechanism, as well as risk stratification, the options (new and old) available for oral anticoagulation for stroke prevention in AF, and the most recent data regarding other potential mechanisms of cardioembolic stroke. Drs Seemant Chaturvedi and Pratik Bhattacharya next review the management of large artery disease. These authors provide a state-of-the-art review of the management of symptomatic and asymptomatic carotid artery stenosis, including an analysis of the data comparing carotid endarterectomy and stenting and the current management—and important role of medical therapy—in patients with vertebral artery disease and intracranial atherosclerosis.

Drs Cheryl Bushnell and Gustavo Saposnik next review the evaluation and management of cerebral venous thrombosis. These authors provide a detailed and very clear discussion of the epidemiology, diagnosis, and management of this uncommon but potentially devastating, though treatable, cause of stroke, which tends to affect young adults and especially young women. Continuing with the theme of stroke in young adults, Dr Jason Mackey discusses specific considerations to keep in mind (in addition to standard stroke risk factors) in the diagnosis, evaluation, and management of stroke in patients younger than age 50, including assessing for cervical artery dissections, patent foramen ovale, and potential hypercoagulable syndromes, with an emphasis of the lack of current clarity on the management of the latter two scenarios. Moving on to an even younger age group, Drs Mahendra Moharir and Gabrielle de Veber discuss pediatric arterial ischemic stroke, and we benefit from their extensive combined experience in the diagnosis and management of this increasingly recognized, but still probably underdiagnosed, important cause of long-term morbidity in children.

In a Continuum issue that avoids hemorrhagic stroke, no article may be more apropos than Dr Kelly’s article on unruptured intracranial aneurysms, an entity in which the treatment, if indicated, is specifically intended to avoid subarachnoid hemorrhage (we chose to include this critically important vascular neurology topic in this issue since it is unlikely to be covered elsewhere in the Continuum core curriculum). In this article, Dr Kelly provides a careful review of the considerations surrounding and the most recent studies addressing this complicated issue to help inform our screening, observation, or management recommendations in patients with asymptomatic intracranial aneurysms. Next, Drs Kevin Barrett and James Meschia review genetic stroke syndromes. In their article, which is remarkably devoid of the complicated molecular genetic information sometimes found in articles with similar titles, these authors provide a very clinically relevant discussion of the diagnostic evaluation and management of the most common genetic disorders associated with stroke. The final review article of the issue, by Dr David Rempe, addresses the current status of outcome prediction after transient ischemic attack and stroke. The author carefully discusses and analyzes the various recently developed scores that attempt to predict mortality and functional outcome after stroke and the risk of symptomatic hemorrhage after thrombolysis (as well as stroke following TIA). The article includes a well-thought-out analysis as to why such outcome prediction scores are not currently ready for real-world stroke prognostication or for clinical decision making in regard to thrombolysis.

In this issue’s Ethical Perspectives section, Dr Justin Sattin carefully dissects the ethical considerations involved in telephone consultations for tissue plasminogen activator (tPA) administration in acute stroke, an issue of particular concern in situations—as in the scenarios described by the author—where such consultation is requested when a preexisting telestroke contractual relationship is not in place. These theoretical scenarios will sound very familiar to many of us who have been on the receiving end of such calls or involved in similar, even if less urgent, “curbside” consultations. In the Practice section, Dr James Burke discusses cost and utility in the diagnostic evaluation of stroke. Using a very recognizable and common clinical scenario, the author provides a careful analysis of cost-benefit implications of different diagnostic strategies in the evaluation of stroke etiology. Finally, Drs Timothy Ingall and Bart Demaerschalk discuss coding for telestroke, including both a brief overview of the practice and a review of the current coding, billing, and reimbursement considerations that relate to this activity.

As with every Continuum issue, a number of opportunities exist for CME. If you need to earn credits specifically approved by the American Board of Psychiatry and Neurology (ABPN) for self-assessment, submit your answers to the multiple-choice questions in the Self-Assessment Pretest that were crafted by Drs Ronnie Bergen and Douglas Gelb before you read the issue; review your results to better tailor your learning needs; and then complete the Postreading CME Test after reading the issue. By doing so you may earn up to 12 AMA PRA Category 1 CME Credits toward self-assessment. Alternatively, you may wish to receive credits toward CME only, in which case, reading the issue and submitting the Postreading CME Test will allow you to earn up to 10 AMA PRA Category 1 CME Credits. The Patient Management Problem, written by Dr Kelly, involves the management of a 64-year-old man presenting to the emergency department with an acute ischemic stroke. By following his case and answering multiple-choice questions corresponding to important diagnostic and therapeutic—including acute stroke management and secondary prevention—decision points along the course of his stroke and poststroke care (reinforcing a large number of the same issues discussed in the previous articles) you will have the opportunity to earn up to 2 AMA PRA Category 1 CME Credits.

My sincere thanks to Dr Kelly and his team of expert stroke neurologists (and wonderfully clear writers and educators) for putting this volume together, which covers so much material that will help us provide the most up-to-date and informed management and recommendations to our patients with cerebrovascular disease.

—Steven L. Lewis, MD, FAAN


© 2014 American Academy of Neurology