The Neuro-Critical Care Management of the Endovascular Stroke Patient

Abstract

Acute ischemic stroke carries high morbidity and mortality. The advent of intravenous thrombolysis and endovascular reperfusion techniques have helped improve clinical outcomes for patients with large vessel acute ischemic stroke. The care of the post-endovascular stroke patient is complex and encompasses almost all aspects of medicine. Hemodynamics should be optimized post procedure to ensure adequate cerebral perfusion and strict hemodynamic parameters must be adhered to minimize reperfusion injury. Though no studies have specifically examined hemodynamic goals, our practice is to maintain a mean arterial pressure (MAP) > 70 and systolic blood pressure (SBP) < 140 for patients following successful recanalization. Early anti-thrombotic therapy is indicated in patients with stent placement. It remains less clear which patients may benefit from additional anticoagulation or therapy with IIb/IIIa inhibitors. Careful consideration must be paid to volume status to reduce risk of contrast nephropathy and maximize cerebral perfusion. Oral care and attention to dysphagia are key in preventing aspiration pneumonia. Glycemic control should be optimized to avoid excessive hyper and hypoglycemia. In the absence of data to guide treatment of anemia, our practice is to transfuse asymptomatic anemia when Hgb < 7 mg/dL, or if the patient is symptomatic or hemodynamically unstable. Neuro-protective strategies should be considered in the context of clinical trials until further studies are complete. At a minimum, fever should be treated aggressively. Young patients with good pre-morbid functional status who continue to have large volume infarcts may benefit from decompressive hemicraniectomy. When appropriate, aggressive and early mobilization is recommended to prepare patients for acute rehabilitation. Because randomized prospective data is lacking, patients should be encouraged to enroll in clinical trials to optimize care of this growing patient population.

White Cord Syndrome Causing Transient Tetraplegia After Posterior Decompression and Fusion

“…Studies have shown that hypertension following mechanical thrombectomy for large vessel occlusions increases complications and worsens outcomes, 19,20 which has led many centers to maintain systolic blood pressure <140 mmHg after successful recannulization. 21 In the same way that blood pressure targets are decreased after thrombectomy of a large vessel occlusion due to open reperfusion, 19 reduction of the MAP target after decompression of a chronically compressed cord may reduce cord edema and reperfusion injury. Future studies for spinal surgeries should investigate not only minimum MAP goals but should also include maximum MAP goals to better guide providers in the neurosurgical care team.…”

Intensive Care Management Following Endovascular Clot Retrieval for Acute Stroke: A Systematic Review of the Literature

“…Basic management of cerebral edema should be followed including reduction in mechanical obstruction by using "neuro tapes" and raising the head of the bed 45,46 . Control of variables associated with raised intracerebral pressure, such as CO2 and serum sodium are not specifically addressed but seem reasonable.…”

Cerebral Hemodynamic Evaluation After Cerebral Recanalization Therapy for Acute Ischemic Stroke

“…The 2018 Guidelines for the Early Management of Patients with Acute Ischemic Stroke recommended blood pressure (BP) should be controlled at <180/105 mmHg (16). Some neurocritical care experts suggest the target systolic BP to be <140 mmHg and mean arterial pressure of >70 mmHg to decrease the incidence of hemorrhage and reperfusion injury (17). Given the fact that cerebral hemodynamic state varies among patients, a “one size fits all” blood pressure could not possibly maintain effective and stable cerebral perfusion in every single patient.…”