Alberta Stroke Program Early Computed Tomography (ASPECT) score 10. CT angiography shows no occlusion of large extra- and intracranial arteries.
After discussing the case, it was agreed that there were no indications for endovascular treatment with mechanical thrombectomy. At 22.00, systemic thrombolytic therapy was begun (Actilyse 76.5 mg, of which 7 mg in endovenous bolus and 69.5 mg in continuous endovenous infusion for 60 min). In the meantime, the results of the blood tests arrived, which were normal. Clinical evolution during administration of Actilyse, measured with National Institut of Health Stroke Scale (NIHSS), was as follows:
At 22.15: HT(Hyper tension) 130/80; NIHSS = 7/42
At 22.30: HT 140/80; NIHSS = 7/42
At 22.45: HT 120/80; NIHSS = 7/42
At 23.00: HT 130/75; NIHSS = 7/42
While Actilyse was being given, there was continuous monitoring of blood pressure, heart rate and oxygen saturation. Blood pressure was measured every 5 min and a clinical neurological evaluation was made every 15 min. At the end of systemic thrombolytic therapy, the patient was transferred to the stroke unit. 24 h after onset of symptoms, the brain CT scan without contrast was checked.
Hypodense area in the partial territory of the left middle cerebral artery.
Antiplatelet therapy was started with 100 mg/day of aspirin. After 24 h, the NIHSS was 4/42. From a clinical viewpoint, the patient was alert, could pronounce some words and could understand and follow simple orders. There was complete remission of the hemiparesis of the right side. The clinical evolution after 7 days was favourable, with further improvement of NIHSS = 2/42.
2.1.1 Topics of Discussion
How useful is the “stroke code” in the pre- and in-hospital pathway of the patient with acute stroke?
The “stroke code”, meaning the code for maximum severity for both the pre- and in-hospital pathway, is the most important variable for reducing times in the entire pathway and for minimizing the problem of avoidable delay, as a fundamental organizational moment for the clinical outcome of the acute stroke patient [1]. In various clinical studies, applying the “stroke code”, to both prehospital transportation and in-hospital pathway [2], makes it more likely that stroke patients in the acute phase will be offered the best therapy. In other words: the “stroke code” is a system variable which is absolutely indispensible for a good clinical outcome [3–5].
What is the role of triphasic CT angiography in diagnosing stroke in the acute phase?
CT angiography is a speedy method which identifies the location and extension of the arterial occlusion. The use of CT angiography is decisive in choosing the best revascularization therapy (systemic thrombolysis versus a combined therapy of venous thrombolysis and mechanical thrombectomy). Furthermore, studying vascular anatomy via CT angiography allows the medical staff to plan the strategy for endovascular treatment. Last, but not least important, is that the use of the triphasic technique (extra-intracranial arterial phase, venous phase and late intracranial phase) can reliably establish the presence of collateral circulations. The recent ESCAPE trial (see Chap. 1) on mechanical thrombectomy versus medical therapy used this method in patient selection, demonstrating how the presence of collateral circulations is related to a good outcome and means that the therapeutic window can be extended.
2.2 Case Study No. 2
Presentation of the case of a 51-year-old male. Medical history: hypertension, metabolic syndrome and smoking (40 cigarettes per day), under therapy with ACE inhibitor. At 05.30 in the morning, the patient arrived independently at the emergency department of a high-complexity hospital (Hub) because of onset of stroke, which occurred at 04.00 with left hemisyndrome deficit. The neurologist evaluated the patient at 05.40 and at 05.43 contacted the neurovascular interventionist. The objective neurological exam found loss of visual stimulus of the left hemifield, deficit of the VII left cranial nerve, hemiplegia of the left arm and paresis of the left arm. NIHSS = 11/42 = 0-0-0-0-0-2-(0-4-0-2)-1-0-1-1 = 11. At 06.05, the patient was given a brain CT scan without contrast and a CT angiography with triphasic technique.
ASPECT 9/10 (hypodensity of the right-side basal nuclei), hyperdensity of the right-side MCA.
CT angiography: occlusion of the internal right carotid artery at origin (not shown in the image) caused by a coarse atheromatous fibro-calcified plaque. The intracranial extremity of the carotid is revascularized by the ophthalmic artery, with evidence of occlusion in the M1 segment of the right middle cerebral artery and good compensatory circulations via the usual anastomoses.
At 06.20, blood pressure was 140/85, NIHSS = 11/42. Systemic thrombolytic therapy was begun with 81 mg of Actilyse, of which 8 mg in bolus and 73 mg in continuous endovenous infusion for 60 min. At the same time, preparations were made to transport the patient to the angiograph room. Clinical evolution during administration of Actilyse was as follows:
At 06:35: NIHSS = 11/42
At 06:50: NIHSS = 11/42
At 07:05: NIHSS = 11/42
The patient arrived in the angiograph room at 07.20. The first series of angiographic images were carried out at 07.41.
Description of the procedure: the preliminary angiograph confirmed an occlusion of the internal right carotid artery at origin (Image a) and embolic occlusion of segment M1 of the homolateral middle cerebral artery (Images d–f). A micro guide was then passed through the occluded vessel, various dilations were carried out with an angioplasty balloon and a stent was released to guarantee the vessel’s patency (Images a–c). A thrombus aspiration catheter was then inserted as far as the middle cerebral artery, behind the thrombus, which was then removed via aspiration thus completely reopening the hemispheric circulation (Images e–g).
The procedure was concluded at 09.10. NIHSS = 2/42 at the end of the procedure. There remained a trace of central-type deficit of the VII left cranial nerve and a modest loss of strength in the left arm.
A post-angiography brain CT was carried out, which showed no haemorrhagic complications. A bolus of abciximab 22.5 mg (0.25 mg/kg) was then administered and a 12-h continuous infusion of endovenous abciximab (dose 0.125 ug/kg/min diluted in 50 ml of saline solution). Twenty-four hours later, double antiplatelet therapy was introduced using aspirin and ticlopidine. The patient was given an NMR.
The NMR showed only an ischaemic lesion concerning the lentiform nucleus and the right periventricular region.
Clinical evolution after 5 days was decidedly favourable (NIHSS = 0, mRS = 0, BI 100).
2.2.1 Topics of Discussion
How successful is endovenous thrombolysis likely to be, taking into consideration the morphological data of the CT angiography?
Taking into account the evidence that venous thrombolysis is not very effective in cases of tandem occlusion (as in the present clinical case), the setting of the angiography room must immediately be activated, and endovenous fibrinolysis should in any case be initiated.
Is the use of a carotid stent appropriate in the acute phase?
There is very limited evidence supporting treatment of the acute phase with angioplasty and stenting of the extracranial segment of the carotid: that is, a few retrospective series of cases which do however show that this procedure is effective and relatively safe in selected cases [6, 7]. Although, we must not overlook the fact that insertion of a stent means that antiplatelet therapy must be started immediately [8, 9].
Would it be appropriate to use antiplatelets less than 24 h after thrombolysis?
Using antiplatelets in the first 24 h after acute stroke is controversial [10]; in fact, not only has no benefit ever been demonstrated, but there is evidence to associate this practice with increased mortality, as well as with haemorrhagic phenomena (see Chap. 4 and the ARTIS study). In the case we are referring to, antiplatelet therapy was administered in consideration of the elevated risk of thrombosis of the stent in a patient who, from a clinical point of view, presented a deficit which had improved almost totally (NIHSS = 2).
2.3 Case Study No. 3
Presentation of the case of a 62-year-old man. Medical history: smoking, hypertension and known bilateral carotid stenosis. The patient arrived at the emergency department because of recurrent TIA in the right carotid arterial territory. The neurological examination at the emergency department was normal. The ABCD risk assessment score = 2. The patient was given a CT scan without contrast in urgency.
ASPECT Score 10/10.
An extracranial arterial Doppler was performed at the patient’s bed. It highlighted a right carotid bulb stenosis, with a significant acceleration of flow velocity up to 240 cm/s, corresponding to a >70 % stenosis. The patient was submitted to CT angiography.
Atheromatous plaque of the right carotid bulb with reduction of the vessel lumen of 70 % (Fig. C, arrow), in addition to a nonsignificant stenosis of the left carotid bulb (Fig. D).
On the basis of this evidence, the patient was proposed for early surgery with treatment of carotid thromboendoarterectomy on the third day. The patient underwent preoperative cerebral angiography.
Figure E shows the stenosis on preoperative angiography, on the right.
Figure F shows the post-operatory result.
The patient had a regular postoperative recovery and was discharged on the fifth day.
2.3.1 Discussion
Timing of carotid surgery in urgency.
Although not supported by evidence level I, we think that carotid surgery should be performed as early as possible. The selection criteria for the patient to be submitted to carotid revascularization have already been described in Chap. 1, to which reference is made.
What instrumental investigations are necessary in patients undergoing carotid surgery?
Patients with indication for carotid surgery must undergo carotid Doppler study in addition to an instrumental method of neuroimaging (CT angiography or MRI angiography). Angiography is performed only in selected cases when there is a discrepancy between the two methods or clinical indecision persists.
2.4 Case Study No. 4
Presentation of the case of a 64-year-old man. Medical history: ischaemic cardiopathy in dilated-hypokinetic evolution (New York Heart Association [NYHA] III).
The patient suffered from diabetes, had carried a ventricular assistant device (HeartMate II) since 2009 and was a candidate for a heart transplant (Status 2A). Blood group B positive. The patient carried an intracardiac device (ICD). He was suffering from polidistrectual vasculopathy and had a history of tubulovillous adenoma of the colon which had been removed endoscopically in 2012. He was under therapy with the following drugs: ACE inhibitor, beta-blocker, Cardio Aspirin, dipyridamole, omeprazole, folic acid, statins and warfarin. The patient arrived at the emergency department because of a sudden fall at 23.15 caused by the sudden onset of left hemiplegia. He was transported to the emergency department via EMS with a red code assigned to the transportation. The patient arrived at the emergency department at 00.36. At 00.48, he was given a brain CT scan without contrast.
