Updates in the Management of Cerebral Infarctions and Subarachnoid Hemorrhage Secondary to Intracranial Arterial Dissection: A Systematic Review

Endovascular Treatment for Intracranial Artery Dissections in Posterior Circulation

Intracranial artery dissections (IADs), although uncommon, are an important cause of cerebral infarction and subarachnoid hemorrhage (SAH). Some IADs can heal spontaneously after reconstitution of the vessel lumen with excellent prognosis. Meanwhile, others can progress to stroke that requires treatment. The incidence of IAD in the posterior circulation is higher than that in the anterior circulation. Anterior circulation dissections are more likely to develop into ischemia and posterior circulation lesions into hemorrhage. The mortality rate after IAD among patients with SAH is 19%-83%. Further, the mortality rate of IAD without SAH is 0%-3%. Patients with SAH commonly undergo surgery or receive neuroendovascular treatment (EVT) to prevent rebleeding. However, the treatment of IADs is empirical in the absence of data from randomized controlled trials. Recently, EVT has emerged and is considered for IADs because of its less invasiveness and perceived low rates of procedure-related morbidity with good efficacy. EVT strategies can be classified into deconstructive (involving sacrifice of the parent artery) and reconstructive (preserving blood flow via the parent vessel) techniques. In particular, the number of reports on reconstructive techniques is increasing. However, a reconstructive technique for ruptured IADs has not yet been established. This review aimed to provide an overview of IADs in the posterior circulation managed with EVT by performing a literature search.

Neuroendovascular Surgery Applications in Craniocervical Trauma

Cerebrovascular injuries resulting from blunt or penetrating trauma to the head and neck often lead to local hemorrhage and stroke. These injuries present with a wide range of manifestations, including carotid or vertebral artery dissection, pseudoaneurysm, occlusion, transection, arteriovenous fistula, carotid-cavernous fistula, epistaxis, venous sinus thrombosis, and subdural hematoma. A selective review of the literature from 1989 to 2023 was conducted to explore various neuroendovascular surgical techniques for craniocervical trauma. A PubMed search was performed using these terms: endovascular, trauma, dissection, blunt cerebrovascular injury, pseudoaneurysm, occlusion, transection, vasospasm, carotid-cavernous fistula, arteriovenous fistula, epistaxis, cerebral venous sinus thrombosis, subdural hematoma, and middle meningeal artery embolization. An increasing array of neuroendovascular procedures are currently available to treat these traumatic injuries. Coils, liquid embolics (onyx or n-butyl cyanoacrylate), and polyvinyl alcohol particles can be used to embolize lesions, while stents, mechanical thrombectomy employing stent-retrievers or aspiration catheters, and balloon occlusion tests and super selective angiography offer additional treatment options based on the specific case. Neuroendovascular techniques prove valuable when surgical options are limited, although comparative data with surgical techniques in trauma cases is limited. Further research is needed to assess the efficacy and outcomes associated with these interventions.

Antiplatelets Versus Anticoagulation in Cervical Artery Dissection: A Systematic Review and Meta-analysis of 2064 Patients

BACKGROUND AND OBJECTIVES

In young people aged < 50 years, cervical artery dissection (CeAD) is among the most common causes of stroke. Currently, there is no consensus regarding the safest and most effective antithrombotic treatment for CeAD. We aimed to synthesize concrete evidence from studies that compared the efficacy and safety of antiplatelet (AP) versus anticoagulant (AC) therapies for CeAD.

METHODS

We searched major electronic databases/search engines from inception till September 2021. Cohort studies and randomized controlled trials (RCTs) comparing anticoagulants with antiplatelets for CeAD were included. A meta-analysis was conducted using articles that were obtained and found to be relevant. Mean difference (MD) with 95% confidence interval (CI) was used for continuous data and odds ratio (OR) with 95% CI for dichotomous data.

RESULTS

Our analysis included 15 studies involving 2064 patients, 909 (44%) of whom received antiplatelets and 1155 (56%) received anticoagulants. Our analysis showed a non-significant difference in terms of the 3-month mortality (OR 0.47, 95% CI 0.03-7.58), > 3-month mortality (OR 1.63, 95% CI 0.40-6.56), recurrent stroke (OR 0.97, 95% CI 0.46-2.02), recurrent transient ischaemic attack (TIA) (OR 0.93, 95% CI 0.44-1.98), symptomatic intracranial haemorrhage (sICH) (OR 0.38, 95% CI 0.12-1.19), and complete recanalization (OR 0.70, 95% CI 0.46-1.06). Regarding primary ischaemic stroke, the results favoured AC over AP among RCTs (OR 6.97, 95% CI 1.25-38.83).

CONCLUSION

Our study did not show a considerable difference between the two groups, as all outcomes showed non-significant differences between them, except for primary ischaemic stroke (RCTs) and complete recanalization (observational studies), which showed a significant favour of AC over AP. Even though primary ischaemic stroke is an important outcome, several crucial points that could affect these results should be paid attention to. These include the incomplete adjustment for the confounding effect of AP-AC doses, frequencies, administration compliance, and others. We recommend more well-designed studies to assess if unnecessary anticoagulation can be avoided in CeAD.

Related Factors of Cerebral Hemorrhage after Cerebral Infarction and the Effect of Atorvastatin Combined with Intensive Nursing Care

Background

Cerebral infarction is a common neurological disease with high incidence, which is the main factor causing death and disability in adults in China. Cerebral hemorrhage transformation is a common clinical complication. High NIHSS score at admission, atrial fibrillation, and small artery occlusion cerebral infarction can increase the risk of cerebral infarction complicated with hemorrhage transformation.

Aim

To explore the related factors of cerebral hemorrhage transformation after cerebral infarction and the value of atorvastatin calcium tablets combined with early intensive care measures.

Methods

In this study, a case-control study was conducted. Sixty patients with hemorrhagic transformation after cerebral infarction admitted to the Department of Neurology of our hospital from January 2017 to June 2021 were selected as the observation group, and 90 patients with cerebral infarction without hemorrhagic transformation during the same period were selected as the control group. The risk factors of hemorrhagic transformation after cerebral infarction were analyzed.

Results

The results of logistic regression model showed that the increased National Institutes of Health Stroke Scale (NIHSS) score at admission, hypertension, atrial fibrillation, TOAST classification of small artery occlusion, and large infarction lesions were the risk factors for hemorrhagic transformation in patients with cerebral infarction (P < 0.05). After 2 weeks and 4 weeks of treatment, the NIHSS scores of the intervention group were lower than those of the conventional group (P < 0.05). NIHSS scores of the two groups after treatment were significantly lower than those before treatment (P < 0.05). After three months of treatment, the patients in the intervention group with GOS score of 5 points accounted for 16.67%, and the patients with GOS score of 4 points accounted for 56.67%. The patients in the conventional group with GOS score of 5 points accounted for 6.67%, and the patients with GOS score of 4 points accounted for 33.33%. The prognosis of the intervention group was better than that of the conventional group on the whole (P < 0.05).

Conclusion

Patients with hypertension, large infarction lesions, high NIHSS score at admission, atrial fibrillation, and small artery occlusion cerebral infarction can increase the risk of bleeding transformation in patients with cerebral infarction. For patients with bleeding transformation, atorvastatin calcium tablets combined with early intensive nursing intervention has a certain value for improving the prognosis of patients.

Neurocritical care management of poor-grade subarachnoid hemorrhage: Unjustified nihilism to reasonable optimism

BACKGROUND AND PURPOSE

Historically, overall outcomes for patients with high-grade subarachnoid hemorrhage (SAH) have been poor. Generally, between physicians, either reluctance to treat, or selectivity in treating such patients has been the paradigm. Recent studies have shown that early and aggressive care leads to significant improvement in survival rates and favorable outcomes of grade V SAH patients. With advancements in both neurocritical care and end-of-life care, non-treatment or selective treatment of grade V SAH patients is rarely justified. Current paradigm shifts towards early and aggressive care in such cases may lead to improved outcomes for many more patients.

MATERIALS AND METHODS

We performed a detailed review of the current literature regarding neurointensive management strategies in high-grade SAH, discussing multiple aspects. We discussed the neurointensive care management protocols for grade V SAH patients.

RESULTS

Acutely, intracranial pressure control is of utmost importance with external ventricular drain placement, sedation, optimization of cerebral perfusion pressure, osmotherapy and hyperventilation, as well as cardiopulmonary support through management of hypotension and hypertension.

CONCLUSIONS

Advancements of care in SAH patients make it unethical to deny treatment to poor Hunt and Hess grade patients. Early and aggressive treatment results in a significant improvement in survival rate and favorable outcome in such patients.

[Long-term cognitive and functional status in survivors of an aneurysmal subarachnoid hemorrhage: Analysis of a retrospective cohort]

OBJECTIVE

Little data is available on long-term functional and cognitive outcomes in patients with aneurysmal subarachnoid hemorrhage (ASH). The main objective of this study was to assess cognition, functional state, mood disorders, and quality of life in patients with SAH at least six months following the ASH.

PATIENTS AND METHODS

Cross-sectional study of 40 patients (aged 58.2 [SD 9.9] years) with ASH, discharged from a Neurologic Rehabilitation unit between January 2010 and July 2017.

MAIN OUTCOME VARIABLES

functional status (Barthel index), cognition (Pfeiffer questionnaire), depression (Hamilton scale), and health-related quality of life (European Quality of Life-5 Dimensions [EQ-5D]), as well as type and duration of therapeutic rehabilitation procedures after discharge.

RESULTS

From 35 patients with cognitive disorders, only 12 received cognitive therapy at hospital discharge. In the long-term follow-up, cognitive impairment persisted in 22 patients. When compared with those without cognitive impairment, they presented significantly worse mean differences in the Barthel index (15.5 [95% CI: 1.2-29.7]), Hamilton scale (-0.8 [95% CI: -1.27 to -0.37]), and EQ-5D (27.6 [95% CI: 12.4-19]).

CONCLUSION

The prevalence of long-term cognitive impairments in survivors of a SAH episode is high, and their presence is associated with worse functional status, more depression and worse quality of life. The low percentage of subjects who received cognitive therapies through their recovery process and the clinical implications observed, support the need of including neuropsychological therapies in the rehabilitation programs after an SAH event.