Table Of ContentMore Advance Praise for
Cerebrovascular Disease
“I am impressed with this unique format of case reports that are each instructive
of a clinical lesson, including modern brain imaging and intravascular approaches
to the diagnosis and treatment of brain lesions. Th e numerous fi gures are ample,
clear, and helpful. Th is little book will fi nd its way in to the pockets of residents
everywhere.”
—Lewis P. Rowland, MD, Neurological Institute, Columbia University
Medical Center, New York, NY
“Dr. Chong’s book provides a thorough review of vascular neurology, all presented
through a series of quickly digested real-life cases. Each case illustrates a common
stroke-related diagnostic or treatment situation, and provides insight into the
approach of an experienced clinician. Th e rationale for decision-making is fully jus-
tifi ed by the available evidence base where data exist, and by sophisticated reasoning
in the gray areas where there are no data. Novices will appreciate the fundamentals
of stroke neurology, but even experts will fi nd new tidbits of information in this
easy-to-read but comprehensive book.”
—Mitchell S. V. Elkind, MD, MS, FAAN, FAHA, Fellowships Director,
Department of Neurology, Columbia University, New York, NY
“Stroke continues to be a major medical problem encountered by many health care
professionals, and it disables many of our patients. In the last few years, we have
made tremendous advances in the diagnosis, treatment, and prevention of stroke.
Dr. Ji Chong has put together this terrifi c book that instructs us, one case at a time,
about many of the evidence-based approaches to manage our stroke patients. As one
of my former stroke fellows at Columbia Presbyterian Medical Center, Ji provides
an energetic and fresh perspective in stroke care. Clinicians are constantly learning
from their patients and communicate with one another about patients every day. Th e
innovative approach in this book of weaving together the careful patient histories,
illustrative brain images, and other diagnostic images coupled with insightful com-
mentaries is a great way to learn about the latest approaches to stroke management.
Each case makes many teaching points and paints a picture to help us care for count-
less other patients in our daily pursuit to reduce the consequences of stroke.”
—Ralph L. Sacco, MD, Chairman of Neurology, Executive Director,
Evelyn McKnight Brain Institute, Olemberg Family Chair in Neurological Disorders,
Miller Professor of Neurology, Epidemiology and Public Health, Human Genetics,
and Neurosurgery, Chief of Neurology, Jackson Memorial Hospital, Miller School of
Medicine, University of Miami, Florida
What Do I Do Now?
SERIES CO-EDITORS-IN-CHIEF
Lawrence C. Newman, MD
Director of the Headache Institute
Department of Neurology
St. Luke’s Hospital Center
New York, New York
Morris Levin, MD
Professor of Neurology and Psychiatry
Geisel School of Medicine at Dartmouth
Lebanon, NH
PREVIOUS VOLUMES IN THE SERIES
Headache and Facial Pain
Peripheral Nerve and Muscle Disease
Pediatric Neurology
Stroke
Epilepsy
Pain
Neuroinfections
Emergency Neurology
Cerebrovascular
Disease
Ji Y. Chong, MD
Director, Stroke Prevention Program
St. Luke’s Roosevelt Hospital
Assistant Clinical Professor of Neurology
Columbia University
New York
3
1
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Library of Congress Cataloging-in-Publication Data
Chong, Ji Y.
Cerebrovascular disease / Ji Y. Chong.
p. ; cm.—(What do I do now?)
Includes bibliographical references and index.
ISBN 978–0–19–990787–8 (pbk. : alk. paper)
I. Title. II. Series: What do I do now?
[DNLM: 1. Stroke—diagnosis—Case Reports. 2. Stroke—therapy—Case Reports. 3. Cerebrovascular
Disorders—diagnosis—Case Reports. 4. Cerebrovascular Disorders—therapy—Case Reports. WL 356]
616.8′1—dc23
2012042265
Th e science of medicine is a rapidly changing fi eld. As new research and clinical experience broaden our
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accordance with the standards accepted at the time of publication. However, in light of the possibility of human
error or changes in the practice of medicine, neither the author, nor the publisher, nor any other party who has
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Dedicated to my patients, who continue to teach me about resilience
and determination. Bud Rowland, who taught me so much about
neurology, writing, and thinking, and to “never appeal to authority.”
Hwa and Hyun Chong; Bonnie and David Cantor; Kevin, Sam, and
Andrew Noah Cantor, for their constant support.
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Preface
Nearly 800,000 people have a stroke each year in the United States. On
average, this means someone has a stroke every 40 seconds. Stroke is the
leading cause of disability in this country. Th ese numbers add up to a huge
public health problem that needs to be tackled from all directions: preven-
tion of fi rst stroke, diagnosis and acute treatment of stroke, and prevention
of recurrent strokes.
Neurologists, and specifi cally vascular neurologists, are the specialists
who primarily treat patients with cerebrovascular disease. But the sheer
number of patients with stroke, as well as the multiple risk factors for
stroke, guarantee that physicians of all disciplines will see a stroke patient.
Although a couple of unusual cases are presented, most of this book deals
with common, practical questions clinicians will encounter. Case presenta-
tions will highlight evidence-based practice. Th ere are clinical trial data to
support many recommendations, but there are also areas in cerebrovascular
disease treatment that are still uncertain. Usual practice in the absence of
strong data will be noted as such.
Cerebrovascular disease is an exciting and evolving fi eld. Many new ther-
apies and risk factors are being investigated, and there is much promise for
signifi cant advances in the coming years.
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Contents
1 Intravenous Tissue Plasminogen Activator (IV tPA) for Acute Ischemic
Stroke 1
IV tPA is the only FDA-approved treatment for acute ischemic stroke. Eligibility
criteria need to be reviewed carefully. It needs to be delivered in a timely fashion,
but select patients may be treated beyond the three-hour window, out to four and
a half hours.
2 Endovascular Treatment for Acute Ischemic Stroke 7
Select patients who are not eligible for IV tPA and are within an eight-hour
window may be treated with other acute endovascular therapies. Mechanical
thrombectomy with various approved devices is often considered in acute large
vessel occlusion, but the benefi ts have not yet been proven in clinical trials.
3 Combination Reperfusion Therapy for Acute Stroke 13
In patients who do not recanalize with IV tPA, adjunctive endovascular therapies
may be used to improve reperfusion in large vessel occlusion. Patients need to
be selected carefully. Registry data suggest some benefi t, but further randomized
trials are needed.
4 Hemorrhagic Complications of tPA 21
Intracerebral hemorrhage is a known complication of tPA. Neurological change
after thrombolysis requires brain imaging to evaluate for hemorrhage. Diff erent
hemostatic agents can be used for symptomatic hemorrhage. Th ere is no
standardized regimen for this complication.
5 Stroke Mimic and Acute Treatment 25
Patients with stroke mimics who are eligible for tPA may safely be treated. Th e
diagnosis of a stroke mimic is typically made after the acute setting when the
window for acute treatment has closed. Th rombolytic treatment of a patient who
is subsequently diagnosed with a stroke mimic has not been associated with brain
hemorrhagic complications.
6 Minor Stroke Symptoms and Acute Treatment 27
Patients with minor stroke symptoms or rapid improvement of symptoms are at
high risk of worsening. Acute treatment with IV tPA is warranted if there is still a
residual defi cit that is disabling. Waiting for resolution of symptoms removes the
possibility of some acute treatments.
7 Hemicraniectomy for Large MCA Stroke 31
Malignant MCA syndromes have high morbidity and mortality from edema, mass
eff ect, and herniation. Hemicraniectomy in select patients is life-saving, but patients
often have signifi cant disability. Younger patients may have the most benefi t.
