Strokes are a major source of morbidity and mortality worldwide. The long-standing gold standard in stroke therapy, intravenous administration of tissue plasminogen activator (tPA), is limited by strict timing parameters and modest efficacy in large strokes caused by thrombi in the proximal cerebral vasculature. Multiple recent randomized controlled trials have demonstrated the efficacy of mechanical thrombectomy for patients with large vessel occlusions (LVOs). Recent clinical guidelines have been updated to include mechanical thrombectomy as a standard of care in properly selected stroke patients, with ongoing and future studies working to refine the optimal clinical and technical variables of this approach.
Part of the book: Ischemic Stroke
Intracerebral hemorrhage (ICH), defined as bleeding within the brain parenchyma, remains a challenging and controversial neurosurgical entity to treat. ICH has a broad range of etiology—stemming from complications associated with traumatic head injury to complications of hemorrhagic stroke. The role of medical management lies in optimizing blood pressure and intracerebral pressure, preventing secondary injury from complications of the hematoma such as seizures, and correcting coagulopathy. Given the mass effect of a hematoma and the possibility of expansion, surgical interventions attempt to evacuate the clot to restore normal intracerebral pressure and prevent worsening neurologic injury. This chapter reviews the recent controversy associated with surgical evacuation of intracerebral hemorrhage placing particular emphasis on the size and location of the hemorrhage and the methods used to evacuate the expanding ICH. Moreover, this chapter reviews considerations and therapeutic goals of the preoperative and postoperative window to minimize complications and optimize patient care.
Part of the book: Hemorrhagic Stroke