Acute Cerebral Ischemic Stroke Due to a Major Vessel Occlusion-Standard Treatment Guidelines

Introduction

Cerebral Stroke is a sudden onset neurological deficit due to neurovascular pathological conditions. Ischemic stroke due to a major vessel occlusion forms an important group in cerebral stroke. This is a common condition, predominantly affecting the elderly, as atherosclerosis with/without thrombo-embolism is the commonest etiology. It can also occur due to embolism from cardiac or neck vessel source, vasculitis and arteritis, traumatic or spontaneous dissection and other causes. It usually presents with stroke leading to transient / permanent neurological deficits.

Ministry of Health and Family Welfare, Government of India has issued the Standard Treatment Guidelines for Acute Cerebral Ischemic Stroke Due to a Major Vessel Occlusion.
Following are the major recommendations :

Case definition

The diagnosis is established by CT, MRI supplemented with vascular imaging such as CT angiography / MR angiography / catheter angiography. CT Perfusion or MR perfusion may be necessary. Cerebral ischemic stroke cases due to acute occlusion of a major intracranial vessel like ICA, A1/Proximal A2, M1/Proximal M2 and Basilar artery presenting in the recommended therapeutic time window period are suitable for intra arterial therapeutic recanalization procedures. Stroke due to a small vessel involvement as seen in atherosclerosis or vasculitis leading to lacunar infarction are not considered for intra arterial recanalization procedures.

INCIDENCE OF THE CONDITION IN OUR COUNTRY

Cerebral ischemic stroke is one of the important causes of death/disability in the elderly population.

DIFFERENTIAL DIAGNOSIS
Cerebral ischemic stroke involving a major intracranial vessel may be caused by:
Atherothrombosis
Embolism
Dissection
Trauma

Clinically however stroke like picture may be due to a variety of causes including small vessel involvement as in atherosclerosis or vasculitis, and tumors, infection, demyelination etc.

PREVENTION AND COUNSELLING

Preventive measures as advised for atherosclerosis should be followed. These include-
-Avoidance of smoking
-Low fat diet
-Regular exercise
-Control of blood pressure and diabetes

OPTIMAL DIAGNOSTIC CRITERIA, INVESTIGATIONS, TREATMENT & REFERRAL CRITERIA:

Diagnostic criteria / investigations-

Cerebral ischemic stroke due to acute occlusion of a major intracranial vessel like ICA, A1/Proximal A2, M1/Proximal M2 and Basilar artery presenting in the recommended therapeutic time window period are suitable for intra-arterial therapeutic recanalization procedures. For anterior circulation upto 6-8 hrs from the onset of occlusion of vessel is the recommended therapeutic time window. A longer window period is available for posterior circulation and central retinal artery occlusion. Similarly further deferred therapeutic window period is available for cerebral venous sinus recanalization.

Intracranial hemorrhage, hypertension, deranged clotting parameters, low platelet counts, CT demonstrable infarction occupying more than a third of the hemispheric territory are some of the absolute and relative contraindications.

The imaging modalities used are:

1. CT and/or MRI


2. CT Angiography


3. MR Angiography


4. Catheter angiography


5. CT or MR Perfusion imaging


6. Transcranial Doppler

Treatment - It can be treated by endovascular intra arterial thrombolysis and/or clot retrieval/aspiration. Adjuvant intracranial angioplasty/stenting may be required.

Follow up -CT, MRI and non-invasive angiographic techniques are generally used for follow up and monitoring.

Situation 1: At Secondary Hospital / Non-Metro situation: Optimal Standards of Treatment in situations where technology and resources are limited.

Clinical Diagnosis: Cerebral Stroke is a sudden onset neurological deficit due to neurovascular pathological conditions. Lacunar ischemic stroke and hemorrhagic strokes conditions need to be excluded. After clinical evaluation suitable imaging will be required to establish correct diagnosis.

Investigations:
Hemoglobin, Total and Differential Leucocyte counts, ESR, Blood Sugar, INR, Platelets, Serum Creatinine,
Imaging as mentioned in diagnostic criteria

Treatment: It can be treated by endovascular intra arterial thrombolysis and/or clot retrieval/aspiration. Adjuvant intracranial angioplasty/stenting may be required.

Standard operating procedure
In Patient - All cases should be treated as in patients
Out Patient - Not applicable
Day Care - Not applicable

Referral criteria :
Cerebral ischemic stroke cases due to acute occlusion of a major intracranial vessel like ICA, A1/Proximal A2, M1/Proximal M2 and Basilar artery presenting in the recommended therapeutic time window period are suitable for therapeutic recanalization procedures.

If facilities for standard treatment are not available, patient is referred to super specialty hospital where these facilities are available.

Situation 2 : At super specialty facility in metro location where higher-end technology is available.

Clinical Diagnosis

Cerebral Stroke is a sudden onset neurological deficit due to neurovascular pathological conditions. Lacunar ischemic stroke and hemorrhagic strokes conditions need to be excluded. After clinical evaluation suitable imaging will be required to establish correct diagnosis.

Investigations

Hemoglobin, Total and Differential Leucocyte counts, ESR, Blood Sugar, INR, Platelets, Serum Creatinine,

Cerebral ischemic stroke due to acute occlusion of a major intracranial vessel like ICA, A1/Proximal A2, M1/Proximal M2 and Basilar artery presenting in the recommended therapeutic time window period are suitable for intra-arterial therapeutic recanalization procedures. For anterior circulation up to 6-8 hrs from the onset of occlusion of vessel is the recommended therapeutic time window. A longer window period is available for posterior circulation and central retinal artery occlusion. Similarly further deferred therapeutic window period is available for cerebral venous sinus recanalization.

Intracranial hemorrhage, hypertension, deranged clotting parameters, low platelet counts, CT demonstrable infarction occupying more than a third of the hemispheric territory are some of the absolute and relative contraindications.

The imaging modalities used are
CT and/or MRI
CT Angiography
MR Angiography
Catheter angiography
CT or MR Perfusion imaging
Trans cranial Doppler

Treatment : It can be treated by endovascular intra arterial thrombolysis and/or clot retrieval/aspiration. Adjuvant intracranial angioplasty/stenting may be required.

Standard operating procedure

In Patient - All cases are to be treated as in-patients. They should be treated in
centers equipped with DSA, with roadmap facility and facility of ICU care.
Out Patient - Not applicable
Day Care - Not applicable
Referral criteria: Cerebral ischemic stroke cases due to acute occlusion of a
major intracranial vessel like ICA, A1/Proximal A2, M1/Proximal M2 and Basilar artery presenting in the recommended therapeutic time window period are suitable for therapeutic recanalization procedures.

If facilities for standard treatment are not available, patient is referred to super specialty hospital where these facilities are available.

RESOURCES REQUIRED FOR ONE PATIENT / PROCEDURE (PATIENT WEIGHT 60 KGS)

(Units to be specified for human resources, investigations, drugs and consumables and equipment. Quantity to also be specified)

SITUATION	HUMAN RESOURCES	INVESTIGATIONS	DRUGS & CONSUMABLES	EQUIPMENT
1.	Doctors – 3 (Radiologists/spe cialist trained in neurointervention al procedures.-1, Anaesthetist -1, Neurologist - 1 ) Technicians –1 Nurses – 1	Hemoglobin, Total and Differential Leucocyte counts, ESR, Blood Sugar, INR, Platelets, Serum Creatinine	1. Drugs: Aspirin, Clopidogrel, Nitroglycerine, Nimodipine, Heparin, Non Ionic Iodinated contrast media, Urokinase/rTPA 2. Consumables: Arterial access sheath, Guiding catheter, diagnostic angiography catheter, appropriate guidewires, microcatheter/ microwire, infusion pump, clot removal devices like Merci, Penumbra, Solitaire AB stent device, intracranial angioplasty balloon and balloon mounted stent	Digital subtraction angiography system Multiparameter patient monitor Resucitation equipment Transcranial Doppler preferable.
2.	Minimum Same as mentioned above. In addition, Intensivist 1(desirable)	Same as mentioned above	Same as mentioned above	Same as mentioned above. In addition ACT machine ( for activated clotting time determination) is desirable

Guidelines by The Ministry of Health and Family Welfare :

Dr. Chander Mohan
Dr. B.L. Kapur Hospital
New Delhi