Cerebrovascular Disease and Neurointerventional Critical Care
Key concepts
Master the distinction between ischemic and hemorrhagic stroke management. For ischemic stroke, the time-critical question is reperfusion: IV thrombolysis window (≤4.5 h with select exceptions) and mechanical thrombectomy for large-vessel occlusion (extended windows with perfusion imaging). Post-thrombolysis monitoring centers on hemorrhagic transformation - watch for neurologic decline, new headache, and blood pressure lability.
For aneurysmal subarachnoid hemorrhage, understand the complications timeline: rebleeding (early), vasospasm/delayed cerebral ischemia (days 3–14), hydrocephalus, and hyponatremia (SIADH vs cerebral salt wasting). Nimodipine is standard; the trap is confusing its role (improves outcomes, not proven to reverse angiographic vasospasm). Blood pressure targets differ between unsecured aneurysm and post-securing.
Intracerebral hemorrhage management emphasizes BP control (systolic ~140), reversal of anticoagulation, and detecting expansion. Know the spot sign and that early deterioration often reflects hematoma growth.
Traps
- Applying ischemic stroke BP goals to ICH or SAH (targets differ).
- Missing vasospasm because transcranial Doppler velocities are normal early - timing matters.
- Assuming permissive hypertension is safe after thrombolysis (it increases hemorrhage risk).
Rule of thumb
"Time is brain" for ischemia; "prevent the second hit" (rebleed, vasospasm, expansion) for hemorrhage.
Worked example
A patient 36 h post-SAH develops confusion and a new focal deficit. Consider delayed cerebral ischemia from vasospasm; maintain euvolemia and MAP, obtain CTA/CTP, and consider endovascular therapy if confirmed.