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Ischemic Stroke

Stroke is an acute neurological syndrome characterized by the sudden onset of a focal deficit caused by the interruption of cerebral blood flow. It can be ischemic (85% of cases) or hemorrhagic (15%). Timely diagnosis of the pathogenesis is critical, as management differs radically. Stroke predominantly affects the elderly population, with an average age in Italy of 74.6 years and a variable incidence between 130-360 cases per 100,000 inhabitants, with a prevalence of 6.5% between 65 and 85 years of age.

Ischemic stroke is caused by an obstruction of cerebral blood flow, which in most cases can derive from thrombosis on an atheromatous plaque, embolism (cardiac or atheromatous), or arterial dissection. The most important risk factors include hypertension, atrial fibrillation, diabetes, dyslipidemia, smoking, obesity, and obstructive sleep apnea syndrome.

Hemorrhagic stroke, less common but no less severe, is caused by the rupture of a cerebral blood vessel, often associated with chronic hypertension, aneurysms, or vascular malformations.

Stroke symptoms appear suddenly and can include:

  • Weakness or paralysis on one side of the face and/or body (hemiparesis/hemiplegia)

  • Altered sensation on one side of the face and/or body

  • Language difficulties (aphasia/dysarthria)

  • Visual disturbances (amaurosis, diplopia)

  • Loss of balance or coordination (ataxia, falls)

  • Mental confusion or reduced state of consciousness

  • Acute headache (rare in ischemic stroke, more common in hemorrhagic stroke)

  • Epileptic seizures (very rare in ischemic stroke, more common in hemorrhagic stroke)

The onset is generally acute and rapid.

 

Brain imaging:

  • Arterial vessel studies with CT angiography (CTA) or MR angiography (MRA): allow visualization of narrowings, vascular occlusions, or morphological abnormalities of the cerebral circulation.

  • Cerebral angiography: useful in selected cases in the context of ischemic stroke with large vessel occlusion, subarachnoid hemorrhages due to aneurysm rupture, or intracerebral hemorrhages with an underlying vascular malformation.

  • Cerebrospinal fluid (CSF) analysis: only in very selected cases, such as in the suspicion of central nervous system vasculitis.

  • Laboratory tests: to evaluate coagulation, blood glucose, lipid profile, and other blood parameters.

  • Computed Tomography (CT): useful for visualizing subacute and chronic ischemic lesions, as well as any hemorrhages.

  • Magnetic Resonance Imaging (MRI): more sensitive for identifying early ischemic lesions.

Available therapies

  • Intravenous thrombolysis: The first major revolution in the therapy of acute ischemic stroke was the introduction of intravenous thrombolysis with tissue plasminogen activator (rt-PA, Alteplase). This drug aims to dissolve the thrombus and restore blood flow in the occluded cerebral artery. It can be safely administered only within 4.5 hours from symptom onset, due to the narrow time window required to reduce the probability of hemorrhagic complications. Recent perfusion studies, available at our Operative Unit, have demonstrated that in selected cases this window can be extended up to 9 hours from the onset of symptoms.

    Mechanical thrombectomy: Since 2014, mechanical thrombectomy has been available, which consists of the endovascular removal of the thrombus. This technique has expanded the therapeutic options in the acute phase of ischemic stroke, although it is constrained by a narrow time window. Our Stroke Unit, through internal study protocols and national and international collaborations, conducts ongoing clinical research on the safety and efficacy of extending the therapeutic window for patients eligible for thrombolysis and/or thrombectomy, as well as the use of new drugs in the acute and sub-acute phases.

    Antithrombotic therapies: Antiplatelet agents such as acetylsalicylic acid and clopidogrel, and anticoagulants in the case of atrial fibrillation or other specific conditions.

    Management of risk factors: Strict control of hypertension, diabetes, dyslipidemia, and promotion of smoking cessation.

    Rehabilitation: Multidisciplinary programs of physical therapy, occupational therapy, and speech therapy for the recovery of impaired neurological functions.

Research in progress

  • Evaluation of new biomarkers, including the analysis of thrombi retrieved during mechanical thrombectomy procedures, for risk stratification, etiological definition of ischemic stroke, and personalization of therapies.
  • Studies on cerebrovascular risk factors, clinical and radiological aspects, and clinical outcomes within the patient population hospitalized at the Policlinico, including quality control.

Reference laboratory

Contacts and informations

Dott.ssa Sara Bonato
Responsabile Stroke Unit

 

Links to scientific publications or useful resources:

Pubblicazione scientifiche del neurologo ricercatore del Centro (Dott. G. Costamagna)
Linee guida società europea di stroke (ESO)
Linee guida società italiana di stroke (ISA-AII)