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The authors grant unrestricted publishing and distribution rights to the publisher. The electronic versions of the chapters are published under Creative Commons Attribution-NonCommercial 4.0 International (<a href="https://creativecommons.org/licenses/by-nc/4.0/" target="_blank" rel="noopener">CC BY-NC 4.0</a>). Users are allowed to share and adapt the chapters for any non-commercial purposes as long as the authors and the publisher are explicitly identified and properly acknowledged as the original source. The books in their entirety are subject to copyright by the publisher. The reproduction, modification, republication and display of the books in their entirety, in any form, by anyone, for commercial purposes are strictly prohibited without the written consent of the publisher.</p> Front Matter https://exonpublications.com/index.php/exon/article/view/376 STROKE Seena Dehkharghani, MD (Editor) Copyright (c) 2021 Exon Publications https://creativecommons.org/licenses/by-nc/4.0 2021-06-18 2021-06-18 10.36255/exonpublications.stroke.2021.frontmatter Foreword https://exonpublications.com/index.php/exon/article/view/377 <p>Stroke continues to be a leading cause of mortality and morbidity worldwide. It affects nearly 795,000 patients in the United States, resulting in increased disability and health care costs, and resource utilization. Stroke prevention and treatment require a multidisciplinary team of experienced providers to ensure appropriate stroke prevention strategies are performed, acute therapies are provided to eligible patients, as well as rehabilitation and recovery strategies are implemented. Therefore, it is of paramount importance to focus on all these aspects of stroke care to improve patient outcomes. Over the years, we have witnessed a significant transformation in acute stroke treatment. In 1995, the NINDS tPA trial showed a significant benefit of alteplase in improving the functional outcomes of patients with acute ischemic stroke and 20 years later, in 2015, several randomized controlled trials proved the benefit of mechanical thrombectomy using stent retrievers in patients with acute ischemic stroke due to a proximal large artery occlusion.. <a href="https://exonpublications.com/index.php/exon/article/view/377/681">CONTINUE READING.....</a></p> Shadi Yaghi, MD, FAHA Copyright (c) 2021 Shadi Yaghi, MD, FAHA https://creativecommons.org/licenses/by-nc/4.0 2021-06-18 2021-06-18 vii vii 10.36255/exonpublications.stroke.foreword.2021 Preface https://exonpublications.com/index.php/exon/article/view/378 <p>Stroke remains a central, global risk to public health, and a pernicious source of mortality and loss of independence in those afflicted. The preceding decade has seen the transformation of the stroke management landscape, with disruptive diagnostic, therapeutic, prognostic, and rehabilitative strategies rapidly introduced to the armament of clinical and basic stroke neuroscience providers and investigators. Nevertheless, a disappointingly small percentage of stroke patients benefit directly from these advancements, and a staggeringly large percentage of patients remain stricken by consequences of stroke in the modern era. This text offers a unique view of this condition—a human condition which knows no geographic boundaries and continues to draw the attention of an indefatigable community of physicians, scientists, engineers, nurses, and allied care personnel synthesizing the latest among contemporary philosophies regarding the care of such patients. The authors address stroke occurring across all epochs of life, beginning in gestation and continuing through childhood, early adulthood, and well into adult life. <a href="https://exonpublications.com/index.php/exon/article/view/378/680">CONTINUE READING…..</a></p> Seena Dehkharghani, MD Copyright (c) 2021 Seena Dehkharghani, MD https://creativecommons.org/licenses/by-nc/4.0 2021-06-18 2021-06-18 ix ix 10.36255/exonpublications.stroke.preface.2021 Contributors https://exonpublications.com/index.php/exon/article/view/379 <p><strong>ADAM E. GOLDMAN-YASSEN, MD, MS</strong><br>Department of Radiology and Imaging Sciences, Emory University and Children’s Healthcare of Atlanta, Atlanta, GA, USA</p> <p><strong>AIKO OSAWA, MD, PHD</strong><br>Department of Rehabilitation Medicine, National Center for Geriatrics and Gerontology, Aichi, Japan</p> <p><strong>BLAKE S. GERSHON, BS</strong><br>Cerebrovascular Center, Department of Neurosurgery, Mount Sinai, New York, NY, USA</p> <p><strong>BRYONY L. MCGARRY, PHD</strong><br>PRECISE4Q Predictive Modelling in Stroke, Technological University Dublin, Dublin, Ireland</p> <p><strong>CHRISTOPHER A. STACK, MD</strong><br>Stroke Program, University of Maryland Baltimore Washington Medical Center, MD, USA</p> <p><strong>DEVIN V. BAGEAC, BS, BA</strong><br>Cerebrovascular Center, Department of Neurosurgery, Mount Sinai, New York, NY, USA</p> <p><strong>JOHN W. COLE, MD, MS</strong><br>Department of Neurology, University of Maryland School of Medicine and Baltimore Veterans Affairs Medical Center, MD, USA</p> <p><strong>MICHAEL T KOLTZ, MD</strong><br>Department of Neurosurgery, Dell Medical School, The University of Texas at Austin, Austin, TX, USA</p> <p><strong>PETER CSECSEI, MD, PHD</strong><br>Department of Neurosurgery, University of Pecs, Medical School, Pecs, Hungary</p> <p><strong>READE A. DE LEACY, MD</strong><br>Cerebrovascular Center, Department of Neurosurgery, Mount Sinai, New York, NY, USA</p> <p><strong>RISTO A. KAUPPINEN, MD, PHD</strong><br>Department of Electrical and Electronic Engineering, Merchant Venturers Building, University of Bristol, Woodland Road, Bristol BS8 1UB, UK</p> <p><strong>SEENA DEHKHARGHANI, MD</strong><br>Departments of Radiology and Neurology, New York University Langone Medical Center, New York, NY, USA</p> <p><strong>SEREFNUR OZTURK, MD, FEAN</strong><br>Selcuk University Faculty of Medicine, Department of Neurology and Neurointensive Care, Konya, Turkey</p> <p><strong>SHINICHIRO MAESHIMA, MD, PHD</strong><br>Kinjo University, Ishikawa, Japan</p> <p><strong>TIHAMER MOLNAR, MD, PHD</strong><br>Department of Anesthesiology and Intensive Care, University of Pecs, Medical School, Pecs, Hungary</p> <p><strong>VIKRAANT KOHLI, BS</strong><br>Department of Neurosurgery, Dell Medical School, The University of Texas at Austin, Austin, TX, USA</p> List of Contributors Copyright (c) 2021 Exon Publications https://creativecommons.org/licenses/by-nc/4.0 2021-06-18 2021-06-18 xi xii 10.36255/exonpublications.stroke.contributors.2021 Neuroimaging in Perinatal Stroke and Cerebrovascular Disease https://exonpublications.com/index.php/exon/article/view/367 <p><strong>ABSTRACT</strong></p> <p>Approximately one-quarter of childhood strokes occur in the perinatal period, which includes both fetuses and neonates, affecting between one in 2300–5000 births and representing the primary cause of cerebral palsy. Although the pathogenesis is incompletely understood, risk factors for perinatal stroke are often unique from strokes at other ages, with a combination of maternal, obstetric, anatomic, and genetic factors or predispositions leading to infarct. Clinical presentations of perinatal stroke differ from strokes in older children and adults, often presenting as encephalopathy, seizure, altered mental status, or neurologic deficits. However, neuroimaging remains equally indispensable for diagnosis and prognostication. Here, we provide a comprehensive review of perinatal strokes occurring in fetal and neonatal periods, and discuss the etiologies, diagnosis, management, and prognosis, with a focus on neuroimaging utilization and findings. Understanding the appropriate use of imaging in the distinct clinical entity of perinatal stroke is important for guiding appropriate clinical management.</p> Adam E. Goldman-Yassen, MD, MS Seena Dehkharghani, MD Copyright (c) 2021 Adam Goldman-Yassen, Seena Dehkharghani https://creativecommons.org/licenses/by-nc/4.0 2021-06-18 2021-06-18 1 24 10.36255/exonpublications.stroke.perinatalstroke.2021 Neuroimaging in Pediatric Stroke and Cerebrovascular Disease https://exonpublications.com/index.php/exon/article/view/368 <p><strong>ABSTRACT</strong></p> <p>Although less common than in adults, stroke is the sixth leading cause of death in children, affecting ~2–13 children per 100,000 under 18 years of age. Because it is underappreciated clinically, the diagnosis of pediatric stroke is often delayed or even missed, or misdiagnosed as more common conditions such as migraine, epilepsy, or viral illnesses. Since pediatric stroke is caused by unique etiologies and can present differently than in adults, diagnostic imaging should be tailored to the specific and diverse causative entities and distinctive needs of the pediatric population. This chapter provides a comprehensive review of pediatric stroke, including the etiologies, diagnosis, and management, emphasizing the role of neuroimaging in diagnostic and treatment pathways. Understanding the distinct clinical entity of pediatric stroke and the role of imaging in diagnosis is important for early detection and treatment of this underappreciated disease.</p> Adam E. Goldman-Yassen, MD, MS Seena Dehkharghani, MD Copyright (c) 2021 Adam Goldman-Yassen, Seena Dehkharghani https://creativecommons.org/licenses/by-nc/4.0 2021-06-18 2021-06-18 25 51 10.36255/exonpublications.stroke.pediatricstroke.2021 The Clinical Approach to Stroke in Young Adults https://exonpublications.com/index.php/exon/article/view/319 <p><strong>ABSTRACT</strong></p> <p>Stroke in younger adults is less common than in older adults, with approximately 10-15% of all strokes occurring in adults aged 18 to 50 years of age. The pathogenesis of stroke in younger adults requires additional considerations for several less common risk factors and etiologies. As with any stroke patient, a thorough workup including evaluations of the brain, the blood vessels of the head and neck, the heart, and basic bloodwork must be performed. On the basis of these results, as well as case-specific clinical findings, family history, and other considerations, additional testing for genetic or hypercoagulable causes and specialized vascular and echocardiography can be performed. Overall, it is critical to identify the likely pathogeneses to prevent stroke recurrence. Regardless of pathogenesis, young stroke survivors with high rates of traditional risk factors must have these risk factors aggressively managed for long-term risk reduction. In this chapter, we focus on ischemic stroke in the young emphasizing a clinical evaluation framework, describing key considerations regarding etiology, treatment, and prevention that providers should contemplate in course of individualized patient care.</p> John W. Cole, MD, MS Christopher A. Stack, MD Copyright (c) 2021 John W. Cole, MD, MS, Christopher A. Stack, MD https://creativecommons.org/licenses/by-nc/4.0 2021-06-18 2021-06-18 53 78 10.36255/exonpublications.stroke.adultstroke.2021 Timing the Ischemic Stroke by Multiparametric Quantitative Magnetic Resonance Imaging https://exonpublications.com/index.php/exon/article/view/321 <p><strong>ABSTRACT</strong></p> <p>The advent of recanalization therapies has transformed the management of acute ischemic stroke patients. The timing of symptom onset is one of the key criteria for selecting the recanalization method as pharmacological and non-pharmacological recanalization therapies are only safe when administered within strict, but evolving, time windows. Magnetic resonance imaging (MRI) reveals ischemia within minutes and estimates ischemia duration in brain parenchyma. Preclinical studies have shown that by combining diffusion and relaxometric MRI, timing ischemic strokes is possible with clinically acceptable accuracy. MRI-based stroke timing techniques have been adopted in stroke clinics to stratify patients with unknown onset time for intravenous thrombolysis, resulting in improved outcomes in clinical trials. More recent MRI approaches use absolute apparent diffusion coefficient (ADC) and T<sub>2</sub>&nbsp;relaxation time data in a user-independent manner to estimate the stroke onset time in absolute terms. The introduction of expedited MRI acquisition protocols has made MRI a fast neuro-diagnosis modality. Exploiting advanced technologies such as Magnetic Resonance Fingerprinting (MRF), artificial intelligence (AI), and machine learning (ML) for the post-processing of MRI data, combined with fast MRI techniques, is expected to speed up the translation of objective stroke timing procedures into patient management.</p> Bryony L. McGarry, PHD Risto A. Kauppinen, MD, PHD Copyright (c) 2021 Bryony L. McGarry, PHD, Risto A. Kauppinen, MD, PHD https://creativecommons.org/licenses/by-nc/4.0 2021-06-18 2021-06-18 79 96 10.36255/exonpublications.stroke.timingischemicstroke.2021 Indications for Surgical Intervention in the Treatment of Ischemic Stroke https://exonpublications.com/index.php/exon/article/view/309 <p><strong>ABSTRACT</strong></p> <p>Stroke is a leading cause of morbidity and mortality worldwide. The increasing prevalence of acute ischemic stroke treatment has stimulated many areas of active research and contributions to literature, particularly advancements in surgical management. The aim of this chapter is to provide a comprehensive review of the indications for surgical intervention in the treatment of ischemic stroke. Specifically, the evidence surrounding the indications for mechanical thrombectomy, ventriculostomy and decompressive craniectomy is discussed. Decompressive craniectomy is further divided into individual sections on hemicraniectomy and suboccipital craniectomy. Furthermore, mechanical thrombectomy is analyzed with consideration for the plethora of recent data on perfusion imaging.</p> Michael T. Koltz, MD Vikraant Kohli, BS Copyright (c) 2021 Michael T. Koltz, MD, Vikraant Kohli, BS https://creativecommons.org/licenses/by-nc/4.0 2021-06-18 2021-06-18 97 109 10.36255/exonpublications.stroke.surgicalintervention.2021 Memory Impairment Due to Stroke https://exonpublications.com/index.php/exon/article/view/304 <p><strong>ABSTRACT</strong></p> <p>Stroke impairs episodic memory, while retaining immediate and remote memory. Cerebral hemorrhage/infarction in the Papez and Yakovlev circuits (episodic memory) manifests as memory loss. Extensive medial temporal lobe damage impairs retrieval of old memories. Hippocampal damage causes anterograde amnesia. Damage to the hippocampus and parahippocampal gyri causes severe retrograde amnesia. Retrosplenial lesions may cause memory loss if the fibrous communication between the hippocampus and anterior thalamic nucleus is impaired. Basal forebrain amnesia impairs recall but the aspect providing retrieval clues remains relatively intact. Corpus striatum and basal forebrain damage results in serious memory loss. Other cognitive functions require evaluation using intelligence (WAIS-IV) and executive function tests, along with memory loss assessments. The WMS-R can evaluate memory after stroke. The RBMT elucidates the nature of memory loss, especially in the elderly. Cognitive rehabilitation with repetitive training and internal-memory strategies aims to activate the memory processes. External strategies and environmental adjustments provide effective clues and replicate the environment. Rehabilitation protocols should directly solve problems encountered in daily life. This chapter provides an overview of the anatomical basis of memory, pathophysiology of underlying memory loss, and assessment for stroke.</p> Shinichiro Maeshima, MD, PHD Aiko Osawa, MD, PHD Copyright (c) 2021 Shinichiro Maeshima, MD, PHD, Aiko Osawa, MD https://creativecommons.org/licenses/by-nc/4.0 2021-06-18 2021-06-18 111 119 10.36255/exonpublications.stroke.memoryimpairment.2021 Unilateral Spatial Neglect Due to Stroke https://exonpublications.com/index.php/exon/article/view/305 <p><strong>ABSTRACT</strong></p> <p>Unilateral spatial neglect refers to a condition where patients do not react to various environmental stimuli originating from the contralateral side of a brain lesion, in the absence of other sensory or motor deficits. Consequently, activities of daily living can be adversely affected. Cerebral hemorrhage or infarction is often the cause, and approximately 80% of patients with right hemisphere injury from acute stroke show unilateral spatial neglect. The presence of unilateral spatial neglect is determined through a number of different tests. However, even cases that are not apparent from typical tests are often associated with symptoms of neglect in activities of daily living. Stroke-mediated unilateral spatial neglect may improve or disappear during rehabilitation; however, in most cases, it remains. Cerebral hemorrhage, bleeding site, level of hematoma, and age are closely related with prognosis. Treatment approaches include conscious behavioral changes and activation of higher-order central nerves by stimulation from the periphery. Several mechanisms have been proposed to explain the onset of unilateral spatial neglect. Therefore, treatment strategies should be formulated only after careful examination and determination of the causative mechanism specific to each patient. This will enable the rehabilitation team to provide the most appropriate support.</p> Aiko Osawa, MD, PHD Shinichiro Maeshima, MD, PHD Copyright (c) 2021 Aiko Osawa, MD, Shinichiro Maeshima, MD, PHD https://creativecommons.org/licenses/by-nc/4.0 2021-06-18 2021-06-18 121 131 10.36255/exonpublications.stroke.spatialneglect.2021 Prevention of Non-Cardiogenic Ischemic Stroke: Towards Personalized Stroke Care https://exonpublications.com/index.php/exon/article/view/320 <p><strong>ABSTRACT</strong></p> <p>Despite diagnostic advances and new evidence on how to best treat patients with ischemic stroke, the risk of stroke recurrence remains unacceptably high. Therefore, there is a great need for novel therapies and markers to guide risk stratification, reveal stroke aetiology, identify patients who may benefit most from interventions, predict risk for another stroke, and recognize the risk of short-term complications or unfavorable long-term outcomes. The purpose of this chapter is to provide an update on: (i) emerging markers in atherothrombotic stroke; (ii) role of systemic inflammation in contributing to stroke occurrence; (iii) the main antiplatelet agents that have been successfully used in the secondary prevention of non-cardiogenic ischemic stroke and transient ischemic attack; (iv) screening for high-on-treatment platelet reactivity after stroke; and (v) to explore novel and effective antiplatelet strategies for the secondary prevention of ischemic stroke. Rising questions such as indications for antiplatelet therapy after a successful recanalisation following acute ischemic stroke should be answered in the future to optimize outcomes. Finally, we aim to focus on personalized antiplatelet regimens and current translational research findings in this field.</p> Tihamer Molnar, MD, PHD Peter Csecsei, MD, PHD Copyright (c) 2021 Tihamer Molnar, MD, PHD, Peter Csecsei, MD, PHD https://creativecommons.org/licenses/by-nc/4.0 2021-06-18 2021-06-18 133 147 10.36255/exonpublications.stroke.personalizedcare.2021 The Evolution of Devices and Techniques in Endovascular Stroke Therapy https://exonpublications.com/index.php/exon/article/view/340 <p><strong>ABSTRACT</strong>&nbsp;</p> <p>This chapter discusses the evolution of devices and techniques in endovascular stroke therapy, beginning with the development of effective intra-arterial thrombolysis in the late 1990s. We discuss the subsequent rise of early mechanical devices such as the Merci Retriever and Penumbra System, which, despite culminating in a series of failed trials in 2013, set the stage for the modern thrombectomy era. These first-generation devices gave way to the stent retriever, which would change the standard of care for acute large vessel occlusion stroke following a series of landmark trials in 2015. Finally, we discuss the more recent establishment of aspiration thrombectomy as an alternative to stent retrievers, as well as current investigations into novel devices and techniques that might further improve patient outcomes. Throughout, attention is paid to the regulatory landscape and evidentiary standards that shaped the field during its development in order to better understand how lessons from this history can guide future studies.</p> Devin V. Bageac, BS, BA Blake S. Gershon, BS Reade A. De Leacy, MD Copyright (c) 2021 Devin Bageac, Blake Gershon, Reade De Leacy https://creativecommons.org/licenses/by-nc/4.0 2021-06-18 2021-06-18 149 170 10.36255/exonpublications.stroke.devicesandtechniques.2021 COVID-19 and Stroke: A Neurological Perspective https://exonpublications.com/index.php/exon/article/view/328 <p><strong>ABSTRACT</strong>&nbsp;</p> <p>The risk factors for stroke increase with age. During the pandemic, the novel coronavirus disease (COVID-19) has become another risk factor for stroke. Although in its infancy, emerging data suggest that COVID-19 not only increases the risk of stroke, especially in the elderly, but also its severity. Thromboembolic events leading to a hypercoagulative state appear to be the leading mechanism. This chapter provides an overview of our current knowledge of COVID-19 being a risk factor for stroke. The epidemiology, risk factors, pathology, and mechanisms of COVID-19-mediated stroke are discussed from a neurological perspective.</p> Serefnur Ozturk, MD, FEAN Copyright (c) 2021 Serefnur Ozturk, MD, FEAN https://creativecommons.org/licenses/by-nc/4.0 2021-06-18 2021-06-18 171 178 10.36255/exonpublications.stroke.covid19.2021 Index https://exonpublications.com/index.php/exon/article/view/380 Index Copyright (c) 2021 Exon Publications https://creativecommons.org/licenses/by-nc/4.0 2021-06-18 2021-06-18 179 182 10.36255/exonpublications.stroke.2021.index About the Editor https://exonpublications.com/index.php/exon/article/view/381 <p><img src="https://exonpublications.com/public/site/images/bchapter/editor-image-200.jpg" alt="Seena Dehkharghani, MD " width="200" height="207"></p> <p>Seena Dehkharghani, MD, is an Associate Professor of Radiology and Neurology, and the Director of Stroke and Cerebrovascular Imaging at the New York University Langone Medical Center, and New York University Grossman School of Medicine. He previously served as Director of Stroke Imaging at Emory University Hospital, where he was Assistant Professor of Radiology and Imaging Sciences and Neurology. His clinical and academic focus is centered upon the study of cerebral perfusion, metabolism, and viability, as well as hardware development for mobile stroke detection. He has been a funded investigator or co-investigator in multiple federal, foundation, and philanthropically funded studies and industry-funded stroke trials. He has extensively published on stroke and cerebrovascular disease.</p> Seena Dehkharghani, MD Copyright (c) 2021 Exon Publications https://creativecommons.org/licenses/by-nc/4.0 2021-06-18 2021-06-18 10.36255/exonpublications.stroke.2021.editor