Ischemic stroke

After subarachnoid hemorrhage delayed onset vasospasm can result in devastating ischemic stroke.

Ischemia results if blood flow to the brain is below 18 to 20 ml per 100 g per minute, and tissue death occurs if flow dips below 8 to 10 ml per 100 g per minute.

Cerebral Ischemia Pathogenesis.

There are four categories of cerebral hypoxia; they are, in order of severity:

Diffuse cerebral hypoxia (DCH),

Focal cerebral ischemia, cerebral infarction, and global cerebral ischemia. Prolonged hypoxia induces neuronal cell death via apoptosis, resulting in a hypoxic brain injury.


The cranial cavity is a closed compartment and any breach to this confined space secondary to neurosurgery or trauma causes an imbalance between atmospheric pressure and intracranial pressure. As the altitude increases, the atmospheric pressure decreases, and hypoxia with hypercarbia is a well-known fact. In children, there is an argument to suggest that hypoxia can contribute to a mild increase in intracranial pressure during commercial flights 1).

Many competitive breath-hold divers use dry apnoea routines to improve their tolerance to hypoxia and hypercapnia, varying the amount of prior hyperventilation and lung volume. When hyperventilating and exhaling to residual volume prior to starting a breath-hold, hypoxia is reached quickly and without too much discomfort from the respiratory drive. Cerebral hypoxia with loss of consciousness (LOC) can easily result.

Valdivia-Valdivia et al. from the Neurosurgery Department, St. Joseph's Hospital, Tampa report on a case where an unsupervised diver used a nose clip that is thought to have interfered with his resumption of breathing after LOC. Consequently, he suffered an extended period of severe hypoxia, with poor ventilation and recovery. He also held his breath on empty lungs; thus, trying to inhale created an intrathoracic sub-atmospheric pressure. Upon imaging at the hospital, severe intralobular pulmonary edema was noted, with similarities to images presented in divers suffering from pulmonary barotrauma of descent (squeeze, immersion pulmonary edema). Describing the physiological phenomena observed in this case highlights the risks associated with unsupervised exhalatory breath-holding after hyperventilation as a training practice in competitive freediving 2).

In brain tissue, a biochemical cascade known as the ischemic cascade is triggered when the tissue becomes ischemic, potentially resulting in damage to and death of brain cells.

Choice of oral anticoagulant: compared to vitamin K antagonists (VKAs) (e.g. warfarin), the novel oral anticoagulants (NOACs) dabigatran, rivaroxaban & edoxaban are at least as effective in preventing ischemic stroke and systemic embolization in patient with atrial fibrillation.

Ischemic stroke is a major cause of death and long-term disability worldwide.

A total of 781 patients (median [IQR] age, 67 [57-76] years; 414 men [53%]) constituted the derivation cohort, and 3260 patients (median [IQR] age, 72 [61-80] years; 1684 men [52%]) composed the validation cohort. Nine variables were included in the model: age, baseline National Institutes of Health Stroke Scale (NIHSS) score, pre-stroke mRS score, history of diabetes, occlusion location, collateral score, reperfusion grade, NIHSS score at 24 hours, and symptomatic intracranial hemorrhage 24 hours after EVT. External validation in the MR CLEAN Registry showed excellent discriminative ability for functional independence (C statistic, 0.91; 95% CI, 0.90-0.92) and survival (0.89; 95% CI, 0.88-0.90). The proportion of functional independence in the MR CLEAN Registry was systematically higher than predicted by the model (41% vs 34%), whereas observed and predicted survival was similar (72% vs 75%). The model was updated and implemented for clinical use.

The prognostic tool MR PREDICTS@24H can be applied 1 day after EVT to accurately predict functional outcomes for individual patients at 90 days and to provide reliable outcome expectations and personalize follow-up and rehabilitation plans. It will need further validation and updating for contemporary patients 3).

Ischemic Stroke (Emergency Management in Neurology) By Giuseppe D'Aliberti, Marco Longoni, Valentina Oppo, Valentina Perini, Luca Valvassori, Simone Vidale, Cristina Motto

Lo Presti A, Weil AG, Ragheb J. Flying with a shunt. J Neurosurg Pediatr. 2015;15(2):223-224.
Valdivia-Valdivia JM, Räisänen-Sokolowski A, Lindholm P. Prolonged syncope with multifactorial pulmonary oedema related to dry apnoea training: Safety concerns in unsupervised dry static apnoea. Diving Hyperb Med. 2021 Jun 30;51(2):210-215. doi: 10.28920/dhm51.2.210-215. PMID: 34157738.
Chalos V, Venema E, Mulder MJHL, Roozenbeek B, Steyerberg EW, Wermer MJH, Lycklama À Nijeholt GJ, van der Worp HB, Goyal M, Campbell BCV, Muir KW, Guillemin F, Bracard S, White P, Dávalos A, Jovin TG, Hill MD, Mitchell PJ, Demchuk AM, Saver JL, van der Lugt A, Brown S, Dippel DWJ, Lingsma HF; HERMES CollaboratorsMR CLEAN Registry Investigators. Development and Validation of a Postprocedural Model to Predict Outcome After Endovascular Treatment for Ischemic Stroke. JAMA Neurol. 2023 Jul 31. doi: 10.1001/jamaneurol.2023.2392. Epub ahead of print. PMID: 37523199.
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