| S 5-1 |
The identification of the pathophysiologic mechanism of a
transient ischaemic attack (TIA) or a stroke has important prognostic and
therapeutic implications. The diagnosis relies on both clinical and
instrumental data. |
R 5.1
Grade C |
According to the World Health Organisation (WHO) definition,
a TIA is characterised by the sudden development of signs and symptoms of
focal cerebral or visual deficit of vascular origin lasting less than 24
hours. Isolated symptoms such as loss of consciousness, dizziness or
vertigo, transient global amnesia, drop attacks, generalised weakness,
delirium or sphincteric incontinence should not
be classified as TIA. |
R 5.2
Grade C |
The diagnosis of TIA or stroke is only clinical.
Nevertheless the use of computed tomography (CT) or magnetic resonance
imaging (MRI) is recommended to corroborate differential diagnosis with
other pathologies that can mimic TIA or stroke. |
| S 5-2 |
The rupture of an arterial aneurysm is the cause of
spontaneous subarachnoid haemorrhages in 85% of cases. |
R 5.3
Grade C |
A cranial CT or MRI is recommended
as early as possible after stroke onset to distinguish between ischaemic and
haemorrhagic stroke and select the relevant therapeutic approach. |
| S
5-3 |
A sinus thrombosis can
cause venous cerebral infarcts. |
| S
5-4 |
The clinical
presentation of a sinus thrombosis is not specific and can mimick that of
other disorders, including the arterial stroke. |
R 5.4
Grade D |
After a TIA or a stroke, an Holter ECG monitoring
is
recommended only when cardio-embolism is suspected or no other definite
pathophysiologic mechanism is identified. |
R 5.5
Grade D |
After a TIA or a stroke, transthoracic echocardiography (TTE)
is recommended only when a heart disease is clinically suspected. |
R 5.6
Grade
D |
After a TIA or a stroke, when a cardioembolic mechanism is
suspected, transesophageal echocardiography (TEE) is recommended
only in
patients under 45 years of age with no evident causes of cerebral
ischemia, or instrumental evidence of cerebrovascular disease, or major
vascular risk factors. |
| S
5-5 |
Brain CT, a rapid and relatively inexpensive test, can identify early ischaemic
signs reflecting the territory of distribution of the occluded artery. CT also brings to evidence the possible presence of haemorrhagic
transformation of the ischaemic lesion, especially during the sub-acute
period. |
R 5.7
Grade D |
In patients with an isolated TIA or stroke, a brain CT
is recommended
to investigate the presence of an ischaemic brain lesion and its
correspondence to the clinical presentation. |
|
S 5-6 |
Diffusion-weighted MRI can document the core of the ischaemic lesion within
minutes from the event.
Perfusion-weighted MRI is useful to evaluate the ischemic penumbra.
Conventional MRI is used to monitor the ischaemic lesion, especially during
the sub-acute and chronic periods. |
|
S 5-7 |
 Leukoaraiosis cannot be considered as a specific marker of
cerebrovascular disease, even if it is more frequently observed in
patients with cerebrovascular risk factors, such as hypertension. |
|
S 5-8 |
Magnetic resonance can detect silent cerebral infarcts that
are associated with an increased risk of stroke. |
|
S 5-9 |
In patients with previous TIA and/or stroke, MRI is more
sensitive than CT to detect posterior infarcts or small brain lesions. |
|
S 5-10 |
Angio MRI (MRA) is sufficiently accurate to document the patency of intra- and
extra-cranial vessels. |
|
S 5-11 |
Cerebral angiography is
better indicated in children or young
patients with ischaemic stroke because at these ages the cause is often a
cerebral vasculitis. |
|
S 5-12 |
A venous infarct has to
be suspected when an ischaemic
lesion is incongruent with an arterial distribution area and possibly
exhibits haematic material within its context - often associated with the
absence of the classical void signal attributable to a dural sinus. In these cases a venous angio MRI is
appropriate. |
|
S 5-13 |
In patients with previous intracerebral haemorrhage,
accumulation of haemosiderin is a permanent marker of previous bleeding at
brain MRI. |
|
S 5-14 |
When suspecting a cerebral vasculitis or a
non-atherosclerotic disease of extracranial arteries (dissections,
vascular malformations) angiography has the highest diagnostic validity
compared to other non-invasive techniques. |
R 5.8
Grade D |
Angiography of intracranial vessels is the gold standard
for the study of cerebral aneurysms and it is recommended in patients with
subarachnoid haemorrhage who are candidates to surgery or to endovascular
treatment. |
R 5.9
Grade D |
Electroencephalography (EEG)
is recommended in patients who
are suspected to have an epileptic cause of their stroke-like symptoms. |
R 5.10
Grade C |
In patients with TIA or recent stroke, ultrasonography (US)
studies of supra-aortic vessels is recommended among
the investigations aimed
at defining the mechanisms of ischaemia. |
|
S 5-15 |
The degree of carotid stenosis in the perspective of a
surgical or an endovascular treatment, should be primarily estimated using
non-invasive techniques (Duplex US, MRA, CT angiography). Angiography
should be performed when the results of non-invasive examinations are
discordant, or a significant atherosclerotic disease of intracranial
arteries is suspected, especially in vertebrobasilar arteries, or when MRA
or CT angiography give technically poor images. |
R 5.11
Grade B |
Duplex US examination of supra-aortic vessels
is
recommended as final test, replacing
angiography, for assessing patients with carotid stenosis to be submitted
to intervention, after validation against, and if needed integrated with,
other non-invasive techniques (MRA, CT angiography). |
R 5.12
Grade D |
In patients who are undergoing major cardiovascular
surgery,
Duplex US examination of supra-aortic vessels is recommended to look for
possible carotid artery stenoses and therefore to evaluate the risk of
ischaemic cerebral complications. |
R 5.13
Grade D |
After carotid endarterectomy (CEA), Duplex US examination
of supra-aortic vessels is recommended, at 3 and 9 months and every year
thereafter, to monitor recurrent stenosis. |
R 5.14
Grade D |
Duplex US examination of supra-aortic vessels
is
recommended in asymptomatic subjects with:
 | a non-cardiogenic
carotid bruit; |
| a high probability to have carotid stenosis (e.g.
subjects with peripheral artery disease or well-documented coronary artery
disease, or subjects over 65 years with multiple vascular risk factors). |
|
|
S 5-16 |
Atherosclerotic stenosis of intracranial arteries is among the major causal
risk factors of ischaemic stroke also among Western populations. An US
screening with trans-cranial Doppler or Duplex trans-cranial Doppler for
such condition may be sufficiently accurate, at least for disorders of the
anterior circulation . |
R 5.15
Grade D |
Transcranial Doppler is
a complementary examination in
patients with a recent TIA or stroke. It may provide additional
information on patency of cerebral vessels, recanalization and collateral
pathways. |
R 5.16
Grade D |
Transcranial Doppler is a
complementary examination in
patients who are undergoing carotid endarterectomy, helping in
pre-operative evaluation and intraoperative monitoring of flow in the
territory of the operated artery . |
R 5.17
Grade D |
Transcranial Doppler is
recommended as substitute for transesophageal
echocardiography to detect a right-to-left cardiac shunt. |
R 5.18
Grade D |
Transcranial Doppler is recommended
in patients with
subarachnoid haemorrhage to detect the possible occurrence of vasospasm. |
R 5.19
Grade D |
In patients who are candidates to carotid endarterectomy
(CEA), coronary angiography is recommended when there is clinical or
non-invasive instrumental evidence of coronary artery disease at high risk
of myocardial ischemia. |
R 5.20
Grade D |
In patients who are candidates to carotid endarterectomy
(CEA) and have an associated severe coronary artery disease, it is
recommended to first perform the coronary revascularization procedure, even though the two interventions may be performed
simultaneously. |
