Cerebrovascular Health: Stroke and Beyond

Yıl 2025, Cilt: 47 Sayı: Beyin Farkındalığı 2025 Özel Sayısı, 79 - 86, 22.08.2025

Özlem Aykaç

Öz

Stroke is a leading cause of death and long-term disability worldwide; however, cerebrovascular disease extends beyond the acute event, and small-vessel disease, covert infarcts, and microbleeds shape long-term cognitive and functional outcomes. This review synthesizes cerebrovascular health "from stroke and beyond" through a life-course lens, summarizing epidemiology and burden, care pathways from prehospital triage to endovascular reperfusion in acute ischemic stroke, organized stroke-unit care and early rehabilitation, mechanism-based secondary prevention, and small-vessel disease linked to vascular cognitive impairment. Evidence from guidelines, randomized trials, and large cohorts published between 2015 and 2025 indicates that the highest-yield strategies are persistent blood-pressure control, smoking cessation, statin-based intensive lipid lowering, atrial fibrillation screening with appropriate anticoagulation, timely carotid surgery for symptomatic stenosis, and aggressive medical therapy for intracranial atherosclerosis. In the acute phase, rapid and accurate imaging with intravenous thrombolysis and mechanical thrombectomy in eligible patients improves functional outcomes, while stroke-unit care and early rehabilitation are critical to consolidate gains. In conclusion, cerebrovascular health should be managed within an integrated continuum linking primary prevention, hyperacute therapy, organized unit care, early rehabilitation, and lifelong secondary prevention.

Anahtar Kelimeler

stroke , Cerebrovascular Disease , Mechanical Thrombectomy , Rehabilitation , Secondary Prevention

Beyin Damar Sağlığı: İnme ve Ötesi

Öz

İnme, dünya çapında ölüm ve kalıcı sakatlığın önde gelen nedenlerinden biridir; ancak serebrovasküler hastalık akut olayla sınırlı değildir ve küçük damar hastalığı, sessiz enfarktlar ile mikrokanamalar uzun dönem bilişsel ve işlevsel sonuçları belirler. Bu derleme, beyin damar sağlığını "inme ve ötesi" sürekliliğinde, yaşam seyri perspektifiyle ele alarak epidemiyoloji ve hastalık yükünü, akut iskemik inmede hastane öncesi triyajdan endovasküler reperfüzyona uzanan bakımı, organize inme ünitesi ve erken rehabilitasyonu, mekanizmaya dayalı ikincil korunmayı ve vasküler bilişsel bozulmayla ilişkili küçük damar hastalığını bütüncül bir çerçevede özetlemektedir. 2015-2025 dönemine ait kılavuzlar, randomize çalışmalar ve büyük kohortlar temelli bulgular, en yüksek getirili stratejilerin ısrarlı hipertansiyon kontrolü, tütünün bırakılması, statin temelli yoğun lipid düşürme, atriyal fibrilasyon taraması ve uygun antikoagülasyon ile semptomatik karotiste zamanında cerrahi ve intrakranyal aterosklerozda agresif medikal tedavi olduğunu göstermektedir. Akut dönemde hızlı ve doğru görüntüleme eşliğinde uygun hastada intravenöz tromboliz ve mekanik trombektomi olarak beyin damar sağlığı, birincil korunma, hiperakut tedavi, organize ünite bakımı, erken rehabilitasyon ve yaşam boyu ikincil korunmayı birbirine bağlayan entegre bir modelle yönetilmelidir.

Anahtar Kelimeler

İnme , serebrovasküler hastalık , mekanik trombektomi , rehabilitasyon , İkincil koruma

Kaynakça

• 1. GBD 2019 Stroke Collaborators. Global, regional, and national burden of stroke and its risk factors, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Neurol. 2021;20(10):795–820.
• 2. Feigin VL, et al. World Stroke Organization Global Stroke Fact Sheet 2022. Int J Stroke. 2022;17(1):18–29.
• 3. Powers WJ, et al. 2019 update to the 2018 guidelines for the early management of acute ischemic stroke. Stroke. 2019;50:
• 4. Kleindorfer DO, et al. 2021 Guideline for the prevention of stroke in patients with stroke and transient ischemic attack. Stroke. 2021;52(7):e364–e467.
• 5. Nogueira RG, et al. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct (DAWN). N Engl J Med. 2018;378(1):11–21.
• 6. Albers GW, et al. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging (DEFUSE 3). N Engl J Med. 2018;378(8):708–718.
• 7. Yoshimura S, et al. Endovascular therapy for acute stroke with a large ischemic region (RESCUE-Japan LIMIT). N Engl J Med. 2022;386:
• 8. Sarraj A, et al. Trial of endovascular thrombectomy for large ischemic strokes (SELECT2). N Engl J Med. 2023;388(14):1259–1271.
• 9. Tao C, et al. Trial of endovascular treatment of acute basilar-artery occlusion (ATTENTION). N Engl J Med. 2022;387:1361–1372. doi:10.1056/NEJMoa2206317. PMID:36239644.
• 10. Jovin TG, et al. Trial of thrombectomy 6 to 24 hours after stroke due to basilar-artery occlusion (BAOCHE). N Engl J Med. 2022;387:1373–1384. 11. Beyer SE, et al. Randomized trial of endovascular treatment with or without intravenous alteplase in acute ischemic stroke (MR CLEAN–NO IV). N Engl J Med. 2021;385:1833–1844.
• 12. Hesse AC, et al. Direct endovascular thrombectomy versus combined intravenous thrombolysis plus thrombectomy (SWIFT DIRECT). Lancet. 2022;400:1409–1419.
• 13. Zi W, et al. Endovascular treatment alone vs IV alteplase plus EVT (DEVT). JAMA. 2021;325(3):234–243.
• 14. Lapergue B, et al. Contact aspiration vs stent retriever (ASTER). JAMA. 2017;318(5):443–452.
• 15. Anderson CS, et al. Intensive blood pressure control after endovascular thrombectomy (ENCHANTED 2/MT). Lancet. 2022;400:1610–1621.
• 16. Ma H, et al. Thrombolysis guided by perfusion imaging up to 9 hours after onset of stroke (EXTEND). N Engl J Med. 2019;380(19):1795–1803.
• 17. Thomalla G, et al. MRI guided thrombolysis for stroke with unknown time of onset (WAKE UP). N Engl J Med. 2018;379:—.
• 18. Wang Y, et al. Clopidogrel with aspirin in acute minor stroke or TIA (CHANCE). N Engl J Med. 2013;369(1):11–19.
• 19. Johnston SC, et al. Clopidogrel and aspirin in acute ischemic stroke and high risk TIA (POINT). N Engl J Med. 2018;379(3):215–225.
• 20. Johnston SC, et al. Ticagrelor and aspirin or aspirin alone in acute ischemic stroke or TIA (THALES). N Engl J Med. 2020;383(3):207–217.
• 21. Chimowitz MI, et al. Stenting versus aggressive medical therapy for intracranial arterial stenosis (SAMMPRIS). N Engl J Med. 2011;365(11):993–1003.
• 22. Hart RG, et al. Rivaroxaban for stroke prevention after ESUS (NAVIGATE ESUS). N Engl J Med. 2018;378(23):2191–2201.
• 23. Diener HC, et al. Dabigatran for prevention of stroke after ESUS (RE SPECT ESUS). N Engl J Med. 2019;380(20):1906–1917.
• 24. Kamel H, et al. Apixaban to prevent recurrence after cryptogenic stroke in atrial cardiopathy (ARCADIA). JAMA. 2024;331(7):573–581.
• 25. Sanna T, et al. Cryptogenic stroke and underlying atrial fibrillation (CRYSTAL AF). N Engl J Med. 2014;370:
• 26. Bernstein RA, et al. Long term continuous cardiac monitoring vs usual care after stroke (STROKE AF). JAMA. 2021;325(21):2169–2177.
• 27. Buck BH, et al. Implantable vs prolonged external ECG monitoring after ischemic stroke (PER DIEM). JAMA. 2021;325(21):2160–2168.
• 28. Carroll JD, et al. Patent foramen ovale closure vs medical therapy (RESPECT long term). N Engl J Med. 2017;377:1022–1032.
• 29. Mas JL, et al. PFO closure in stroke patients (CLOSE). N Engl J Med. 2017;377:1011–1021.
• 30. Søndergaard L, et al. PFO closure or antiplatelet therapy (REDUCE). N Engl J Med. 2017;377:1033–1042.
• 31. Lee PH, et al. Device closure for high risk PFO (DEFENSE PFO). J Am Coll Cardiol. 2018;71(20):2335–2342.
• 32. Whitlock RP, et al. Left atrial appendage occlusion during cardiac surgery (LAAOS III). N Engl J Med. 2021;384(22):2081–2091..
• 33. Osmancik P, et al. Left atrial appendage closure vs DOAC (PRAGUE 17). J Am Coll Cardiol. 2020;75(25):3122–3135.
• 34. Dennis M, et al. Intermittent pneumatic compression after stroke (CLOTS 3). Lancet. 2013;382(9891):516–524.
• 35. Bernhardt J, et al. Very early mobilisation after stroke (AVERT). Lancet. 2015;386(9988):46–55.
• 36. Middleton S, et al. Fever, hyperglycaemia and swallowing (QASC). Lancet. 2011;378(9804):1699–1706. PMID:21996470.
• 37. Berge E, et al. European Stroke Organisation expedited recommendation on tenecteplase for acute ischaemic stroke. Eur Stroke J. 2023;8(1):