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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Rapid development of focal or global disturbance of cerebral function:

    • – Duration < 24 hours is a transient ischemic attack

    • – Duration > 24 hours is a stroke

  • Early CT scan is negative, which excludes intracerebral or subarachnoid hemorrhage

  • Duplex ultrasound (neck) or angiography (head) shows large-vessel disease

GENERAL CONSIDERATIONS

  • Acute cerebrovascular disorders cause more morbidity and mortality than any other disease in those over age 45 years

  • In North America, about 80% of strokes are ischemic and are caused by thrombosis in cerebral arteries, emboli to the brain arteries, or hypertension

  • Hemorrhagic strokes are more common in East Asia and are due to rupture of an intracerebral artery

  • About 25% of ischemic strokes are from cardiac emboli

  • 25% are lacunar (deep brain and small)

  • 25% are due to large-vessel atherosclerosis

  • 5% are due to less common causes such as dissection or vasculitis

  • 20% are of uncertain etiology

  • Risk factors for stroke include

    • – Hypertension (most important)

    • – Smoking

    • – Atrial fibrillation

    • – Diabetes

    • – Elevated cholesterol levels

    • – Hypercoagulability or oral contraceptive use

    • – Cocaine or methamphetamine use

    • – Migraine headaches

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Transient ischemic attack:

    • – Focal neurologic defects that usually last < 1 hour but certainly last < 24 hours without evidence of cerebral infarction

  • Stroke:

    • – Sudden numbness or weakness of the face, arm, or leg

    • – Sudden decrease in vision in 1 or both eyes

    • – Sudden loss of balance or coordination or difficulty walking

    • – Impaired consciousness or difficulty in speaking or understanding

    • – Sudden severe headache of unknown cause

    • – In some instances, symptoms are not sudden but gradually progress over a few days

PHYSICAL EXAM FINDINGS

  • Unilateral or bilateral motor defects

  • Unilateral or bilateral sensory defects

  • Aphasia or dysphagia

  • Monocular vision problems

  • Hemianopia

  • Atypical—confusion, vertigo, dizziness

DIFFERENTIAL DIAGNOSIS

  • Subdural hematoma

  • Epilepsy

  • Migraine

  • Hypoglycemia or hyperglycemia

  • Vertigo

  • Hypertensive encephalopathy

  • Cerebral infection

  • Brain tumor

  • Multiple sclerosis

  • Bell’s palsy

  • Neuropathies

  • Transient global amnesia

  • Hyponatremia

  • Hepatic or renal encephalopathy

  • Drug overdose

  • Spinal cord disease

  • Hysterical conversion

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • CBC, electrolytes, glucose, creatinine, BUN

  • Coagulation studies

  • Lipid panel, homocysteine

  • Cardiac biomarkers (troponins)

  • Other specific tests based on the specific patient (eg, toxicology screen)

ELECTROCARDIOGRAPHY

  • ECG abnormalities are common, but specific findings may suggest the cause of the stroke, such as myocardial infarction or atrial fibrillation

  • Prolonged QT and torsades de pointes can occur as a result of a stroke

IMAGING STUDIES

  • CT scan to distinguish ischemia from hemorrhage

  • Magnetic resonance angiography in selected patients to detect vascular occlusion

  • Duplex ultrasonography to assess extracranial blood vessels

  • Echocardiography to detect structural heart disease

DIAGNOSTIC PROCEDURES

  • Digital subtraction angiography is the gold standard for evaluating extra- and intracranial ...

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