Cerebrovascular Disease: Transient Ischemic Attack and Stroke
Cerebrovascular disease (CVD)
General—disorders affecting part of the brain transiently or permanently by ischemia or bleeding
Classification
Transient ischemic attack (TIA)
Brief neurologic deficit caused by brain ischemia typically lasting <A onclick="get_content(event,'AB1-M12'); return false;" onmouseover="window.status=this.title; return true;" onmouseout="window.status=''; return true;" title="<1 hour
After a TIA, the 90-day risk of stroke is approximately 10%.
Differential diagnosis of a TIA—stroke, seizure, syncope, or migraine
Stroke
A neurologic deficit involving a particular distribution which lasts ” class=LK href=”javascript:void(0)” target=right xpath=”/CT{06b9ee1beed59419a81e5e1e1a4f60b0cc8cd1057525de73425b2b43f4df7f1b5817677ec05b804319c77b6aae240d64}/ID(AB1-M10)”>>24 hours
Types
Ischemic stroke (85% of strokes)
Thrombotic (most common)
Risk factors—hypertension, diabetes, atherosclerosis, and so on
Embolic
Risk factors—atrial fibrillation, valve disease, and so on
Hemorrhagic stroke (15% of strokes)
Subarachnoid hemorrhage (SAH)
Intracerebral hemorrhage
Evaluation
Clinical—presentation is contingent on the cerebral vessel involved. (Table 2.13.1)
Imaging
Noncontrast head CT to rule out cerebral hemorrhage or mass lesion and aid in diagnosis.
Brain magnetic resonance imaging (MRI) may not identify hemorrhage.
Management
Thrombolysis with tissue plasminogen activator (tPA)
Indication—for those who present within 180 minutes of onset of symptoms (Table 2.13.2)
Blood pressure control
Within the first 24 hours of a TIA or stroke, do not treat blood pressure, unless ” class=LK href=”javascript:void(0)” target=right xpath=”/CT{06b9ee1beed59419a81e5e1e1a4f60b0cc8cd1057525de73425b2b43f4df7f1b5817677ec05b804319c77b6aae240d64}/ID(AB1-M10)”>>220/120
Exceptions—hypertensive crisis, end organ compromise, dissection, and so on
Pharmacologic treatment
DBP ” class=LK href=”javascript:void(0)” target=right xpath=”/CT{06b9ee1beed59419a81e5e1e1a4f60b0cc8cd1057525de73425b2b43f4df7f1b5817677ec05b804319c77b6aae240d64}/ID(AB1-M10)”>>140—nitroprusside (Nitropress) 0.5 μg/kg/min/min IV
Thrombolytic candidate
Pre-tPA with DBP ” class=LK href=”javascript:void(0)” target=right xpath=”/CT{06b9ee1beed59419a81e5e1e1a4f60b0cc8cd1057525de73425b2b43f4df7f1b5817677ec05b804319c77b6aae240d64}/ID(AB1-M10)”>>110—Nitropaste 1 to 2 in.
Blood pressure should be <A onclick="get_content(event,'AB1-M12'); return false;" onmouseover="window.status=this.title; return true;" onmouseout="window.status=''; return true;" title="<185/110 before giving tPA.
Post-tPA … Similar to nonthrombolytic candidates
Antiplatelet therapy—initiate quickly if patient is not a tPA candidate; options include:
The drug is given for those intolerant to aspirin OR on aspirin during an event.
Adverse effects—neutropenia and thrombocytopenic purpura are rare.
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