NEURO

Case 44 Cerebrovascular Accident/Transient Ischemic Attack:

- Transient ischemic attack (TIA): a focal neurologic deficit lasting
less than 24 hrs. o Pts w/ a TIA are at increased risk for
subsequent stroke.
- Residual ischemic neurologic deficit (RIND): a neurologic deficit of greater than 24 hrs & less than 2
weeks.
- HTN is the single most important risk factor for stroke.
- Strokes are generally classified as being of thrombotic or embolic origin. Strokes that affect the
small branches of the main arteries of brain are termed lacunar infarcts or small-vessel strokes.
These strokes often forewarn a larger, more debilitating stroke.
- Sudden onset of focal neurologic deficit is the usual presentation of stroke patients, although
some pts can have a gradual worsening of symptoms.
- If the middle cerebral artery territory is affect, the patient would experience aphasia (when
dominant hemisphere is involved), contralateral hemiparesis, sensory loss, spatial neglect, &
contralateral impaired conjugate gaze.
- When the territory of the anterior cerebral artery is affected, foot & leg deficits are more frequent
than arm deficits. These pts often have associated cognitive & personality changes.
- Vertebrobasilar stroke symptoms & signs include motor or sensory loss in all 4 limbs, crossed
signs, disconjugate gaze, nystagmus, dysarthria, & dysphagia.
- There can be ipsilateral limb ataxia & gait ataxia if the cerebellum is affected.
- When it is determined that a stroke is the cause of presentation, it is crucial to
differentiate b/w ischemic & hemorrhagic stroke b/c of the implications on further
treatment.
- A CT scan of the brain w/out contrast is the initial imaging test of choice.
- Unless a hypertensive encephalopathy, aortic dissection, acute renal failure, or pulmonary
edema is present, the treatment of arterial hypertension should be cautious.
- Fever & high blood sugar after a stroke are often associated w/ poorer outcomes & should be
controlled during the poststroke period.
- Except when thrombolytic therapy is given, most patients w/ nonhemorrhagic stroke should receive
aspirin w/in the first 48 hrs.
- Judiciously selected pts can benefit from intravenous administration of recombinant tissue-
type plasminogen activator (rtPA) fi they can be treated w/in 3 hrs of the onset of ischemic
stroke.
o Contraindications to the use of thrombolytic therapy, including recent surgery, trauma, GI
bleeding, MI, use of certain anticoagulant medications, & uncontrolled HTN.