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This chapter addresses the following Geriatric Fellowship Curriculum Milestone: #16

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LEARNING OBJECTIVES

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Learning Objectives

  • Understand the pathophysiology and clinical presentations of different types of strokes, and specific symptoms and signs associated with the involvement of each major cerebral artery and location of infarction.

  • Learn about the state-of-the-art neuroimaging techniques and other tests available to evaluate and diagnose stroke.

  • Acquire latest information about the pharmacology, specific indications, and adverse effects of various drugs and surgical interventions available to treat different stages and types of strokes.

  • Learn about the results of pivotal clinical trials forming the basis for latest guidelines to treat different types of strokes.

  • Understand the rationale for various preventive strategies commonly used for different types of strokes.

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Key Clinical Points

  1. It is important to identify the pathophysiology in each stroke patient, as it drives selection of the best treatment choice.

  2. Magnetic resonance imaging (MRI) brain scans with diffusion-weighted imaging (DWI) are the best way of identifying cerebral infarcts acutely and accurately, while computed tomography (CT) scanning is insensitive to recent infarcts of less than 12 hours.

  3. Imaging of the cervical and cerebral large arterial system with CT angiography (CTA) or MR angiography (MRA) should be urgently performed to assess the arterial system. CTA offers the best resolution.

  4. Recombinant tissue plasminogen activator (rt-PA) initiated within 3 hours of symptom onset has been shown to reduce stroke-related disability. In general, use of rt-PA in older adults with stroke outweighs risks.

  5. Benefits of using heparin in acute stroke are uncertain.

  6. Efficacy of carotid endarterectomy for symptomatic disease with more than 70% stenosis is high. Carotid stenting is reserved for patients in whom surgery is contraindicated.

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Although stroke is the fifth leading cause of death in the United States, it remains the single most important cause of disability. Many varied pathologic processes lead to either occlusion of an extra- or intracranial artery or vein causing ischemic stroke or transient ischemic attack (TIA), or rupture of an intracranial artery causing hemorrhagic stroke. With TIAs, and ischemic or hemorrhagic stroke, the key to acute or chronic therapy is the determination of the precise diagnosis. The diagnostic formulation must not only establish that the clinical entity is indeed an ischemic stroke or TIA, or a hemorrhagic stroke, but it also must localize and characterize the precise arterial or venous pathologic process causing the stroke and elucidate the nature of the spared collateral circulation (Figures 65-1 and 65-2). This chapter focuses on identifying this pathologic process as the pivot on which hinges rational medical and/or surgical treatments or preventive strategies. For both ischemic and/or hemorrhagic stroke, the precise pathophysiologic process divides logically into specific stroke or TIA subtypes.

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FIGURE 65-1.

A. Arrangement of the major arteries of the right side carrying blood from the heart to the brain. Also shown are vessels of collateral circulation that may modify the effects of cerebral ischemia (a, b, and c). ...

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