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PATIENT STORY

A 65-year-old hypertensive black man presented to the emergency department with onset of right face, arm, and hand paralysis, and difficulty communicating. Rapid diagnostic testing using MRI revealed an ischemic infarct in the left middle cerebral artery (Figure 241-1). He was evaluated by a stroke response team and was found to be a candidate for tissue plasminogen activator (TPA). After the stroke, he was treated with aspirin, antihypertensives, and cholesterol-lowering medication. He recovered 80% of his neurologic deficit over the next 3 months. Figure 241-2 is a noncontrast CT image of this patient 2 weeks later.

FIGURE 241-1

Acute left middle cerebral artery infarct on MRI of a 65-year-old hypertensive man. The MRI demonstrates increased signal intensity (arrows). Abnormalities in MRI occur before those seen on CT during ischemic strokes. (Reproduced with permission from Chen MYM, Pope TL, Ott DJ. Basic Radiology. New York, NY: McGraw-Hill Education; 2004.)

FIGURE 241-2

Noncontrast CT image of a subacute left middle cerebral artery infarct (arrows). This was done 2 weeks after the stroke in the same patient as previous figure. CT findings occur later than MRI findings in ischemic strokes. (Reproduced with permission from Chen MYM, Pope TL, Ott DJ. Basic Radiology. New York, NY: McGraw-Hill Education; 2004.)

INTRODUCTION

Cerebral vascular accidents or strokes are common, especially in older populations. Most strokes are ischemic or hemorrhagic. Risk factors include hypertension, smoking, diabetes mellitus, and atrial fibrillation. Thirty-day mortality for a first stroke is greater than 20%.

SYNONYMS

Stroke.

EPIDEMIOLOGY

  • Cerebral vascular accidents (CVAs) affect approximately 795,000 people per year in the United States, most being older than age 65 years, although strokes can and do occur at any age.1

  • As many as 46% to 51% of strokes are cryptogenic or have an undetermined cause.2 Other known causes account for 2% to 4% of strokes. Of the remaining, approximately 80% are caused by ischemic infarction, while 20% result from intracerebral or subarachnoid hemorrhage, each accounting for 10%.3

  • Among ages 18 and older, stroke prevalence rates for ethnic groups in the United States are as follows: Asian/Pacific Islanders, 1.8%, Hispanics of any race, 2.4%, Non-Hispanic whites, 2.5%, Non-Hispanic blacks, 4.5%, American Indian/Alaska natives, 5.4%.3

  • Black patients at ages 45 and 65 are 2.9 and 1.66 times more likely to have a stroke compared to white patients.4

  • Mortality is higher in blacks than in whites: 95.8 versus 73.7 per 100,000 for black and white men, respectively.1

  • Hispanics have witnessed an increase in death rates due to stroke since 2013.2

  • Each year in the United States, ...

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