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Introduction

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A mild attack of apoplexy may be called death’s retaining fee.

Gilles Ménage (1613–92)

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Glossary of terms

Stroke  A focal neurological deficit lasting longer than 24 hours caused by intracerebral haemorrhage or infarction.

Stroke in evolution  An enlarging neurological deficit, presumably due to infarction, which increases over 24–48 hours.

Transient cerebral ischaemic attack (TIA)  A transient episode of neurological dysfunction caused by focal brain or retinal ischaemia without infarction.1

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Key facts and checkpoints

  • A stroke or TIA must be considered a medical emergency.

  • One in 10 patients with a TIA is likely to have a stroke shortly afterwards—usually within 2 weeks and most within 48 hours. The risk is greatest if older than 60, symptoms last more than 10 minutes and there is weakness or a speech impediment with the TIA.2

  • Clinical assessment (including neurological examination) investigations and treatment should be commenced quickly.

  • The best approach to stroke management is aggressive attention to primary and secondary prevention.

  • The main risk factors for stroke are atrial fibrillation, hypertension, smoking, age and diabetes.

  • Cardiac disease is now a more recognised source of emboli.

  • Most patients with a stroke or TIA require urgent imaging to find the cause and guide treatment.

  • Ideally patients should be referred to a stroke unit ASAP—within 3 hours.

  • Consider the possibility of a cryptogenic stroke,1 especially from a patent foramen ovale (PFO) (in 20–25% of population and responsible for 50% of these strokes) in relatively young people presenting with a stroke: this leads to paradoxical emboli (from veins to the brain). PFOs may be detected by echocardiography and sealed with a percutaneous closure device.

  • Consider the possibility of endocarditis if there is a heart murmur.

  • Order a CT or MRI scan on all patients with suspected TIAs and strokes (if not referring to a stroke unit): if normal repeat in 7 days (CT scans unreliable after 7 days). Such imaging is required to differentiate between ischaemia and haemorrhage.

  • Keep in mind atherosclerotic disease of aortic arch as a source of cerebral embolism.

  • The place of carotid endarterectomy for asymptomatic carotid stenosis remains controversial. It should be seriously considered if the stenosis is severe, the risk of surgery is low (3% risk of major stroke), the team has proven expertise and the patient is medically fit with a good life expectancy.1

  • Carotid artery stenting for the treatment and prevention of stroke is an evolving procedure.

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Modifiable risk factors for cerebrovascular disease2

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Major: hypertension, smoking, cardiovascular disease, atrial fibrillation (especially valvular), diabetes.

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Others: cardiac failure, dyslipidaemia, obesity, alcohol excess, oral contraception, migraine, stress.

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Control of risk factors is the key approach to management. Control of hypertension, including systolic hypertension in the elderly, and smoking cessation are vital factors for reduction of the incidence of stroke. A meta-analysis of 14 randomised trials showed that a reduction of ...

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