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

GILLES MÉNAGE (1613–1692)

Glossary of terms

Stroke A focal neurological deficit lasting longer than24 hours caused by intracerebral haemorrhage orinfarction.

Stroke in evolution An enlarging neurological deficit, presumably due to infarction, which increases over24-48 hours.

Transient cerebral ischaemic attack (TIA) A transientepisode of neurological dysfunction caused byfocal brain, spinal cord or retinal ischaemia withoutinfarction.1

Key facts and checkpoints

  • Stroke is the second most common (10-12%)cause of death in the Western world. Most areischaemic (thrombotic or embolic), but 15-20% arehaemorrhagic.

  • A stroke or TIA must be considered a medicalemergency.

  • One in 10 patients with a TIA is likely to have astroke shortly afterwards—usually within 2 weeksand most within 48 hours. The risk is greatest ifolder than 60, symptoms last more than 10 minutesand there is weakness or a speech impedimentwith the TIA.2

  • Clinical assessment (including neurologicalexamination) investigations and treatment shouldbe commenced quickly.

  • The best approach to stroke management isaggressive attention to primary and secondaryprevention.

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

  • Cardiac disease can be a source of emboli.

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

  • Ideally, patients should be referred to a stroke unitASAP—within 3 hours.

  • Order a CT or MRI scan on all patients withsuspected TIAs and strokes (if not referring to a stroke unit): if normal, repeat within 7 days (CTscans unreliable after 7 days). Such imaging isrequired to differentiate between ischaemia andhaemorrhage.

  • Consider the possibility of a cryptogenic stroke,1especially from a patent foramen ovale (PFO) (in20-25% of population and responsible for 50%of cryptogenic strokes) in relatively young peoplepresenting with a stroke: this leads to paradoxicalemboli (from veins to the brain). PFOs may bedetected by echocardiography and sealed with apercutaneous closure device, although this is notroutine.

  • Consider the possibility of endocarditis if there is aheart murmur.

  • Keep in mind atherosclerotic disease of the aorticarch as a source of cerebral embolism.

  • The place of carotid endarterectomy forasymptomatic carotid stenosis remainscontroversial. It should be seriously considered ifthe stenosis is severe, the risk of surgery is low(3% risk of major stroke), the team has provenexpertise and the patient is medically fit with agood life expectancy.1

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


2Major: hypertension, smoking, cardiovascular disease, atrial fibrillation (especially valvular), diabetes.

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

Control of risk factors is the key approach to management. Control of hyper tension, 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 blood pressure of 5-6 mmHg is ...

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