0521779407-C01 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:53
Cerebrovascular Disease & Stroke 295■Focal signs depend on site of cerebral ischemia
➣Anterior circulation: hemiparesis, hemisensory loss, aphasia,
homonymous hemianopia
➣Posterior circulation: dysarthria, dysphagia, ataxia, homony-
mous hemianopia, vertigo, nystagmus, cranial neuropathies,
monoparesis, hemiparesis or quadriparesis
➣Lacunar: pure motor or sensory deficit, ataxic hemiparesis,
clumsy hand
■May be retinal emboli, cardiac arrhythmias or murmurs, carotid
bruit, tender temporal arteries or evidence of hypertension
■Neck stiffness may signify intracranial hemorrhage or increased ICPtests
■Blood studies: CBC & differential count, ESR, PT/PTT, FBS, LFT, RPR,
cardiac enzymes, cholesterol & lipids, antiphospholipid antibodies
■Chest x-ray
■ECG
■Cranial CT scan in first 24 hr to detect hemorrhage & mass lesion
(tumor, abscess) simulating stroke
■Cranial MRI & MRA (including neck vessels) after 24 hr to define
extent of lesion & status of affected vasculature
■Doppler ultrasonography of neck vesselsdifferential diagnosis
■Acute myocardial infarct may present as stroke: requires immediate
ECG & cardiac enzyme studies
■Cardiogenic embolism suspected: echo & Holter monitoring as
needed
■Hypercoagulable state: assess for sickle cell disease, polycythemia,
protein C or S deficiency, afibrinogenemia, antithrombin III defi-
ciency, homocystinemia, TTP, etc, depending on age, ethnicity, fam-
ily history
■Vasculopathy (eg, necrotizing vasculitis, collagen vascular disease,
syphilis, giant cell arteritis): check ESR, CSF (for pleocytosis, VDRL)
■In hemorrhagic stroke, exclude vascular anomalies (eg, AVM,
aneurysm, cavernoma) or underlying tumor by MRI; recreational
drug use (amphetamines, cocaine, ephedrine, others) by toxicology
screen & history
■Other structural lesions: detected by brain imaging studies
management
■Supportive care