Internal Medicine

0521779407-C01 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:53

296 Cerebrovascular Disease & Stroke

■Anticonvulsant drugs if seizures occur

■Assess type of stroke (ischemic or hemorrhagic) & candidacy for

therapy

■Reduce ICP w/ mannitol (1 g/kg IV over 30 min) if necessary after

intracerebral hemorrhage; consider surgical decompression of cere-

bellar hematomas or superficial cerebral hematoma exerting mass

effect

specific therapy

■IV thrombolytic therapy indicated for ischemic stroke within 3 hours

of onset; contraindications include:

➣CT evidence of hemorrhage

➣Recent hemorrhage

➣Treatment w/ anticoagulants

➣Hypertension (systolic pressure >185 mm Hg or diastolic pres-

sure >110 mm Hg)

■Anticoagulants for cardiogenic embolism: heparin+warfarin (aim

for INR 2–3); contraindications include:

➣CT evidence of hemorrhage

➣Blood-stained CSF

■Treatment of underlying hyperviscosity states, bleeding disorders,

vasculopathy or structural lesions as required; antihypertensive

medication if needed after 3 wk (do not give in acute phase after

stroke, as cerebral ischemia may be exacerbated)

follow-up

■Aim is to reduce risk of recurrence

➣Control hypertension, hyperlipidemia, cigarette smoking, dia-

betes

➣Consider antithrombotic agents (aspirin [optimal dose not deter-

mined], ticlopidine or clopidogrel) to prevent ischemic stroke

➣Warfarin for persisting cardiac source of embolism

➣Consider carotid endarterectomy for stenosis >70% in pts w/

TIA, amaurosis fugax or nondisabling completed stroke (not for

asymptomatic stenosis)

complications and prognosis

■Prognosis depends on age, cause of stroke, general medical condi-

tion, severity of deficit

■Among survivors, 15% require institutional care