Stroke Cerebrovascular Accident

Key Points

• Strokes usually occur without warning, and less than 20% of CVAs are preceded by a warning TIA.

• Stroke risk factors include hypertension, smoking, atrial fibrillation, internal carotid artery stenosis, and diabetes.

• The time-related cellular death in areas of hypoperfusion requires reperfusing the ischemic penumbra.

• Both dipyridamole (plus aspirin) and clopidogrel are reasonable first-line antiplatelet agents for secondary stroke prevention.

• During the first day after an ischemic stroke, most patients with elevated blood pressure should not be treated unless systolic is consistently higher than 220 or diastolic is consistently higher than 120 mm Hg.

Cerebrovascular accident (CVA, stroke) is the third leading cause of death in the United States and the leading cause of significant disability in adults. About 750,000 new cases of stroke occur each year. Despite a decline in ischemic stroke rate (which accounts for most strokes), the absolute number of strokes in the United States continues to rise. This continued annual increase is the result of an increase in the mean age of the population. Current projections predict 1 million strokes each year in the United States by 2050. The mortality rate for CVA is about 15%, and only slightly less than one third of patients who suffer a stroke regain normal cerebral function. Furthermore, the recurrence rate for patients who survive a stroke is about 10% per year. Thus, CVA remains a major public health problem in the United States (Bena-vente and Hart, 1999; Hart and Benavente, 1999).

Stroke is generally defined as the rapid onset of a neurologic deficit involving a certain vascular territory that lasts longer than 24 hours. A transient ischemic attack (TIA) is similarly characterized by the rapid onset of a neurologic deficit, but it generally lasts for less than 24 hours, and usually for only minutes. CVAs may be of ischemic or hemorrhagic origin, whereas TIAs are generally ischemic events. Statistically, most patients have ischemic rather than hemorrhagic strokes. About two thirds of ischemic strokes are caused by thrombosis, and slightly less than one third are caused by embolus. Ischemic strokes result from many causes, including intracranial atherosclerosis, cervical carotid artery stenosis, and occlusive disease of the small, penetrating arteries, leading to lacunar infarcts. Hemorrhagic strokes are generally related to intracranial or subarachnoid hemorrhage, with intracranial hemorrhages being more common. No specific cause is identified in as many as 30% of patients with stroke; patients with cryptogenic CVA are often younger.

Strokes usually occur without warning, and less than 20% are preceded by a warning TIA. Patients with a previous TIA or CVA have a 4.5% to 6.6% annual risk for subsequent stroke. The risk for CVA after a retinal TIA (amaurosis fugax) is much lower than that after a hemispheric TIA.

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