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Stroke

Cerebrovascular Accident

A cerebrovascular accident, more commonly known as a stroke, occurs when the blood supply to determined parts of the brain suddenly ceases. This may be due to the occlusion of a cerebral vessel, in which case the patient suffers an ischemic infarction, or due to the rupture of a blood vessel. The latter leads causes a hemorrhagic stroke. Ischemic strokes are much more common than hemorrhagic ones, but mortality is significantly higher after an intracranial hemorrhage.


Presentation

Both the occlusion of a blood vessel supplying the brain and the rupture of a cerebral vessel occur suddenly and mostly unexpectedly. Neurons are unable to tolerate oxygen and glucose deficiency for prolonged periods of time and neuronal death ensues shortly afterwards. Thus, symptom onset in stroke patients is acute. In general, a cerebrovascular accident may cause any type of neurological deficits, ranging from motor and sensory loss to cognitive impairment and decreased levels of consciousness. The type of deficits to be observed in an individual case largely depends on the location and the extent of the infarction. To some extent, on the basis of clinical symptoms, neurologists may deduce which part of the patient's brain is affected. Commonly observed neurological deficits include:

Space-occupying brain edema is a serious and potentially fatal complication of cerebrovascular accidents. It usually occurs between the second and fourth day after the onset of stroke symptoms [6] and possibly involves an exacerbation of neurological deficits. Brain edema is accompanied by an increase of intracranial pressure and thus, edema-mediated brain damage is not necessarily restricted to those brain regions originally affected by the cerebrovascular accident. Decreased levels of consciousness, hypertension, bradycardia and anisocoria may indicate a pathological rise of intracranial pressure due to cerebral edema.

Another possible source of delayed aggravation is reperfusion injury. Despite the fact that stroke therapy aims at recanalization and restoration of blood flow to affected brain regions, it can't currently be excluded that tissue reperfusion contributes to neuroinflammation and neuronal death. Although molecular and cellular events following tissue reperfusion are well described, evidence regarding possibly detrimental effects of reperfusion in stroke patients is still scarce [7].

Weakness
  • In the video, The Village People's iconic 1970's hit "Y.M.C.A." refreshes its lyrics to“F.A.S.T.,” a memory aid that stands for face drooping, arm weakness, speech difficulty, and time to call 911.[strokeassociation.org]
  • At 3weeks after onset, he presented with severe weakness of the left extremities. The weakness of his left extremities had recovered as follows at 3 months after onset. Consequently, he was able to walk independently on an even floor.[ncbi.nlm.nih.gov]
  • Stroke Complications After you’ve had a stroke, you may develop other complications, such as: Blood clots and muscle weakness.[web.archive.org]
  • A related disability that is not as debilitating as paralysis is one-sided weakness or hemiparesis. Stroke may cause problems with thinking, awareness, attention, learning, judgment, and memory.[ninds.nih.gov]
Coronary Artery Disease
  • artery disease, and peripheral artery disease (PAD).[ncbi.nlm.nih.gov]
  • Coronary heart disease (also called coronary artery disease), cardiomyopathy (KAR-de-o-mi-OP-a-the), heart failure, and atrial fibrillation can cause blood clots that can lead to a stroke. Brain aneurysms or arteriovenous malformations (AVMs).[web.archive.org]
  • According to one study in patients with coronary artery disease, those patients who took 75 percent or less of their medications as prescribed had a four times higher risk of stroke than patients who took their medications exactly as directed.[hopkinsmedicine.org]
Epilepsy
  • Patients with a history of epilepsy before the stroke (n 19) or who died in the first day after the stroke (n 17) were excluded from these analyses.[bmj.com]
  • The 5 year actuarial risk of a post stroke seizure in survivors (excluding 19 patients with a history of epilepsy and 3 patients in whom the seizure occurred shortly before death from another cause) was 11.5% (95% confidence interval 4.8% to 18.2%).[ncbi.nlm.nih.gov]
  • Two of 52 patients with ES had known epilepsy and were excluded; consequently, a total of 1195 acute stroke patients were included in the study.[doi.org]
  • […] cerebral (see also Infarct, brain) 434.91 cortical 434.91 lacunar 434.91 PRIND (prolonged reversible ischemic neurologic deficit) 434.91 RIND (reversible ischemic neurological deficit) 434.91 Stroke 434.91 brain - see Infarct, brain epileptic - see Epilepsy[icd9data.com]
Fatigue
  • They will be taught various strategies to help improve their memory, reduce their stress or cope with post-stroke fatigue. Each three-hour session costs 30, but those with the Community Health Assist Scheme card pay just 6 for each session.[straitstimes.com]
  • Secondary outcomes were sedentary time, time spent in light intensity physical activity, walking duration, fatigue, mood, quality of life, community participation and adverse events.[ncbi.nlm.nih.gov]
  • Her fatigue was so debilitating she realised she wouldn't be back at work after a few weeks like she hoped. It wasn't until a friend suggested she talk to Headway she was able to understand and accept how her brain injury had changed her.[headway.org.uk]
  • Many people suffer from extreme tiredness (fatigue) in the first few weeks after a stroke, and may also have difficulty sleeping, making them even more tired.[hse.ie]
  • After onset of the GFD and with iron supplement, pericardial effusion, along with peripheral edema and fatigue, decreases[ 94, 96 ]. Presence of left ventricle dilation, suggesting an initial phase of heart damage, is reversible on the GFD[ 96 ].[dx.doi.org]
Difficulty Walking
  • Other symptoms include: confusion, difficulty speaking or understanding speech; difficulty seeing with one or both eyes; difficulty walking, dizziness, loss of balance or coordination; severe headache with no known cause; fainting or unconsciousness.[who.int]
  • walking or unexplained dizziness or unsteadiness; especially in combination with any of the previously noted symptoms Other less common symptoms of stroke may include sudden nausea or vomiting, fainting, confusion, seizures or coma.[barnesjewish.org]
  • They include Sudden numbness or weakness of the face, arm, or leg (especially on one side of the body) Sudden confusion, trouble speaking, or understanding speech Sudden trouble seeing in one or both eyes Sudden difficulty walking, dizziness, loss of[medlineplus.gov]
  • Additional symptoms that don’t fit in the FAST description include: sudden confusion, such as difficulty understanding what a person is saying difficulty walking, sudden dizziness, or loss of coordination sudden, severe headache that doesn’t have any[healthline.com]
  • Symptoms can include: Headache, with or without vomiting Dizziness or confusion Weakness or paralysis on one side of the body Sudden, severe numbness in any part of the body Visual disturbance, including sudden loss of vision Difficulty walking, including[drugs.com]
Vomiting
  • We present a case of a previously healthy 36-year-old man who presented with vertigo and vomiting. MRI showed posterior circulation territory infarction.[ncbi.nlm.nih.gov]
  • Slurred speech or dysarthria Double vision or other vision problems A headache Nausea and or vomiting 2017 Fast Parody Video When it comes to spotting stroke and getting help, the faster, the better.[strokeassociation.org]
  • He developed headache, nausea, vomiting, blurred vision, diplopia, dizziness, and ataxia following the procedure. Initial history and examination suggested that the patient's symptoms were vascular in origin.[ncbi.nlm.nih.gov]
  • . * Sudden nausea and vomiting, unrelated to viral illness. * An episode of unconsciousness or convulsions.[curlie.org]
  • Four common effects of strokes in the cerebellum include the following: inability to walk and problems with coordination and balance (ataxia) dizziness headache nausea and vomiting Effects of a stroke in the brain stem: The brain stem is located at the[web.archive.org]
Nausea
  • Slurred speech or dysarthria Double vision or other vision problems A headache Nausea and or vomiting 2017 Fast Parody Video When it comes to spotting stroke and getting help, the faster, the better.[strokeassociation.org]
  • He developed headache, nausea, vomiting, blurred vision, diplopia, dizziness, and ataxia following the procedure. Initial history and examination suggested that the patient's symptoms were vascular in origin.[ncbi.nlm.nih.gov]
  • . * Sudden nausea and vomiting, unrelated to viral illness. * An episode of unconsciousness or convulsions.[curlie.org]
  • Four common effects of strokes in the cerebellum include the following: inability to walk and problems with coordination and balance (ataxia) dizziness headache nausea and vomiting Effects of a stroke in the brain stem: The brain stem is located at the[web.archive.org]
  • Sudden severe headache with no apparent cause Sudden episodes of difficulty walking or unexplained dizziness or unsteadiness; especially in combination with any of the previously noted symptoms Other less common symptoms of stroke may include sudden nausea[barnesjewish.org]
Dysphagia
  • CASE PRESENTATION: We describe a case of an 84-year old right-handed man who presented to hospital with dysarthria, dysphagia, right-sided facial drop, a history of generalized weakness and multiple falls.[ncbi.nlm.nih.gov]
  • Mahendra T Bhati , Linda L Carpenter , Darin D Dougherty , Robert H Howland , Ali R Rezai , Donald A Malone J Neurol Neurosurg Psychiatry Mar 2017, 88 (3) 262-265; DOI: 10.1136/jnnp-2016-313803 The association between delays in screening for and assessing dysphagia[jnnp.bmj.com]
  • Dysphagia or dysarthria. Isolated reduced level of consciousness can result from bilateral thalamic or brain stem ischaemia.[patient.info]
  • A stroke can lead to a number of longer term effects such as problems with speech, swallowing (dysphagia) and one-sided weakness (hemiparesis) or paralysis (hemiplegia). For more information, see Effects of brain injury.[headway.org.uk]
Constipation
  • Loss of bowel control or constipation also may occur after a stroke.[web.archive.org]
  • […] problems with your speech, reading and writing problems with your sight – you might have double vision or find it hard to see problems with your memory and difficulty concentrating difficulty controlling your bladder and bowel movements (incontinence or constipation[bupa.co.uk]
  • Bladder and bowel problems: urinary incontinence, faecal incontinence, constipation. Swallowing problems, poor oral health, malnutrition, dehydration. Sexual dysfunction. Difficulties with activities of daily living: personal, social and vocational.[patient.info]
Hypertension
  • Abstract Hypertension and stroke Hypertension is a major risk factor for stroke, and stroke prevention is the most important achievement of modern antihypertensive treatment.[doi.org]
  • Hypertension and stroke Hypertension is a major risk factor for stroke, and stroke prevention is the most important achievement of modern antihypertensive treatment.[web.archive.org]
  • Subscribe to journal Get new issue alerts Strandgaard Svend Original Articles: PDF Only Abstract Hypertension and stroke Hypertension is a major risk factor for stroke, and stroke prevention is the most important achievement of modern antihypertensive[journals.lww.com]
  • The largest proportions of chameleons were AMS, syncope, hypertensive emergency, systemic infection, and suspected ACS. Patients diagnosed with hypertensive emergency or AMS had an 8% and 7% chance of having an acute stroke.[ncbi.nlm.nih.gov]
  • hypertensive or not (5665 patients).[ncbi.nlm.nih.gov]
Tachycardia
  • There is a higher prevalence of CD in patients with Postural Orthostatic Tachycardia Syndrome (POTS)[ 163 ]; thus these patients should also be screened for CD[ 164 ].[dx.doi.org]
Diplopia
  • He developed headache, nausea, vomiting, blurred vision, diplopia, dizziness, and ataxia following the procedure. Initial history and examination suggested that the patient's symptoms were vascular in origin.[ncbi.nlm.nih.gov]
  • Symptoms associated with high agreement for the diagnosis of stroke or transient ischemic attack vs no vascular event are a sudden change in speech, visual loss, diplopia, numbness or tingling, paralysis or weakness, and non-orthostatic dizziness (kappa[ncbi.nlm.nih.gov]
  • Symptoms associated with high agreement for the diagnosis of stroke or transient ischemic attack vs no vascular event are a sudden change in speech, visual loss, diplopia, numbness or tingling, paralysis or weakness, and non-orthostatic dizziness (κ 0.60[oadoi.org]
Anisocoria
  • Decreased levels of consciousness, hypertension, bradycardia and anisocoria may indicate a pathological rise of intracranial pressure due to cerebral edema. Another possible source of delayed aggravation is reperfusion injury.[symptoma.com]
Headache
  • Additional brain imaging should be considered in 4-FA-intoxicated patients, not only in the presence of neurological deficits, but also in the case of severe headache.[ncbi.nlm.nih.gov]
  • Slurred speech or dysarthria Double vision or other vision problems A headache Nausea and or vomiting 2017 Fast Parody Video When it comes to spotting stroke and getting help, the faster, the better.[strokeassociation.org]
  • Subarachnoid hemorrhage presents most commonly with severe headache and may require analysis of cerebrospinal fluid when neuroimaging is not definitive.[ncbi.nlm.nih.gov]
  • Stroke symptoms come on suddenly and include trouble speaking; confusion; weakness, numbness, or paralysis on one side of the face or body; vision problems; severe headache; or trouble with walking or balance.[health.com]
  • […] numbness or weakness, especially on one side of the body; sudden confusion or trouble speaking or understanding speech; sudden trouble seeing in one or both eyes; sudden trouble with walking, dizziness, or loss of balance or coordination; or sudden severe headache[ninds.nih.gov]
Confusion
  • The symptoms of a stroke include sudden numbness or weakness, especially on one side of the body; sudden confusion or trouble speaking or understanding speech; sudden trouble seeing in one or both eyes; sudden trouble with walking, dizziness, or loss[ninds.nih.gov]
  • The signs of a stroke include a sudden severe headache, weakness, numbness, vision problems, confusion, trouble walking or talking, dizziness and slurred speech.[webmd.com]
  • . – Other Symptoms You Should Know Sudden NUMBNESS or weakness of face, arm, or leg, especially on one side of the body Sudden CONFUSION, trouble speaking or understanding speech Sudden TROUBLE SEEING in one or both eyes Sudden TROUBLE WALKING, dizziness[strokeassociation.org]
  • Other symptoms include: confusion, difficulty speaking or understanding speech; difficulty seeing with one or both eyes; difficulty walking, dizziness, loss of balance or coordination; severe headache with no known cause; fainting or unconsciousness.[who.int]
Dizziness
  • The symptoms of a stroke include sudden numbness or weakness, especially on one side of the body; sudden confusion or trouble speaking or understanding speech; sudden trouble seeing in one or both eyes; sudden trouble with walking, dizziness, or loss[ninds.nih.gov]
  • The signs of a stroke include a sudden severe headache, weakness, numbness, vision problems, confusion, trouble walking or talking, dizziness and slurred speech.[webmd.com]
  • . – Other Symptoms You Should Know Sudden NUMBNESS or weakness of face, arm, or leg, especially on one side of the body Sudden CONFUSION, trouble speaking or understanding speech Sudden TROUBLE SEEING in one or both eyes Sudden TROUBLE WALKING, dizziness[strokeassociation.org]
  • He developed headache, nausea, vomiting, blurred vision, diplopia, dizziness, and ataxia following the procedure. Initial history and examination suggested that the patient's symptoms were vascular in origin.[ncbi.nlm.nih.gov]
Seizure
  • Occurrence of single and recurrent seizures. 52 patients had one or more post stroke seizures; in 25 the seizures were recurrent.[ncbi.nlm.nih.gov]
  • We report an event in which a seizure and stroke occurred together and consider that the stroke may have been caused by seizure-induced demand ischaemia.[ncbi.nlm.nih.gov]
  • Twenty patients (40%) had a single seizure, and most seizures (34, or 68%) were simple partial seizures or partial seizures with 2 generalization. Eleven of the seizures (22%) were characterized as primary generalized tonic-clonic seizures.[doi.org]
Neglect
  • LESSONS: Allocentric neglect due to injury of IFOF was demonstrated in a stroke patient using DTT. It appears that DTT would be helpful in demonstrating the neglect type and pathway in patients with neglect. Copyright 2017 The Authors.[ncbi.nlm.nih.gov]
  • This systematic review summarizes the effectiveness of mirror therapy for improving motor function, activities of daily living, pain, and visuospatial neglect in patients after stroke.[ncbi.nlm.nih.gov]
  • Abstract A 67-year-old right-handed woman presented with dysarthria, left upper extremity weakness and right-sided neglect of 3 hours duration.[ncbi.nlm.nih.gov]
  • Objectives This systematic review summarizes the effectiveness of mirror therapy for improving motor function, activities of daily living, pain, and visuospatial neglect in patients after stroke.[stroke.ahajournals.org]

Workup

Brain imaging is the single most important tool to assess cerebrovascular accidents. Both computed tomography scans and magnetic resonance imaging are employed to this end, and specific approaches include computed tomography or magnetic resonance angiography, diffusion- and perfusion-weighted imaging as well as fluid-attenuated inversion recovery [8] [9]:

  • In most cases, initial computed tomography scans will be conducted without contrast agents to exclude intracranial hemorrhages as a possible cause of neurological deficits. This technique is widely available and results can be obtained within short periods of time.
  • Subsequently, contrast-enhanced computed tomography angiograms may be recorded. They provide detailed information regarding the cause and location of the interruption of blood flow and are thus highly valuable in guiding treatment decisions.
  • However, even greater sensitivity of stroke detection is attributed to diffusion-weighted magnetic resonance imaging. Major disadvantages of this technique are limited availability and high costs.

The aforementioned imaging methods are also very helpful to reveal the cause of the ischemic or hemorrhagic cerebral infarction, but should be complemented with blood analyses and cardiac examination.

Periodic Lateralized Epileptiform Discharges
  • Periodic lateralized epileptiform discharges: Aetiology and association with EEG seizures. Neurology Asia 9: 107-108. Markus HS (2004) Cerebral perfusion and stroke. J Neurol Neurosurg Psychiatry 75: 353-361.[omicsonline.org]
T Wave Inversion
  • An electrocardiogram showed atrial fibrillation, with inferolateral T wave inversion, and left ventricular hypertrophy. A chest X-ray showed features consistent with pulmonary edema.[ncbi.nlm.nih.gov]
Brain Edema
  • Brain edema is accompanied by an increase of intracranial pressure and thus, edema-mediated brain damage is not necessarily restricted to those brain regions originally affected by the cerebrovascular accident.[symptoma.com]
  • This type of stroke requires decompressive craniectomy to avoid life-threatening brain edema and resulting elevation of intracranial pressure.[cosbid.org]
  • Animal models demonstrate that persistence of the hematoma in brain tissue results in progressive brain edema, metabolic distress, and potentially other mechanisms, which result in long-term disability.[doi.org]
  • Hofmeijer J, Algra A, Kappelle LJ, van der Worp HB: Predictors of life-threatening brain edema in middle cerebral artery infarction. Cerebrovasc Dis 2008, 25 :176–184. PubMed CrossRef Google Scholar 42.[doi.org]

Treatment

Treatment for stroke includes acute stroke management and surgical management [10]. Acute stroke management includes restoration of homeostasis done by oxygen therapy, blood sugar control with optimal insulin therapy and antihypertensive treatment for hypertensive encephalopathy, hypertensive nephropathy, hypertensive cardiac failure, aortic dissection, preeclampsia and intracerebral hemorrhage. People with acute stroke have to be provided with aspirin, thrombolytic treatment, anticoagulants and tranquilizers. Surgery is necessary for supratentorial hemorrhage or cerebellar hematoma. Carotid endarterectomy is performed for carotid artery stenosis. Surgical decompressive hemicraniectomy is performed for middle cerebral artery infarction, which has to be finished within 48 hours [11].

Prognosis

Prognosis of stroke was observed in 77 patients in a 7 year follow-up study. The study revealed that 31 patients had normal cranial blood flow and the remaining 46 had subnormal cranial blood flow. During the follow-up study, 7 patients died, 3 from stroke and 4 from other causes. Out of 24 patients of subnormal cranial blood flow group, 13 died from stroke and 11 from various diseases. The survival rate was lower consistently in the subnormal cranial blood flow group than in the normal one. The difference in the survival rate was found significant during the 5 and 7 years of follow-up [5].

Etiology

Etiologies of around 60 patients in the age range of 15 to 40 years with cerebral infarction in a research study by Grindal A.B. et. al. were monitored. Some of the causes for this disease were broadly identified as cardiac, hematologic, inflammatory, occlusive extra cranial vascular disease, postpartum and trauma. Cardiac causes are further divided into rheumatic heart disease with or without atrial fibrillation, sub-acute bacterial endocarditis, atrial fibrillation without rheumatic heart disease and myocardial infarction.

Hematologic causes are divided into polycythemia, sickle cell disease, thrombocytosis and disseminated intravascular coagulation. Inflammatory cause is subdivided into systemic lupus erythematosus, polyarteritis nodosa and syphilis. Other vascular causes of cerebral infarction are atherosclerosis-atherothrombosis, arterial dissection, cardio embolism, vasculitis, meningitis and fungal vasculitis, hypercoagulability, inherited metabolic disorders, and fibromuscular dysplasia and other angiopathies [2].

Epidemiology

In a research sturdy conducted in 1994, hospital and population statistics show that cerebral infarction indicates about 80 percent of all strokes. A decrease in mortality associated stroke and cerebral infarction in particular was observed in many countries in the recent period. Research studies have explained that treatment of severe or moderate hypertension reduces the stroke incidence. Annual risk of cerebral infarction is found to be related to asymptomatic carotid artery stenosis, which is estimated to be between 1 and 2 percent [3].

Sex distribution
Age distribution

Pathophysiology

The infarction on the first day appears as poorly demarcated area of softening. In the last stages of edema, the infarction appears hypodense and bright on T2 magnetic resonance imaging. The tissue of infarction will get demarcated sharply and will soften progressively. The tissue starts disintegrating from the second week and a cavity is created at that place. The anatomy of vascular territories indicates the size and location of the infarction. Microscopic evaluation during the first 24 to 48 hours discloses anoxic neurons, vacuolization of the white matter due to disentanglement of swellings of myelin and axon. Initially, there was inflammation around the blood vessels due to the release of arachidonic acid and other fatty acids. As the infarction degenerates, proliferation of peripheral region endothelial cells will continue and the capillaries will form a dead tissue [4].

Prevention

Appropriate risk assessment tool is used for assessing cardiovascular risk. Lifestyle factors like dietary advice, physical activity, weight management, alcohol consumption, and cessation of smoking are performed to prevent the disease. Drug treatment for hypertension, anti-thrombosis, lipid lowering and aspirin are helpful in primary prevention. Secondary prevention is possible with the use of dipyridamole, clopidogrel and anti-lipid agents [12].

Summary

Cerebral infarction of the brain is associated with the tiny spheroidal necrosis of the nervous tissue in the ischemic area with the distribution of the arterial vessel. Ischemia precedes infarction and both are reversible. If infarction is permanent, then there will be irreversible damage to the nervous tissue. Necrosis of nervous tissue needs not occur in all the ischemic cases. Various cell types have different intensities of sensitivities to ischemia. Penumbra is the peripheral area of the ischemic region, where the cells survive for a few hours under risk, if the blood circulation is not established. When a vessel is occluded, the entire region that it is supplying does not become ischemic as collateral circulation occurs effectively and quickly.

Circle of Willis and anastomoses of carotid arteries are examples of effective collateral circulation. Main reasons for cerebral infarction include atherosclerotic obstruction of bigger vessels, embolic blocking of distal vessels, arterial spasm and vasculitis. Common symptoms include stroke accompanied by neurological syndromes [1].

Patient Information

  • Definition: Tiny spheroidal necrosis of nervous tissue in the ischemic area with the arterial vessel distribution is called as cerebral infarction of the brain. If the damage due to infarction is permanent in the nervous tissue, then it is irreversible. 
  • Cause: Some of the causes of cerebral infarction include atherosclerosis, vasculitis, cardio-embolism, systemic lupus erythematosus, vascular spasm, meningitis, sickle cell disease, hypercoagulability and inherited metabolic disorders.
  • Symptoms: Some of the symptoms of cerebral infarction are contralateral hemiplegia that is initially flaccid and then become spastic, sensory loss, homonymous hemianopia and dysphasia
  • Diagnosis: Initial diagnosis of cerebral infarction is done by blood tests, ventricular hypertrophy is evaluated by electrocardiogram, chest X-ray and echocardiography are utilized for assessing large left atrium and myocardial infarction. Brain imaging is performed for patients having undergone blood tests and those with severe headache.
  • Treatment: Acute stroke management for cerebral infarction is done by oxygen therapy, antihypertensive treatment and optimal insulin therapy. Acute stroke is treated with anticoagulants, thrombolytic treatment, aspirin, and tranquilizers. Surgery is suggested for cerebellar hematoma

References

Article

  1. Amarenco P, Lavallée PC, Labreuche J, et al. Prevalence of coronary atherosclerosis in patients with cerebral infarction. Stroke 2011; 42:22.
  2. Moncayo J, Devuyst G, Van Melle G, Bogousslavsky J. Coexisting causes of ischemic stroke. Arch Neurol 2000; 57:1139.
  3. Caplan LR, Gorelick PB, Hier DB. Race, sex and occlusive cerebrovascular disease: a review. Stroke 1986; 17:648.
  4. Caplan LR. Brain embolism. In: Practical Clinical Neurocardiology, Caplan LR, Chimowitz M, Hurst JW. (Eds), Marcel Dekker, New York 1999
  5. Capes SE, Hunt D, Malmberg K, et al. Stress hyperglycemia and prognosis of stroke in nondiabetic and diabetic patients: a systematic overview. Stroke 2001; 32:2426.
  6. Bardutzky J, Schwab S. Antiedema therapy in ischemic stroke. Stroke. 2007; 38(11):3084-3094.
  7. Nour M, Scalzo F, Liebeskind DS. Ischemia-reperfusion injury in stroke. Interv Neurol. 2013; 1(3-4):185-199.
  8. Birenbaum D, Bancroft LW, Felsberg GJ. Imaging in acute stroke. West J Emerg Med. 2011; 12(1):67-76.
  9. Wintermark M, Sanelli PC, Albers GW, et al. Imaging recommendations for acute stroke and transient ischemic attack patients: A joint statement by the American Society of Neuroradiology, the American College of Radiology, and the Society of NeuroInterventional Surgery. AJNR Am J Neuroradiol. 2013; 34(11):E117-127.
  10. Goldstein LB, Samsa GP. Reliability of the National Institutes of Health Stroke Scale. Extension to non-neurologists in the context of a clinical trial. Stroke 1997; 28:307.
  11. Bruno A, Durkalski VL, Hall CE, et al. The Stroke Hyperglycemia Insulin Network Effort (SHINE) trial protocol: a randomized, blinded, efficacy trial of standard vs. intensive hyperglycemia management in acute stroke. Int J Stroke 2014; 9:246.
  12. Aiyagari V, Gorelick PB. Management of blood pressure for acute and recurrent stroke. Stroke 2009; 40:2251.

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Last updated: 2018-06-21 22:59