CURRENT Essentials of Critical Care.pdf

Chapter 13 Neurology 201Stroke■ Essentials of Diagnosis• Signs depend on location and include hemiplegia, hemiparesis,hemisensory loss, aphasia, cranial nerve abnormalities, hemianopia,impaired cerebellar function, impaired cortical function,dysarthria• Sudden neurologic symptoms reaching maximal deficit at onsetseen with acute embolic strokes• Acute hemorrhagic stroke with sudden onset; likelihood of hemorrhageincreases with coma, vomiting, severe headache, systolicblood pressure 220 mm Hg, warfarin use• Sudden onset followed by stepwise or progressive involvementseen with occlusive vascular disease• Head CT scan insensitive in first 24 hours if bland infarct; verysensitive for hemorrhagic stroke• MRI may have higher sensitivity in early ischemic stroke; MRangiography useful for evaluating occlusive disease• Risk factors: hypertension, diabetes, smoking, cardiovasculardisease, atrial fibrillation, valvular heart disease, family historyof premature cardiovascular disease■ Differential Diagnosis• Seizure • Hypoglycemia• Neurosyphilis • Brain tumor• Subdural or epidural hematoma • Vasculitis■ Treatment• Stabilize and protect airway; ensure adequate intravenous access;monitor and treat cardiac arrhythmias• Optimal blood pressure control not clear; cautious use of parenteralmedication for SBP 220 mm Hg or DBP 120 mmHg• Assess neurologic examination serially for decompensation• Aspirin given within 24–48 hours• Tissue plasminogen activator (r-tPA) for carefully selected patientswith ischemic stroke treated within 3 h of onset; intraarterialthrombolysis may be helpful• Correct abnormalities such as hypoglycemia or hyponatremia■ PearlHypotension or rapid decreases in blood pressure should be avoidedbecause autoregulation of cerebral blood flow is impaired and regionalbrain perfusion is dependent upon systemic blood pressure.ReferenceAdams HP et al: Guidelines for the early management of patients with ischemicstroke. Stroke 2003;34:1056. [PMID: 12677087]