Emergency medicine clinics of North America
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Emerg. Med. Clin. North Am. · Aug 2012
ReviewTransient ischemic attack: reviewing the evolution of the definition, diagnosis, risk stratification, and management for the emergency physician.
A transient ischemic attack (TIA) is an episode of reversible neurologic deficit caused by temporary focal central nervous system hypoperfusion. TIA is a medical emergency. Because patients with TIA in the emergency department (ED) have a high risk for stroke within the next 48 hours, it is imperative for the clinician to recognize this golden opportunity to prevent a disabling stroke. This article reviews our conceptual understanding of TIA, its definition, diagnosis, ways to stratify stroke risk, the acute management and disposition in the ED, and the potential future role of diagnostic biomarkers.
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Despite the success of acute reperfusion therapies for the treatment of acute ischemic stroke, only a minority of patients receive such treatment. Even patients who receive reperfusion therapy remain at risk for further neuronal death through progressive infarction and secondary injury mechanisms. The goal of neurocritical care for the patient with acute ischemic stroke is to optimize long-term outcomes by minimizing the amount of brain tissue that is lost to these processes. ⋯ Because of the rapid and irreversible nature of ischemic brain injury, it is crucial for best neurocritical care practices to begin as early as possible. Therefore, this chapter will discuss optimal, pragmatic neurocritical care management of patients with acute ischemic stroke during the "golden" emergency department hours from the perspective of the neurointensivist. Major topics include cerebral perfusion optimization; management of cerebral edema; post-thrombolytic care; acute anticoagulation; treatment of commonly associated cardiac and pulmonary complications; fluid, electrolyte and glucose management; the role of induced normothermia and therapeutic hypothermia; and prophylaxis against common complications.
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Emerg. Med. Clin. North Am. · Aug 2012
ReviewVertigo, vertebrobasilar disease, and posterior circulation ischemic stroke.
Dizzy patients present a significant diagnostic challenge to the emergency clinician. The discrimination between peripheral and central causes is important and will inform subsequent diagnostic evaluation and treatment. ⋯ Research involving strokes of the posterior circulation has lagged behind that of the anterior cerebral circulation. Investigations of the last 20 years, using new technologies in brain imaging in combination with detailed clinical studies, have revolutionized our understanding of the clinical presentation, causes, treatments, and prognosis of posterior circulation ischemia.
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Emerg. Med. Clin. North Am. · Aug 2012
ReviewPrehospital diagnosis and management of patients with acute stroke.
Significant advances in the early management of ischemic stroke have been made since the 1995 National Institute of Neurologic Disorders and Stroke data demonstrated the benefit of early intravenous administration of tissue plasminogen activator to select patients with acute ischemic stroke within a 3-hour onset window of suspected stroke symptoms. One concept in stroke care that has become better understood is the importance of time management and the ability to deliver patients with acute stroke to appropriate care as soon as possible. Minimizing delay to definitive therapy remains the current focus in the prehospital phase of stroke care.
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Stroke should not solely be considered a disease of the elderly, and racial disparities are most evident among young adults. Acute stroke can present at any age and it is important to be familiar with the evaluation and treatment of stroke to provide timely care. The National Institute of Health Stroke Scale helps physicians objectively evaluate stroke patients. This article presents an overview of basic information on neuroanatomy, pathophysiology, and stroke syndromes.