TY  - CHAP
M1  - Book, Section
TI  - Cerebrovascular Disease
A1  - Powers, William J.
A1  - Jordan, Dedrick
A2  - Hall, Jesse B.
A2  - Schmidt, Gregory A.
A2  - Kress, John P.
PY  - 2015
T2  - Principles of Critical Care, 4e
AB  - EtiologyCardioembolic  and  other  nonarteriosclerotic  causes  of  cerebral  infarction  occur  more  commonly  in  patients  admitted  to  the  ICU  and  should  be  carefully  sought  by  appropriate  diagnostic  tests.In  hypertensive  patients  with  hemispheric  lobar  hemorrhages  and  in  patients  without  hypertension,  causes  for  intracerebral  hemorrhage  such  as  coagulopathies,  arteriovenous  malformations,  or  saccular  aneurysms  should  be  sought.Nontraumatic  spontaneous  subarachnoid  hemorrhage  is  almost  always  due  to  a  ruptured  saccular  aneurysm  and  should  be  evaluated  by  arteriography.Clinical  and  Laboratory  DiagnosisX-ray  computed  tomography  (CT)  is  the  diagnostic  neuroimaging  test  of  choice  for  patients  with  acute  stoke.  It  is  rapid,  can  be  performed  easily  on  acutely  ill  patients  and  acute  intracerebral  or  subarachnoid  hemorrhage  are  easily  identified.Lumbar  puncture  is  the  most  sensitive  test  for  detection  of  SAH;  it  should  be  performed  when  there  is  a  strong  clinical  suspicion  and  a  negative  CT  scan,  or  when  CT  is  not  available  or  feasible.In  suspected  ischemic  stroke,  diffusion-weighted  MRI  can  be  helpful  for  improving  diagnostic  certainty  when  there  is  no  clear  history  of  an  abrupt  onset  or  the  localization  of  the  neurological  findings  is  confusing.  MRI  has  not  been  shown  to  be  of  value  in  selecting  patients  for  thrombolytic  therapy.Early  electrocardiographic  (ECG)  monitoring  detects  previously  unsuspected  atrial  fibrillation  in  3%  to  5%  of  patients  with  acute  cerebral  ischemia.Patients  with  transient  ischemic  attacks  (TIAs)  or  mild  stroke  who  are  good  surgical  candidates  for  carotid  endarterectomy  should  be  evaluated  for  symptomatic  carotid  stenosis  immediately  since  the  risk  of  stroke  can  be  as  high  as  1  in  20  within  the  first  2  days.Treatment  of  Cerebral  InfarctionThe  following  statements  can  be  made  based  on  good  clinical  trial  data.Routine  use  of  supplemental  oxygen  does  not  reduce  mortality.Early  treatment  of  hyperglycemia  to  achieve  levels  <7  mmol/L  does  not  improve  outcome.In  patients  with  systolic  blood  pressures  of  160  to  200  mm  Hg,  pharmacological  reduction  of  systolic  pressure  by  20  to  25  mm  Hg  within  the  first  24  hours  is  safe,  but  does  not  improve  outcome.In  hemiplegic  patients,  subcutaneous  low-dose  heparin  or  enoxaparin  reduces  deep  venous  thrombosis.Intravenously  administered  t-PA  improves  outcome  in  carefully  selected  patients  with  acute  ischemic  stroke  when  instituted  within  4.5  hours  of  onset.The  clinical  value  of  any  intra-arterial  pharmacological  or  mechanical  revascularization  therapy  for  acute  ischemic  stroke  has  not  been  demonstrated.Aspirin  160  or  300  mg/d  of  aspirin  begun  within  48  hours  of  the  onset  of  ischemic  stroke  results  in  a  net  decrease  in  further  stroke  or  death.Full  anticoagulation  with  heparin  or  similar  drugs  in  patients  with  acute  ischemic  stroke  provides  no  clinical  benefit  in  general  or  in  any  subgroup,  including  those  with  atrial  fibrillation  or  other  cardioembolic  sources.Hemicraniectomy  reduces  mortality  in  patients  with  large  hemispheric  infarcts  and  depressed  level  of  consciousness  who  are  operated  within  48  hours  of  stroke  onset.Treatment  of  Intracerebral  HemorrhageThe  following  statements  can  be  made  based  on  good  clinical  trial  dataProphylaxis  for  deep  venous  thrombosis  with  low-dose  subcutaneous  heparin  or  heparinoids  may  be  instituted  safely  on  the  second  day  after  the  hemorrhage  and  reduces  subsequent  deep  venous  thrombosis  if  begun  before  day  4.In  patients  with  systolic  blood  pressure  of  150  to  220  mm  Hg,  rapid  pharmacological  ...
SN  - 
PB  - McGraw-Hill Education
CY  - New York, NY
Y2  - 2024/04/18
UR  - accessanesthesiology.mhmedical.com/content.aspx?aid=1107722032
ER  -