Albertson Megan, Sharma Jitendra
S D Med. 2014 Nov;67(11):455, 457-61, 463-5.
Cerebrovascular accidents (CVAs) are the leading cause of disability and the fourth leading cause of death in the U.S. The WHO defines stroke as "rapidly developing clinical signs of focal disturbance of cerebral function lasting more than 24 hours with no apparent cause other than of vascular origin." Strokes are subdivided into two major classifications: ischemic (80-87 percent) andhemorrhagic (13-20 percent). Ischemic strokes occur from thrombi, emboli, or global hypoperfusion. Hemorrhagic strokes are either parenchymal (10 percent of all strokes) or subarachnoid (3 percent of all strokes). There are a variety of recognized risk factors for stroke which include: age, race, family history, hypertension, diabetes mellitus, atherosclerosis, cardiac arrhythmias, prosthetic valves, hyperlipidemia, cigarette smoking, and others (drugs or hormones). The initial assessment of a patient suspected of stroke should be done quickly enough to ensure maximal reperfusion of brain tissue. The steps to achieve this goal are: 1) exclude an intracranial hemorrhage, 2) assess for contraindications to thrombolytics, 3) characterize the infarct. The workup for a patient should first include a history (especially the time when neurologic symptoms began), a physical exam (including the NIHSS), and imaging studies (to rule out hemorrhagic components). In addition, several lab studies can also be obtained including: PT/INR, glucose, complete blood count, metabolic panel, creatine kinase, ECG, echocardiogram, lipid panel, carotid Doppler, MRA or CTA. Acute management of a stroke is primarily focused on stabilizing the patient and allowing as much reperfusion as possible for at-risk brain tissue. Stroke management in the acute setting includes: use of thrombolytics if indicated, and re-assessment to monitor progression. Several trials have been completed in pursuit of safety and effectiveness of intra-arterial stroke therapy for patients outside the recommended thrombolytic time window, but so far they are only experimental treatment options. The best preventative measures for first time or recurrent stroke are: starting or switching antiplatelet therapy, treatment of cardiovascular risk factors (atrial fibrillation and carotid stenosis), optimization of hypertension, dyslipidemia and diabetes mellitus management, and smoking cessation.
脑血管意外（CVA）是美国致残的主要原因，也是第四大死因。世界卫生组织将中风定义为“迅速发展的局灶性脑功能障碍的临床体征，持续超过24小时，且无明显病因，除非源于血管性。”中风主要分为两大类：缺血性（80%-87%）和出血性（13%-20%）。缺血性中风由血栓、栓子或全身性灌注不足引起。出血性中风要么是实质性的（占所有中风的10%），要么是蛛网膜下腔的（占所有中风的3%）。中风有多种公认的危险因素，包括：年龄、种族、家族史、高血压、糖尿病、动脉粥样硬化、心律失常、人工瓣膜、高脂血症、吸烟以及其他因素（药物或激素）。对疑似中风患者的初始评估应足够迅速，以确保脑组织最大程度地再灌注。实现这一目标的步骤如下：1）排除颅内出血；2）评估溶栓治疗的禁忌症；3）对梗死灶进行特征描述。对患者的检查首先应包括病史（尤其是神经症状开始的时间）、体格检查（包括美国国立卫生研究院卒中量表）和影像学检查（以排除出血成分）。此外，还可进行多项实验室检查，包括：凝血酶原时间/国际标准化比值、血糖、全血细胞计数、代谢指标、肌酸激酶、心电图、超声心动图、血脂指标、颈动脉多普勒检查、磁共振血管造影或CT血管造影。中风的急性处理主要集中在稳定患者病情，并为有风险的脑组织提供尽可能多的再灌注。急性中风的处理包括：如有指征，使用溶栓药物，并进行重新评估以监测病情进展。为了探寻动脉内中风治疗对于超出推荐溶栓时间窗的患者的安全性和有效性已完成了多项试验，但到目前为止，这些都只是实验性的治疗选择。首次或复发性中风的最佳预防措施包括：开始或更换抗血小板治疗、治疗心血管危险因素（心房颤动和颈动脉狭窄）、优化高血压治疗、血脂异常和糖尿病管理以及戒烟。
