Continuum, August 2005, Volume 11, Issue 4

Cardiac considerations are important for most ischemic stroke patients for two reasons: (1) most stroke subtypes are most common in older adults where risk factors for cardiac disease are also prevalent ( Gorelick et al, 1999); and (2) cardiac concerns may influence the management of patients with transient ischemic attack and stroke. In a perfect medical world, neurologists who become involved after stroke could deal with stroke-specific concerns with the knowledge that the internist, primary care physician, or cardiologist was managing general vascular and cardiac issues both before and after the stroke. However, this cannot always be assumed. Treatment choices need to balance competing risks and consider comorbid conditions. This chapter is aimed at common questions regarding cardiac disease that arise with ischemic stroke patients.(C) 2005 American Academy of Neurology

Extracranial carotid artery stenosis represents one of the potentially treatable causes of ischemic stroke. In addition to general risk factor management, carotid endarterectomy provides a specific prophylactic intervention aimed at decreasing the risk of stroke related to carotid artery disease. The potential benefit of the procedure is dependent on several factors, including the patient's symptom status. A basic knowledge of cerebrovascular anatomy is required to correctly interpret the symptoms and signs of carotid disease. Knowledge of test characteristics is necessary for determining an appropriate evaluation strategy, and an understanding of data regarding the benefits and risks of the procedure relevant to a specific patient is critical when deciding whether to recommend the procedure.(C) 2005 American Academy of Neurology

Anticoagulant therapy has been used for the treatment and prevention of stroke since the late 1950s. Since that time, intense basic and clinical research has addressed the development and demonstration of efficacy of diverse anticoagulant agents for prevention of cerebrovascular disease in a wide variety of clinical states and disease processes. Early investigators in the pre-computed tomography (CT) scan era recognized that the major complication of anticoagulant therapy is bleeding, both systemic and intracranial, which for the most part is dose related. The high risk of intracranial hemorrhage in these pre-CT scan era studies may have been related to the use of high intensities of anticoagulant therapy, unsuspected initial intracerebral hemorrhage, suboptimal control of hypertension, and initiation of therapy in the acute phase of stroke ( Levine et al, 2004). Recent investigators have examined putative risk factors associated with bleeding during anticoagulation therapy with an eye toward optimizing the use of anticoagulant therapy. This chapter has several objectives: (1) to review the pharmacology of available and emerging anticoagulant therapies; (2) to illustrate the system for evaluating the quality of clinical evidence and grading therapeutic recommendations; (3) to present a detailed evidence-based review of the use of anticoagulants for specific disease processes, as well as during pregnancy, and when possible, to supplement the clinical trial data by high-quality observational epidemiological studies and expert opinion; and (4) to discuss the occurrence of and risk factors for intracranial hemorrhage with anticoagulant therapy.(C) 2005 American Academy of Neurology

Vascular cognitive impairment (VCI) is a term that encompasses vascular cognitive impairment, no dementia (vascular CIND), vascular dementia (VaD) and mixed VaD and other pathology (usually Alzheimer's disease [AD]). VCI is a common sequelae of stroke and small vessel ischemic disease. The neurocognitive deficits associated with VCI differ from those of AD and are typically characterized by more prominent executive dysfunction (eg, planning, organizing, multitasking), psychomotor slowing, and behavioral disturbance. These deficits may be less apparent within the structured setting of a medical evaluation than other neurocognitive changes, such as memory deterioration. Potentially modifiable risk factors for VCI include hypertension, diabetes, and hyperlipidemia, among others. Because of the close association of these factors with stroke, prevention of VCI is largely tied to control of stroke risk factors.(C) 2005 American Academy of Neurology