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A systematic Medline search of the medical literature was performed in January 2008 using Ovid. Subject headings included Cerebrovascular Accident/Prevention and Control, Drug Therapy, Surgery, Therapy.

Stroke is a common diagnosis in primary care and it is the third leading cause of death in Americans. Primary care clinicians provide stroke care to three main groups of patients: (1) patients at high risk of stroke requiring primary prevention, (2) patients with a history of stroke requiring secondary prevention, or (3) patients with signs and symptoms consistent with acute stroke, requiring urgent care. The purpose of this chapter is to review the risk factors, the clinical presentation and diagnosis of stroke and the recommended approach to acute treatment and prevention.

Stroke can be either ischemic or hemorrhagic. Ischemic stroke is the most common, representing 87% of the more than 700,000 strokes reported in the United States.1 The classification of stroke is illustrated in Fig. 16-1. Understanding the etiopathogenesis of the stroke is paramount in determining the correct treatment, intervention and/or prevention strategies.

Figure 16-1.

Classification of stroke. The types of stroke are illustrated, showing their location and prevalence.

The presentation and etiologies of ischemic stroke vary based on the vessels affected. Atherosclerosis of large, medium, and small arteries can result in ischemic stroke. Aortic, carotid, and vertebral artery plaque can be a source of emboli to the brain leading to stroke. Atherosclerosis can cause stenosis and impede further blood flow. Lipohyalinosis usually affects the small penetrating arteries and accounts for lacunar (small, deep) infarcts. Cardiac diseases such as atrial fibrillation (which predisposes to embolic phenomenon), acute myocardial infarction, cardiomypopathy, and valvular disease are a few of the many conditions that can predispose to a stroke. Hypotension can cause borderzone infarcts in different vascular territories. Other causes such as hypercoagulable states, vasculitis, and dissections also should be sought. In spite of an exhaustive work up, at times the etiology or cause of the stroke remains elusive. These cryptogenic strokes account for 30% of ischemic strokes.

Hemorrhagic strokes are most commonly caused by uncontrolled hypertension and usually affect penetrating arteries in the putamen, thalamus, pons, and cerebellum. Amyloid angiopathy in the elderly is another cause of hemorrhagic stroke and is often responsible for hemorrhages in the parietal or occipital lobes. Hemorrhage in a young patient without the history of hypertension should raise suspicion of other causes such as drug abuse (e.g., cocaine, amphetamines, methylphenidate, etc.), arteriovenous malformations, and brain tumors. Medications such as thrombolytic therapy (e.g., tissue plasminogen activator [tPA]), or anticoagulants (e.g., warfarin) are also associated with the development of hemorrhagic stroke. Hemorrhagic transformation of an ischemic stroke is seen most often in embolic strokes, large infarcts, middle cerebral artery stem occlusion, and also in the setting of uncontrolled hypertension and early use of anticoagulants.

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