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Stroke neuroimaging: Evaluation of a recent stroke patient

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Effective treatment of patients with cerebrovascular disease depends on accurate diagnosis. An outpatient ambulatory setting offers the physician advantages and disadvantages over inpatient encounters in caring for patients with cerebrovascular disease, and different issues may arise. The office allows more privacy, room, time, and freedom from distractions. The patient and any accompanying friends or family can be interviewed behind closed doors and at more leisure than in the usual hospital room. Somehow, seeing the patient and significant others in their usual attire adds an insight into their character that is not gotten from seeing the patient in hospital uniform.
Effective management of cerebrovascular disease patients depends on accurate diagnosis. Outpatient ambulatory visits have advantages and disadvantages over inpatient encounters. In ambulatory patients, the key questions are as follows: What is the diagnosis (what and where are the vascular and brain lesions)? How urgent is the problem? Should the patient be hospitalized? What tests should be ordered, and how soon? What treatment should be prescribed? What explanations and instructions should be given? This article focuses on making the diagnosis and planning the evaluation of a patient suspected of having cerebrovascular disease.
Although extracranial-intracranial (EC-IC) artery anastomosis seems to result in symptomatic improvement in certain types of cerebrovascular ischemic disease, this procedure can also be associated with significant morbidity, some of which paradoxically may be the direct result of a patent bypass. A review of the last 51/2 years at the Oregon Health Sciences University shows that 50 patients underwent 51 superficial temporal artery to middle cerebral artery bypass procedures with an angiographic patency rate of 91%. Of the 50 patients, 17 had intracranial stenotic lesions of either the middle cerebral artery (7 patients) or the internal carotid artery (10 patients). One patient had posterior cerebral artery stenosis. Five of the 18 patients with stenosis and a patent bypass developed a symptomatic occlusion of the stenotic lesion within 30 days after the anastomosis. It is hypothesized that the EC-IC bypass may have contributed to the occlusion in some of these patients by causing a change in the hemodynamic state. Possibly the bypass reversed the direction of flow distal to the stenosis to result in stasis and subsequent occlusion at the site of the stenosis or in some other manner affected hemostasis (i.e., the coagulation cascade).