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length In the carotid system, thrombus at times propagates distally from the site of origin in the neck to the supraclinoid portion and possibly into the anterior cerebral artery, preventing collateral ow from the opposite side In middle cerebral occlusion, retrograde thrombosis may extend to the mouth of the anterior cerebral, perhaps secondarily leading to infarction of the territory of that vessel And nally, abrupt progression of a stroke may be the result of artery-to-artery embolism, as described above Several other circumstances in uence the immediate prognosis in cerebral thrombosis In the case of very large infarcts, swelling of the infarcted tissue may occur, followed by displacement of central structures, transtentorial herniation, and death of the patient after several days (Fig 34-18) This can be anticipated by the sheer volume of the infarct and is usually evident on the CT or MRI scan within a day of the stroke Smaller infarcts of the inferior surface of the cerebellum may also cause a fatal herniation into the foramen magnum Milder degrees of swelling and increased intracranial pressure may progress slightly for 2 to 3 days but do not prove fatal In extensive brainstem infarction associated with deep coma due to basilar artery occlusion, the early mortality rate approaches 40 percent In any type of stroke, if coma or stupor is present from the beginning, survival is largely determined by success in keeping the airway clear, controlling brain swelling, preventing aspiration pneumonia, and maintaining uid and electrolyte balance, as described further on under Treatment of Cerebral Edema and Raised Intracranial Pressure With smaller thrombotic infarcts, the mortality is 3 to 6 percent, much of it from myocardial infarction and aspiration pneumonia As for the eventual or long-term prognosis of the neurologic de cit, there are many possibilities Improvement is the rule if the patient survives The patient with a lacunar infarct and pure motor hemiparesis usually fares well With other small infarcts, recovery may start within a day or two, and restoration may be complete or.

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nearly complete within a week In cases of severe de cit, there may be no signi cant recovery; after months of assiduous efforts at rehabilitation, the patient may remain bereft of speech and understanding, with the upper extremity still useless and the lower extremity serving only as an uncertain prop during attempts to walk Between these two extremes there is every gradation of recovery In general, and not surprisingly, the longer the delay in onset of recovery, the poorer the prognosis Measurement of central motor conduction by magnetic stimulation has been predictive of recovery and survival but is not widely used for clinical work If clinical recovery does not begin in 1 or 2 weeks, the outlook is gloomy for both motor and language functions Constructional apraxia, uninhibited anger (with left and rarely with right temporal lesions), nonsensical logorrhea and placidity, unawareness of the paralysis and neglect (with nondominant parietal lesions), and confusion and delirium (with nondominant temporal lesions) all tend to diminish and may disappear within a few weeks A hemianopia that has not cleared in a few weeks will usually be permanent, although reading and color discrimination may continue to improve In lateral medullary infarction, dif culty in swallowing may be protracted, lasting 4 to 8 weeks or longer; yet relatively normal function is nally restored in nearly every instance Aphasia, dysarthria, cerebellar ataxia, and walking may improve for a year or longer, but for all practical purposes it may be said that whatever motor and language de cits remain after 5 to 6 months will be permanent Characteristically, the paralyzed muscles are accid in the rst days or weeks following a stroke; the tendon re exes are usually unchanged but may be slightly increased or decreased Gradually spasticity develops, and the tendon re exes become brisker The arm tends to assume a exed adducted posture and the leg an extended one Function is rarely if ever restored after the slow evolution of spasticity (however, the use of botulinum toxin may help considerably in relieving the spasticity) Conversely, the early de-.

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Figure 34-18 Massive ischemic infarct of left cerebral hemisphere mainly in the distribution of the superior division of the middle cerebral artery CT scans taken 24 h (left) and 72 h (right) following the onset of neurologic symptoms The second scan demonstrates marked swelling of the infarcted tissue and displacement of central structures

Looking at the three options (hyperlinks) at the top of the screen, you see that you can select Create New Blank Web Template This link gives you access to a blank template and allows you to create your own template from scratch New Web Template with Pattern Wizard patterns via the Pattern Wizard This link gives you access to the BI

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