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these mechanisms is likely in the typical case Although hypotension may cause focal EEG changes, it has not, in the authors experience, reproduced the attacks in either the carotid or basilar territory In the majority of cases, the attacks bear no strict relation to position or activity, although they are likely to occur when the patient is up and around rather than lying down Nevertheless, a small proportion of patients with carotid or basilar artery stenosis clearly relate the onset of their attacks to standing up after lying or sitting Transient symptoms present on awakening from sleep usually indicate that a stroke is impending Rarely, TIAs are experienced in relation to exercise, outbursts of anger or joy, and bouts of coughing On the other hand, exercise and postural TIAs are particularly suggestive of stenosis of aortic branches, as occurs in Takayasu disease (see further on) and dissection of the aortic arch and occasionally in a xed carotid stenosis TIAs induced by hyperventilation are said to be characteristic of moyamoya disease, a progressive stenosis of intracranial vessels discussed in a later section In states of anemia, polycythemia, thrombocythemia, extreme hyperlipidemia, hyperviscosity from macroglobulinemia, sickle cell anemia, and hypoglycemia, there may be transient neurologic de cits related to rheologic changes in blood, as already mentioned In some of these cases, stenosis in a large or small vessel appears to have accounted for a restricted neurologic de cit, but just as often the vasculature is normal Patients with antiphospholipid antibodies may have TIAs, the mechanism of which is unde ned In some instances the TIAs begin after the artery has already been occluded by thrombus As shown by Barnett, emboli may arise from the distal end of the thrombus or enter the upper part of the occluded vessel through a collateral artery However, almost one- fth of carotid TIAs in the series of Pessin and colleagues and a somewhat larger proportion of cases reported by Ueda and coworkers had neither stenosis nor ulceration of the carotid arteries In most of the cases with normal carotids, the ischemic attacks exceeded 1 h in duration, suggesting embolism from the heart or great vessels including the aortic arch; but there were also a small number of brief ischemic attacks that were unexplained even after arteriography In general, hemodynamic changes in the retinal or cerebral circulation make their appearance when the lumen of the internal carotid artery is reduced to 15 mm or less (normal diameter, 70 mm; range, 5 to 10 mm, smaller part of this range in women) This corresponds to a reduction in cross-sectional area of more than 95 percent The exact degree of stenosis that may cause TIAs and the risk of stroke with mild and moderate degrees of stenosis is controversial and is addressed further on Differential Diagnosis of Transient Ischemic Attacks Transient focal neurologic symptoms are ubiquitous in neurologic practice They may be due to seizures, migraine, or unusual conditions such as transient global amnesia (page 379), and they occur occasionally in patients with multiple sclerosis Almost always the clinical setting in which they occur indicates the nature of the attack Transient episodes, indistinguishable from TIAs, are also known to occur in patients with meningioma, glioblastoma, metastatic brain tumors situated in or near the cortex, and even with subdural hematoma Although infrequent, these attacks are important mainly because the use of anticoagulants is relatively contraindicated in some of these circumstances The episodes that we have seen with meningiomas and subdural hematomas have consisted mainly of transient aphasia or speech arrest lasting from 2.

min to several hours, but sensory symptoms with or without spread over the body, arm weakness, and hemiparesis have also been reported Some remarkable cases of meningioma have involved repeated transient attacks for decades Seizures are always suspected in these cases but cannot be proved It has been speculated that a local vascular disturbance of some kind is operative, but the mechanism is not understood

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As you can see, the rows are made up of Country and Sold-to Party and the columns are Incoming Orders and Order Entry Quantity Remember these positions since we will see them quite a bit in this chapter and understanding formatting of each of the queries you are using will help in the development of the different Web items such as the different charts and graphs

The main objective in these forms of cerebrovascular disease is the prevention of stroke Ideally this should be accomplished by nding patients in the asymptomatic stage of atherosclerosis However, the medical profession has no ef cient means of screening large populations at risk of developing stroke and only limited methods for altering the progression of the atherosclerotic process, even if discovered in its early stages The widespread use of cholesterollowering statin medications has been shown to reduce the incidence of stroke and will probably be more widely prescribed to normal older adults For all practical purposes, treatment is directed to patients who have already begun to have symptoms, either TIAs or ischemic lesions that are reversible to some extent The current treatment of atherothrombotic disease may be divided into four parts: (1) management in the acute phase, (2) measures to restore the circulation and arrest the pathologic process, (3) physical therapy and rehabilitation, and (4) measures to prevent further strokes and progression of vascular disease Management in the Acute Phase The relative advantages of placing the seriously ill acute stroke patient in a neurologic special care or stroke unit have been the subject of many articles It is our impression that the outcome in terms of morbidity and mortality in the seriously ill stroke patient is improved, though admittedly this is dif cult to document (for details, see Ropper and also Brott and Reed) Like the well-organized coronary care unit, stroke units have the capability of expediting the evaluation and early rehabilitation of these patients As already emphasized, the prevention of aspiration and of pneumonia are paramount, and probably avoidable Also deserving attention are the prevention of venous thrombosis in the legs, pulmonary embolism, and coronary syndromes Patients with impaired consciousness require special care of skin, eyes, mouth, bladder, and bowel These measures are best provided in a unit with trained clinical staff and the technology to monitor blood pressure, pulmonary function, blood gases, and, when appropriate, intracranial pressure (page 740) Measures to Restore the Circulation and Arrest the Pathologic Process Once a thrombotic stroke has developed fully (ie, the completed stroke), none of the therapeutic measures so far devised has proved to be consistently effective in restoring the damaged cerebral tissue to a functional state The in uence of anticoagulants and thrombolysis at an early stage of stroke are discussed below One s efforts must be directed to making a diagnosis of thrombosis at the earliest possible stage and circumventing the full catastrophe by all means available without risking the safety of the patient Even when the symptoms and signs have become persistent, it is conceivable that some of the affected tissue, particularly at the edges of the infarct, has not been irreversibly damaged and will survive if perfusion can be re-established On the assumption that.

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