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there is excessive risk due to falling or hematologic disease Patients below approximately age 65 who are lone brillators (have no other cardiac or systemic disease) need not receive anticoagulation unless there has been a previous embolism Whether younger patients who have additional vascular risk factors, such as diabetes or hypertension, bene t from anticoagulation is not known If warfarin is to be discontinued for a necessary surgical procedure, it should be reinstated as soon as the surgeon deems it safe, since this is a time of increased stroke vulnerability It has been the sense of many cardiologists that intermittent atrial brillation and brillation- utter tachycardias also represent a risk of cerebral embolism, but there are no adequate studies to con rm this The Patient with a Recent Stroke That May Not Be Complete Here the basic problem is whether a thrombotic infarction (venous or arterial) will spread and involve more brain tissue; or if embolic, whether the ischemic tissue will become hemorrhagic or another embolus will occur; or if there is an arterial dissection, whether it will give rise to emboli Therapies are controversial in most of these circumstances In some centers it is the practice to try to prevent propagation of a thrombus by administering heparin (or low-molecular-weight heparin) followed by warfarin, as discussed earlier Thrombolytic agents are an alternative if the stroke has occurred within the previous 2 or 3 h and is not too large Except perhaps in cases of recent myocardial infarction, atrial brillation, or carotid disease, it is not imperative to begin heparin immediately while awaiting the effects of warfarin The Inevident or Misconstrued Syndromes of Cerebrovascular Disease Although hemiplegia is the classic type of stroke, cerebrovascular disease may manifest itself by signs that spare the motor pathways but have the same serious diagnostic and therapeutic implications The following stroke syndromes tend to be overlooked Sometimes disregarded is a leaking aneurysm presenting as a sudden and intense generalized headache lasting hours or days and unlike any headache in the past Examination may disclose no abnormality except for a slightly stiff neck and raised blood pressure Failure to investigate such a case by imaging procedures and examination of the CSF may permit the occurrence of a later massive subarachnoid hemorrhage Small cerebral hemorrhages, subdural hematomas, or brain tumors gure into the differential diagnosis, which is usually settled by a CT scan or MRI A second unobvious stroke is one caused by occlusion of the posterior cerebral artery, usually embolic This may not be recognized unless the visual elds are routinely tested at the bedside The patient himself may not be aware of the dif culty or will complain only of blurring of vision or the need for new glasses Accompanying de cits are inability to name colors or recognize manipulable objects or faces, dif culty in reading, etc MRI or CT scanning usually corroborates the clinical diagnosis, and therapy is directed against further emboli or extension of the thrombosis Another inapparent or confounding stroke that may be mistaken for psychiatric disease is an attack of paraphasic speech from embolic occlusion of a branch of the left middle cerebral artery The patient talks in nonsensical phrases, appears confused, and does not fully comprehend what is said to him He may perform satisfactorily at a super cial level and offer socially appropriate greetings and gestures Only scrutiny of language function and behavior will lead to the correct diagnosis Infarction (or trauma) of the dominant or nondominant temporal lobe and rarely of the cau-.

a hard order Second-guessing their initial assessment of the risk of a situation is the rst mistake managers make Keep it simple Too many people make things just too dif cult and make mountains out of mole hills The more complex your risk strategy, the more dif cult it is to manage and likely the more expensive it is Buy and hold is not a bad strategy; it has proven to be successful, but you will be old and gray by the time you get to enjoy it There is money to be made in the market, short and long term truckloads of it To be successful keep your investment and risk strategies simple and easy to read, analyze Understand where the risk is going at all times Nothing is worse than to look back at a group of strategies and think, where did the money all go Track what you can manage Diversify Diversify Diversify Have your ETF products, add some managed funds, toss in a few short strangles and condors, and pick up that ridiculously cheap I-don t-care-ifit-goes-to-zero stock, sell some bond calls, and buy some risk-free rate instruments Whatever the combination you put together, spread it out Cover your systemic risk in the broad indices and spread out the wealth to many areas, industries, and securities and futures products We have covered a great deal of the in uence of fund traders on the broad market throughout the book A nal thought to take from the discussion of risk regarding the funds is that they, in many cases, are a signi cant representation of the broader market sentiment Because funds represent chunks of capital from large and small investors, they are in themselves a market barometer

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Inevitably, most patients are seen rst by clinicians who may not be expert in all the ne points of cerebrovascular disease Situations arise in which critical decisions must be made regarding anticoagulation, further laboratory investigation, and the advice and prognosis to be given to the family The following are some of the situations encountered by the authors that may be of value to students and residents and to nonspecialists in the eld The Patient with a History of an Ischemic Attack or Small Stroke in the Past The patient may be functioning normally when examined, but it has been ascertained by the history or radiologic procedures that a stroke or TIA occurred in the past The problem is what measures should be taken to reduce the risk of further strokes This is particularly problematic if a surgical procedure is planned A brief focal TIA, several minutes or less in duration, or many stereotyped spells usually represent severe stenosis of the internal carotid artery on the side of the affected cerebral hemisphere If the symptoms have occurred recently, these may be forerunners of complete occlusion If the TIA was far in the past more than several weeks previously the immediate risks of occlusion are reduced The initial approach is to establish the patency of the carotid arteries by ultrasound or MRA If there is a reduction in diameter of greater than 70 percent when compared with an adjacent normal segment of vessel, and probably if there is a severely ulcerated but not critically stenotic plaque, carotid surgery (or angioplasty) is advisable If a single TIA lasted more than an hour or the neurologic examination discloses minor signs referable to the region of the hemisphere affected by the TIA, a search for a source of embolus is indicated Appropriate diagnostic studies include ECG, a transesophageal echocardiogram, monitoring for cardiac arrhythmia, ultrasound of the carotid arteries, and a CT scan or MRI if it has not already been performed Preventive anticoagulation (warfarin) is instituted if a source of clot within the cardiac chambers is found or if there is atrial brillation Aspirin is appropriate but not imperative if no abnormality is found Control of elevated blood pressure and addressing high cholesterol levels are ancillary steps The mistake is to ignore the potential signi cance of a small stroke or TIA The Patient with Atrial Fibrillation In patients with this arhythmia who are over age 65 and in those of any age with valvular disease, anticoagulation with warfarin is virtually mandated unless.

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