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the distal carotid or the stem of the middle cerebral artery and in a larger proportion of sizable cerebellar infarcts In the case of massive cerebral edema, management follows along the same lines as that for atherosclerotic thrombotic infarction (page 695) The eventual prognosis is determined by the occurrence of further emboli and the gravity of the underlying illness cardiac failure, myocardial infarction, bacterial endocarditis, malignancy, and so on In a small number of cases, the rst episode of cerebral embolism will be followed by another, frequently with severe consequences if the second stroke affects the opposite hemisphere There is no certain way of predicting when the second embolus will strike However, the occurence of this second event, once thought to be as high as 20 percent, has been revised downward, to perhaps 2 percent, based on several large trials that were designed to test the effects of anticoagulation (see the review of Swanson) This has a bearing on the choice of early treatment after embolic stroke Treatment and Prevention Three phases of therapy (1) general medical management in the acute phase, (2) measures directed to restoring the circulation, and (3) physical therapy and rehabilitation are much the same as described earlier, under Atherothrombotic Infarction Issues pertaining to the prevention of recurrent embolism are discussed below Thrombolysis has been successful to the extent indicated previously, under Thrombolytic Therapy (page 694), and should be attempted by intravenous injection of t-PA when practical There is no evidence that the risk of symptomatic hemorrhage (6 to 20 percent) from this treatment is any higher than in other types of stroke Embolectomy at the bifurcation of the common carotid artery has usually failed; it is therefore rarely attempted Similarly, embolectomy of the middle cerebral artery has been successful only in rare cases and is rarely undertaken However, intra-arterial thrombolysis, by a catheter or thrombolytic agent, is being studied by several means, mainly as a method of restoring cerebral circulation in the period beyond the 3 h of opportunity for intravenous thrombolysis Of prime importance is the prevention of cerebral embolism; this applies both to patients who have had an episode of embolism and to those who have not but are at risk of doing so The longterm use of anticoagulants has proved to be effective in the prevention of embolism in cases of atrial brillation, myocardial infarction, and valve prosthesis, as noted below The roles of aspirin and warfarin depend on the speci c circumstances and presumed origin of the embolus The most convincing evidence favoring the ef cacy of anticoagulants in the prevention of embolism in one group of patients has been presented by the Boston Area Anticoagulant Trial for Atrial Fibrillation The special group of patients at risk for stroke from chronic atrial brillation was maintained for 2 years on warfarin (INR of 15 to 2); there were 212 anticoagulated patients and 208 controls Recurrent strokes were reduced by 86 percent in the warfarin group, and the death rate was also lower One fatal hemorrhage occurred in each group; minor hemorrhages occurred in 38 of the warfarin group and in 21 of the control group In a similar study from Copenhagen, the incidence of stroke in a group receiving warfarin was calculated to be 2 percent per year, in comparison to 55 percent per year in an untreated group Several subsequent trials have attested to the ef cacy of warfarin in the prevention of stroke in patients with nonrheumatic atrial brillation (Singer) Subsequent studies have suggested that an INR between 2 and 3. word barcode generator Barcode Add-In for Microsoft Word - Creating Barcodes with Word
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