Primary prevention involves the therapeutic modification or elimination of risk factors.
Patients with asymptomatic stenosis are given antiplatelet therapy (APT) consisting of aspirin, aspirin-dipyridamole combination, or clopido-grel. Endarterectomy may be indicated in asymptomatic high-grade stenosis (>80%4 or
> 90 %3). Anticoagulants may be indicated in patients with atrial fibrillation without rheumatic valvular heart disease, depending on their individual risk profile (TIAs, age, comorbidities). Acute treatment is based on the existence of a 3-6-hour interval between the onset of ischemia and the occurrence of maximum irreversible tissue damage (treatment window). General treatment measures include the assurance of adequate cardiorespiratory status (normal blood oxygenation is essential for the survival of the ischemic penumbra); because autoregulation of CBF in the penumbra is impaired, the systolic BP should be maintained above 160 mmHg. The serum glucose level should not be allowed to exceed 200 mg/100 ml. Balanced fluid replacement should be provided, and fever, if it occurs, should be treated. Physicians should be vigilant in the recognition and treatment of complications such as aspiration (secondary to dysphagia), deep venous thrombosis (secondary to immobility of a plegic limb), cardiac arrhythmia, pneumonia, urinary tract infection, and pressure sores. Rehabilitation measures include physical, occupational, and speech therapy, as well as psychological counseling of the patient and family.
Special treatment measures: APT (after exclusion of hemorrhage); thrombolysis, treatment of cerebral edema, surgical decompression in space-occupying cerebellar or MCA infarcts, and anticonvulsants, as needed. Secondary prevention. APT (TIA, mild stroke, atherothrombotic stroke); oral anticoagulation (cardiac embolism, arterial dissection); en-darterectomy (in symptomatic carotid stenosis
> 70%4, or > 80 %3, or after mild strokes). The potential utility and indications of carotid an-gioplasty and stenting in the treatment of carotid stenosis are currently under intensive study.
TDiffusion-weighted imaging (DWI) demonstrates the zone of infarction; the early CT signs of infarction (blurring of insular cortex, hypodensity of basal ganglia, cortical swelling) are less reliable.
2Perfusion-weighted imaging (PWI) demonstrates the ischemic penumbra and zone of oligemia (tissue at risk).
3Data from the European Carotid Surgery Trial (ECST).
4Data from the North American Symptomatic Carotid Endarterectomy Trial (NASCET).
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