Cerebrovascular disease and stroke
Cerebrovascular disease and stroke
The exam tests rapid localization, reperfusion decisions, hemorrhagic stroke control, and secondary prevention. Treat stroke as a time-critical syndrome: ABCs, glucose, NIHSS, noncontrast CT, vascular imaging, and ECG. Ischemic stroke within 4.5 hours may receive IV alteplase if no contraindication and BP <185/110; selected large-vessel occlusions benefit from thrombectomy up to 24 hours using perfusion or clinical-core mismatch. Aspirin is avoided for 24 hours after thrombolysis. In ICH, reverse anticoagulation, control BP, and treat elevated ICP; in SAH, secure the aneurysm and prevent rebleeding.
Worked example
A 68-year-old with atrial fibrillation develops right hemiparesis and aphasia 90 minutes ago; NIHSS 14, CT shows no blood, CTA shows left M1 occlusion, BP 190/110. Reasoning: left MCA syndrome, within window, no hemorrhage. Lower BP below 185/110, give alteplase, and proceed to thrombectomy; do not wait for improvement. Start anticoagulation only after imaging excludes hemorrhagic transformation and timing is appropriate.
Traps
Do not withhold CT for early symptoms; do not give aspirin immediately after alteplase; do not treat wake-up stroke as automatically ineligible without mismatch imaging; do not miss anticoagulant reversal in ICH; do not ignore posterior circulation signs such as diplopia and ataxia.