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Special Situations Cerebellar stroke: Cerebella stroke: Cerebellar infarction and hemorrhage warrant separate consideration because of the rapid and life-threatening brainstem compression they may produce. Patients with cerebellar strokes may present with sudden onset of dizziness, nystagmus, vomiting, truncal ataxia, gait disturbance, gaze palsy, or stupor. The hematoma from a cerebellar hemorrhage or the swollen cerebellar hemisphere in an infarction can cause brainstem compression. Symptoms of brainstem compression include decreasing level of consciousness, facial weakness, and gaze palsy. Patients may rapidly progress to coma and herniation therefore prompt surgical decompression is indicated. All cerebellar strokes are neurosurgical emergencies requiring early neurosurgical consultation. Transient Ischemic Attacks: Transient ischemic attacks (TIAs) are neurologic deficits that resolve within twenty-four hours with most resolving within thirty minutes. Patients usually present for evaluation after the neurologic signs have ceased and therefore the diagnosis is often based on history. A TIA is a warning of an impending stroke. Approximately 10% of patients with TIA will have a subsequent stroke within 3 months of the TIA, 50% of whom will have the event within 48 hours. Antiplatelet therapy with aspirin is of proven benefit in the prevention of stroke following TIA. Ticlopidine is another antiplatelet agent of proven benefit but is more expensive, takes several days for maximum effect and requires careful hematologic monitoring because it can cause pancytopenia. However, ticlopidine is useful for aspirin allergic patients. Anticoagulant therapy is not routinely recommended for patients following a TIA as there is no evidence to support its efficacy unless there is a cardiac source of embolism. Despite the lack of available data some recommend consideration of anticoagulation for patients with: a pattern of crescendo TIAs, development of a TIA while on aspirin, known high grade carotid stenosis and posterior circulation TIA. All patients presenting with a possible TIA require a CT scan to exclude other etiologies of their neurologic symptoms. The remainder of the work-up is individualized based upon the patient*s characteristics and the type of TIA. The evaluation of carotid arterial blood flow by doppler technology is often performed for screening but results do not always correlate with angiography. Carotid endarterectomy is of proven benefit in patients with TIA who have angiographically demonstrated carotid stenosis of 70% or greater, are at low risk for surgical complications, and for whom a skilled surgeon is available. Patients with TIAs are at high risk for stroke and management should be expedient. The need for close observation, rapid determination of etiology and institution of appropriate therapy justify admission for patients with a recent TIA (less than 72 hours) or crescendo TIAs. |
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