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CT or MRI scan of the head will exclude the possibility of a small cerebral hemorrhage or a cerebral tumor masquerading as a transient ischemic attack A number of noninvasive techniques, such as ultrasonography, have been developed for studying the cerebral circulation and imaging the major vessels to the head Carotid duplex ultrasonography is useful for detecting significant stenosis of the internal carotid artery, but arteriography remains important for demonstrating the status of the cerebrovascular system MR or CT angiography may reveal stenotic lesions of large vessels but is less sensitive than conventional arteriography Accordingly, if the findings on CT scan or MRI are normal, if there is no cardiac source of embolization, and if age and general condition indicate that the patient is a good operative risk, bilateral carotid arteriography should be considered in the further evaluation of carotid ischemic attacks, although the ultrasound findings may help in selecting patients for study

One can see the reasons for an invoice split by selecting the documents one wishes to bill collectively, either from transaction code [VF04] or [VF01], as shown in Figure 7-9

Clinical and laboratory evaluation must include assessment for hypertension, heart disease, hematologic disorders, diabetes mellitus, hyperlipidemia, and peripheral vascular disease It should include complete blood count, fasting blood glucose and serum cholesterol and homocysteine determinations, serologic tests for syphilis, and an ECG and chest x-ray Echocardiography with bubble contrast is performed if a cardiac source is likely, and blood cultures are obtained if endocarditis is suspected Holter monitoring is indicated if a transient, paroxysmal disturbance of cardiac rhythm is suspected

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If anticoagulants are indicated for the treatment of embolism from the heart, they should be started immediately, provided there is no contraindication to their use There is no advantage in delay, and the common fear of causing hemorrhage into a previously infarcted area is misplaced, since there is a far greater risk of further embolism to the cerebral circulation if treatment is withheld Treatment is initiated with intravenous heparin (in a loading dose of 5000 10,000 units of standardmolecular-weight heparin, and maintenance infusion of 1000 2000 units per hour depending on the partial thromboplastin time), while warfarin sodium is introduced in a daily dose of 5 15 mg orally, depending on the international normalized ratio (INR) Warfarin is more effective than aspirin in reducing the incidence of cardioembolic events, but

Focal seizures usually cause abnormal motor or sensory phenomena such as clonic limb movements, paresthesias, or tingling, rather than weakness or loss of feeling Symptoms generally spread ( march ) up the limb and may lead to a generalized tonic-clonic seizure

disease, AIDS, recreational drug abuse, heavy alcohol consumption, family history of stroke) and improved prophylactic measures and surveillance of those at increased risk have been contributory Elevation of the blood homocysteine level is also a risk factor for stroke, but it is unclear whether this risk is reduced by treatment to lower the level A previous stroke makes individual patients more susceptible to additional strokes For years, strokes have been subdivided pathologically into infarcts (thrombotic or embolic) and hemorrhages, and clinical criteria for distinguishing between these possibilities have been emphasized However, it is often difficult to determine on clinical grounds the pathologic basis for stroke (Table 24 4)

when its use is contraindicated, aspirin (325 mg daily) may be used in patients with nonrheumatic atrial fibrillation to reduce the risk of stroke

In patients with presumed or angiographically verified atherosclerotic changes in the extracranial or intracranial cerebrovascular circulation, antithrombotic medication is prescribed Platelets adhere to and aggregate around an atherosclerotic plaque and release various substances including thromboxane A2 Treatment with aspirin significantly reduces the frequency of transient ischemic attacks and the incidence of stroke or myocardial infarcts in high-risk patients A daily dose of 325 mg is adequate Aspirin can be combined with sustained-release dipyridamole (200 mg twice daily) for optimal stroke prevention In patients intolerant of aspirin, clopidogrel (75 mg) can be used; the combination of clopidogrel and aspirin appears to offer no greater benefit than aspirin alone Anticoagulant drugs (eg, warfarin, with temporary heparinization until the dose of warfarin is adequate) are not recommended; there is no benefit over antiplatelet therapy and the risk of serious hemorrhagic adverse effects is greater Surgical extracranial-intracranial arterial anastomosis is generally not helpful in patients with transient ischemic attacks associated with stenotic lesions of the distal internal carotid or the proximal middle cerebral arteries

Chimowitz MI et al; Warfarin-Aspirin Symptomatic Intracranial Disease Trial Investigators Comparison of warfarin and aspirin for symptomatic intracranial arterial stenosis N Engl J Med 2005 Mar 31;352(13):1305 16 [PMID: 15800226] Johnston SC et al National Stroke Association guidelines for the management of transient ischemic attacks Ann Neurol 2006 Sep;60(3):301 13 [PMID: 16912978] Nguyen-Huynh MN et al Transient ischemic attack: a neurologic emergency Curr Neurol Neurosci Rep 2005 Feb;5(1): 13 20 [PMID: 15676103] Rothwell PM et al Recent advances in management of transient ischaemic attacks and minor ischaemic strokes Lancet Neurol 2006 Apr;5(4):323 31 [PMID: 16545749]

FIGURE 7-9

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