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Lacunar infarcts are small lesions (usually < 5 mm in diameter) that occur in the distribution of short penetrating arterioles in the basal ganglia, pons, cerebellum, anterior limb of the internal capsule, and, less commonly, the deep cerebral white matter Lacunar infarcts are associated with poorly controlled hypertension or diabetes and have been found in several clinical syndromes, including contralateral pure motor or pure sensory deficit, ipsilateral ataxia with crural paresis, and dysarthria with clumsiness of the hand The neurologic deficit may progress over 24 36 hours before stabilizing Lacunar infarcts are sometimes visible on CT scans as small, punched-out, hypodense areas, but in other patients no abnormality is seen In some instances, patients with a clinical syndrome suggestive of lacunar infarction are found on CT scanning to have a severe hemispheric infarct Early mortality and risk of stroke recurrence is higher for patients with nonlacunar than lacunar infarcts The prognosis for recovery from the deficit produced by a lacunar infarct is usually good, with partial or complete resolution occurring over the following 4 6 weeks in many instances

Lastilla M Lacunar infarct Clin Exp Hypertens 2006 AprMay;28(3 4):205 15 [PMID: 16833026]

Sudden onset of characteristic neurologic deficit Patient often has history of hypertension, diabetes mellitus, valvular heart disease, or atherosclerosis Distinctive neurologic signs reflect the region of the brain involved

Thrombotic or embolic occlusion of a major vessel leads to cerebral infarction Causes include the disorders predisposing to transient ischemic attacks (see above) and atherosclerosis of cerebral arteries The resulting deficit depends on the particular vessel involved and the extent of any collateral circulation Cerebral ischemia leads to release of excitatory and other neuropeptides that may augment calcium flux into neurons, thereby leading to cell death and increasing the neurologic deficit

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In the United States, stroke remains the third leading cause of death, despite a general decline in the incidence of stroke in the last 30 years The precise reasons for this decline are uncertain, but increased awareness of risk factors (hypertension, diabetes, hyperlipidemia, cigarette smoking, cardiac

Onset is usually abrupt, and there may then be very little progression except that due to brain swelling Clinical evaluation should always include examination of the heart and auscultation over the subclavian and carotid vessels to determine whether there are any bruits

Stroke Type and Subtype Ischemic stroke Lacunar infarct Small (< 5 mm) lesions in the basal ganglia, pons, cerebellum, or internal capsule; less often in deep cerebral white matter; prognosis generally good; clinical features depend on location, but may worsen over first 24 36 hours See text signs vary depending on occluded vessel CT may reveal small hypodensity but is often normal Aspirin; long-term management is to control risk factors (hypertension and diabetes mellitus) Clinical Features Diagnosis Treatment

Remember too that you are telling SAP to combine documents by using a formula or special code; instead, whatever documents you select to be billed on a day will be collectively billed if you select the collective billing option The system will then automatically split according to the criteria we have listed This is true for delivery- and order-related billing for example, it is possible to combine credit memo requests into a single credit memo In Figure 7-9 the last two delivery documents have been selected to be billed collectively Should you click the Simulation icon (which looks like an abacus with 3 blue dots and 2 red dots) or alternatively press SHIFT-F5, you will see a screen similar to Figure 7-10 Select both lines, then click the Split Analysis button and you will see the reasons why the split occurred Note in combination to the values in the VBRK-ZUKRI field, the system also checks the fields in VBRK, for example: SD document currency Sales organization Sales and distribution: pricing procedure Billing date for billing index Sales district Export indicator

Noncontrast CT to exclude hemorrhage; CT may be normal during first 6 24 hours of an ischemic stroke, whereas diffusion-weighted MRI is more sensitive; electrocardiography, blood glucose, complete blood count, and tests for hypercoagulable states, hyperlipidemia are indicated; echocardiography or Holter monitoring in selected instances As for carotid circulation obstruction

Select patients for intravenous thrombolytics or intra-arterial mechanical thrombolysis; aspirin (325 mg/d orally) combined with sustainedrelease dipyridamole (200 mg twice daily) is first-line therapy; anticoagulation with heparin for cardioembolic strokes, and sometimes for evolving stroke when no contraindications exist As for carotid circulation obstruction

See text signs vary based on location of occluded vessel Commonly associated with hypertension; also with bleeding disorders, amyloid angiopathy Location: basal ganglia more common than pons, thalamus, cerebellum, or cerebral white matter

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