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This chapter discusses the diagnosis, evaluation and management of ischemic strokes. Patients with ischemic strokes may present with altered mental status or airway compromise requiring immediate treatment. If the patient is not protecting his/her airway due to neurological deficits or level of consciousness, intubation will be required. If possible, the neurological examination prior to intubation has to be assessed. Blood pressure monitoring is essential for maintaining brain perfusion and decreasing the risk of conversion to hemorrhagic stroke. The most likely cause of sudden decompensation is intracranial hemorrhage during tissue plasminogen activator (tPA) administration or increased intracranial pressure due to cerebral edema. The goal should be to maintain normocarbia while minimizing positive endexpiratory pressure (PEEP). Increased PEEP can lower venous return to the heart, leading to reduced cardiac output and worsening cerebral perfusion. Consultant neurosurgery can be pivotal during cerebellar infarcts or massive hemispheric infarcts.
Sid M. Shah, Assistant Clinical Professor Michigan State University; Faculty member of Sparrow/MSU Emergency Medicine Residency Program Lansing, Michigan,
Kevin M. Kelly, Associate Professor of Neurology Drexel University College of Medicine
When convulsions and altered sensorium occur in the pregnant patient past 20 weeks gestation or in the first 2 weeks postpartum, eclampsia is the prime suspect. Phenytoin can be used to control seizures that are resistant to magnesium. Phenytoin is also a good choice if a woman is identified as high risk for eclamptic seizures and needs treatment for a prolonged period of time. Adequate control of hypertension is essential for prevention of central nervous system (CNS) complications in these patients. All patients with eclampsia and many with preeclampsia need hospitalization. Seizures are one of the most frequent neurological disorders encountered in pregnancy and carry an increased risk to the fetus from trauma, hypoxia, and metabolic acidosis. Quite common during pregnancy, headache is generally benign, but it can occasionally herald serious pathology. Chorea gravidarum (CG) is chorea occurring during pregnancy. Myasthenia gravis (MG) worsens in 40% of women with pregnancy.
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