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Stroke continues to be a major cause of morbidity and mortality in adult populations worldwide. Over 750,000 patients are newly diagnosed with stroke each year in the United States alone, and this entity remains the third most frequent cause of death among adults.1 This disease is a leading cause of disability in the adult population. More than 50% of stroke sufferers will be left with permanent disability, 25% will require some assistance with activities of daily living, and 25% of patients will remain in an institutional setting 6 months poststroke.2

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The management of acute stroke had been strictly supportive until 1995 when the National Institute of Neurological Disorders and Stroke (NINDS) rt-PA Stroke Study Group published their trial of recombinant tissue plasminogen activator (rt-PA) in the treatment of acute ischemic stroke.3 The availability of an effective therapy triggered a renewed interest in treatment of acute ischemic infarction as well as the development of specialized “stroke centers” in an attempt to improve outcome in patients with cerebral ischemic infarction. These interventions have improved the outcomes in acute ischemic infarction; however, the 30-day mortality following acute stroke is still unacceptably high at 15–30%.4 Clearly, more interventions are needed in this devastating disease. New hope has been instilled with the advent of interventional neuroradiology.

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It is now even more important for the emergency physician to be able to recognize acute ischemic infarction, order appropriate imaging studies, initiate intravenous (IV) thrombolytic therapy and rapidly consult neurologists and interventional neuroradiologists. This paradigm is akin to the treatment of ST-elevation myocardial infarction (STEMI). This chapter will review (1) basic neurologic syndromes as localized by their arterial distributions (i.e., anterior cerebral artery [ACA], middle cerebral artery [MCA], posterior cerebral artery [PCA], basilar artery, etc.) as an effort to simplify recognition of large-vessel infarctions, (2) new imaging modalities, (3) initial medical management, and (4) interventional management.

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Computed tomography (CT) scans do not “rule out” acute ischemic infarctions. This is an unfortunate reality that forces the non-neurologist to perform a detailed neurologic examination. Identifying these patterns can assist in the identification of stroke syndromes that can be treated with thrombolytic therapy, as opposed to stroke syndromes that do not follow vascular territories such as hemorrhages, venous infarctions (extremely rare), or stroke mimics such as extreme ranges of blood sugar, seizures, or tumors. The history of a sudden onset of neurologic deficit and the time of onset are paramount to making the diagnosis and treatment decisions.

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The presentation of acute stroke follows distinctive anatomic patterns that are predictive of the involved arterial territory. Here are anatomic structures and associated syndromes as supplied by each major vessel:

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  • ACA: The first segment (A1) of the ACA gives rise to the recurrent artery of Huebner that supplies the caudate head, anterior limb of the internal capsule, and anterior aspect of the putamen and globus pallidus (there is some variability). Infarcts to these ...

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