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Chapter 5

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Case

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A 62-year-old man with no known prior medical history presents to the emergency department (ED) after being found by emergency medical technicians (EMTs) for reportedly being intoxicated. Pedestrians had noted him walking on the street disoriented and “rambling,” and he appeared to have difficulty walking. A local business owner who had seen him on the street before thought this behavior was uncharacteristic and activated 911 at 1300. The EMTs noted that he was unable to speak coherently, but he did not appear to smell of having alcohol in his system. As they were escorting the patient to the ambulance, he developed acute onset right face, arm, and leg weakness. The ED received notification of an acute stroke, and the stroke team was activated before the patient arrived to the ED. Upon arrival his vital signs are blood pressure, 142/78 mm Hg; heart rate, 78 (regular); and respiratory rate, 16.

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How common is stroke, and what is its public health burden?

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Acute ischemic stroke is in most areas of the world the most prevalent neurological emergency; one American has a stroke every 40 seconds. In the United States alone there are more than 780,000 strokes per year, with the majority being new events.1 The number of hospitalizations in the United States continues to increase. The cost associated with the care of stroke patients in 2008 was $65.5 billion; the cost of care per patient is almost double for severe strokes. Stroke is the third leading cause of death in the United States, and among adults the leading cause of long-term disability. Stroke is disproportionately a disease of individuals of lower socioeconomic status, African Americans, elderly persons, and women in the older age groups. Ischemic stroke accounts for the majority of stroke subtypes in case series from the United States.1

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The majority of stroke survivors have some form of a residual disability, though 50% to 70% will nonetheless regain functional independence.1 These patients remain at high risk for subsequent morbidity and mortality. A small proportion of acute ischemic stroke patients will be eligible for reperfusion therapy, and an even smaller proportion will actually receive it. In series from various locations in the United States the rates of thrombolysis varies when considering all stroke patients but remains low at 2% to 8.5%2; however, analysis of data from the Nationwide Inpatient Service reveals this rate to be less than 2%.3 The primary reason for not receiving reperfusion therapy is arrival outside of the appropriate time window.4 Those who arrive by the appropriate window still have several reasons within the national guidelines for not being treated, and in some hospital series there are sizeable numbers of patients who do not meet any exclusion criteria but still are not treated.5 Prevention and treatment of the complications related to stroke remain the cornerstone of treatment for ischemic stroke.

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