Cerebrovascular Disease

Clinical Presentation

Symptoms of cerebrovascular disease may include weakness, paresthesia or sensory loss, neglect, altered visual-spatial capacity, and monocular blindness, affecting either side of the body, as noted by the American Heart Association 1, 2
Aphasia may be a sign of ischemia in the distribution of the internal carotid artery, particularly in ambidextrous or left-handed individuals 1, 2

Cerebrovascular disease symptoms are typically defined as lasting less than 24 hours, with a usual duration of less than 15 minutes 1, 2
Ischemic stroke is defined as neurological signs or symptoms lasting ≥24 hours or until death, with pathology or neuroimaging evidence of CNS infarction, as stated by the American College of Cardiology 3
Transient ischemic attack (TIA) is defined as neurological signs or symptoms lasting <24 hours presumed to be due to focal brain, spinal cord, or retinal ischemia, but without evidence of acute infarction by neuroimaging or pathology, as defined by the American College of Cardiology 3
The following diagnostic criteria are used to distinguish between TIA and ischemic stroke:
Condition Duration of Symptoms Evidence of Infarction
TIA <24 hours No
Ischemic Stroke ≥24 hours Yes

Condition	Duration of Symptoms	Evidence of Infarction
TIA	<24 hours	No
Ischemic Stroke	≥24 hours	Yes

Urgent brain imaging (CT or MRI), vascular imaging, and cardiac evaluation are recommended to rule out stroke and identify underlying causes, with a risk of stroke within 7 days of 8.8% and within 90 days of 11.6%, as recommended by the American College of Radiology 4
A comprehensive vascular assessment should include a complete CTA or MRA from aortic arch to vertex to identify potential vascular abnormalities, as recommended by the International Journal of Stroke 5

The following diagnostic tests are recommended:

Diagnostic Test	Recommended Timing
Non-contrast CT or MRI	As soon as possible
Vascular imaging (CTA, MRA, or carotid ultrasound)	Within 24-48 hours
Blood glucose levels	Immediately
Complete blood count with platelet count, coagulation studies, serum electrolytes, and renal function tests	As soon as possible
12-lead ECG	As soon as possible

The ABCD2 score is used to assess the risk of stroke after a TIA, with points assigned for Age ≥60 years, Blood pressure ≥140/90 mmHg, Clinical features (unilateral weakness, speech disturbance), Duration of symptoms, and Diabetes, and the risk interpretation is as follows:
Risk Level Points Stroke Risk at 2 days
High 6-7 ~8.1%
Moderate 4-5 ~4.1%
Low 0-3 ~1.0%

Antiplatelet therapy, such as aspirin (initial dose 160-325mg, then 81-100mg daily), clopidogrel 75mg daily, or aspirin-dipyridamole extended-release combination, should be initiated within 24 hours if no contraindications exist, according to the American Heart Association, with a strength of evidence level of high [@7@, 9, 13, 1]
High-intensity statin therapy regardless of baseline cholesterol, with a target LDL <100 mg/dL, is recommended for patients with TIA, according to the American Heart Association, with a strength of evidence level of high [@9@, 9]
Aggressive management of modifiable risk factors, including hypertension control, diabetes management, smoking cessation, moderate alcohol consumption, weight management, regular physical activity, and dietary modifications, is essential for preventing stroke in young patients with TIA, according to the American Heart Association, with a strength of evidence level of high 13, 1, 9, 11, 14
Carotid endarterectomy (CEA) is recommended for patients with symptomatic carotid stenosis >70% and hemispheric TIAs, and early CEA (within 2 weeks) provides the highest benefit for stable patients, according to the American Heart Association, with a strength of evidence level of high [@11@, 9]

Initial follow-up should occur at 2-4 weeks after the event, with subsequent follow-up every 3-6 months, according to the American Heart Association, with a strength of evidence level of moderate [@12@, 9, 7]
Patient education on recognizing TIA/stroke symptoms, adhering to treatment, and modifying lifestyle habits is recommended by the American Heart Association, with a strength of evidence level of high 9
Target blood pressure should be less than 140/90 mmHg, avoiding excessive blood pressure lowering in the first few days post-TIA, as recommended by the European Society of Cardiology and the American Heart Association, with a strength of evidence level of moderate [15, @8@, 9]
Long-term oral anticoagulation is recommended, with options including warfarin (target INR 2.0-3.0) or direct oral anticoagulants, according to the American Heart Association 9

For private drivers, a 1-4 week restriction applies to most cases, as recommended by the Australian Clinical Guidelines for Acute Stroke Management, with a strength of evidence level of moderate 7, 16
Commercial drivers are subject to more stringent criteria, with longer restriction periods typically required, according to the Australian Clinical Guidelines for Acute Stroke Management, with a strength of evidence level of moderate 16
National and state-specific guidelines for driving after TIA may vary, and these should be followed, according to the Australian Clinical Guidelines for Acute Stroke Management, with a strength of evidence level of moderate 7