Many patients with nonvalvular AF have substantial rates of ischemic stroke. Stratification of stroke risk identifies AF patients who benefit most and least from lifelong anticoagulation. Warfarin is recommended for high-risk AF patients who can safely receive it. Aspirin may be indicated for those with a low stroke risk and for those who cannot receive warfarin. For AF patients considered to have a moderate risk of stroke, individual bleeding risk during anticoagulation and patient preference should particularly influence the choice of antithrombotic prophylaxis.
Eight patients are described who developed infarctions in the vertebral-basilar artery distribution following chiropractic neck manipulation or spontaneous head turning. The angiographic and autopsy findings indicate that injury to the intima of the vertebral artery at the atlantoaxial joint forms a nidus for thrombus formation which may propogate or embolize to involve other vessels in the vertebral-basilar system and result in progressive brainstem infarction. The role of anticoagulation in these patients is discussed.
A retrospective study of 228 consecutive carotid endarterectomies was conducted to determine the operative stroke and mortality rate in two 600-bed community hospitals. The combined stroke-mortality rate for the series was 21.1% (48 of 228). Eleven endarterectomies were performed for asymptomatic bruits and the combined stroke-mortality rate was 18.2% (2 of 11). Fifty-seven endarterectomies were performed for transient ischemic attach(s) in the symptomatic carotid artery distribution and the combined stroke-mortality rate was 21.1% (12 of 57). Seventy-one endarterectomies were performed following a mild-moderate stroke in the symptomatic carotid artery distribution and the combined stroke-mortality rate was 21.1% (15 of 71). Twelve endarterectomies were performed following a severe stroke in the symptomatic carotid artery distribution and the combined stroke-mortality rate was 41.7% (5 of 12). There was no trend toward more or less operation strokes or deaths from 1970 to 1976. The similarity of results among the eleven board-certified neurological and vascular surgeons who performed the 228 endarterectomies suggests that the operative stroke and mortality rates for carotid endarterectomy reported here are likely to be representative of those in many other community hospitals in this country in the 1970s.
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