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The symptoms of transient ischemic attacks vary markedly among patients; however, the symptoms in a given individual tend to be constant in type Onset is abrupt and without warning, and recovery usually occurs rapidly, often within a few minutes If the ischemia is in the carotid territory, common symptoms are weakness and heaviness of the contralateral arm, leg, or face, singly or in any combination Numbness or paresthesias may also occur either as the sole manifestation of the attack or in combination with the motor deficit There may be slowness of movement, dysphasia, or monocular visual loss in the eye contralateral to affected limbs During an attack, examination may reveal flaccid weakness with pyramidal distribution, sensory changes, hyperreflexia or an extensor plantar response on the affected side, dysphasia, or any combination of these findings Subsequently, examination reveals no neurologic abnormality, but the presence of a carotid bruit or cardiac abnormality may provide a clue to the cause of symptoms

An important cause of transient cerebral ischemia is embolization In many patients with these attacks, a source is readily apparent in the heart or a major extracranial artery to the head, and emboli sometimes are visible in the retinal arteries Moreover, an embolic phenomenon explains why separate attacks may affect different parts of the territory supplied by the same major vessel Cardiac causes of embolic ischemic attacks include atrial fibrillation, rheumatic heart disease,

The code for the Form1.cs file is shown in Example A-55.

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Vertebrobasilar ischemic attacks may be characterized by vertigo, ataxia, diplopia, dysarthria, dimness or blurring of vision, perioral numbness and paresthesias, and weakness or sensory complaints on one, both, or alternating sides of the body These symptoms may occur singly or in any combination Drop attacks due to bilateral leg weakness, without headache or loss of consciousness, may occur, sometimes in relation to head movements The natural history of attacks is variable Some patients will have a major stroke after only a few attacks, whereas others may have frequent attacks for weeks or months without having a stroke Attacks may occur intermittently over a long period of time, or they may stop spontaneously In general, carotid ischemic attacks are more liable than vertebrobasilar ischemic attacks to be followed by stroke The stroke risk is greater in patients older than 60 years, in diabetics, or after transient ischemic attacks that last longer than 10 minutes and with symptoms or signs of weakness, speech impairment, or gait disturbance

Classic migraine is easily recognized by the visual premonitory symptoms, followed by nausea, headache, and photophobia, but less typical cases may be hard to distinguish The patient s age and medical history (including family history) may be helpful in this regard Patients with migraine commonly have a history of episodes since adolescence and report that other family members have a similar disorder Focal neurologic deficits may occur during periods of hypoglycemia in diabetic patients receiving insulin or oral hypoglycemic agent therapy

Hospitalization should be considered for patients seen within 48 hours of their first attack or with crescendo attacks, symptoms lasting for more than 1 hour, symptomatic carotid stenosis, or a known cardiac source of emboli or hypercoagulable state; such hospitalization facilitates early intervention for any recurrence and rapid institution of secondary prevention measures When arteriography reveals a surgically accessible high-grade stenosis (70 99% in luminal diameter) on the side appropriate to carotid ischemic attacks and there is relatively little atherosclerosis elsewhere in the cerebrovascular system, operative treatment (carotid thromboendarterectomy) reduces the risk of ipsilateral carotid stroke, especially when transient ischemic attacks are of recent onset (< 1 month) Surgery is not indicated for mild stenosis (< 30%); its benefits are unclear with severe stenosis plus diffuse intracranial atherosclerotic disease See 12 for additional discussion In patients with carotid ischemic attacks who are poor operative candidates (and thus have not undergone arteriography) or who are found to have extensive vascular disease, medical treatment should be instituted Similarly, patients with vertebrobasilar ischemic attacks are treated medically and are not subjected to arteriography unless there is clinical evidence of stenosis or occlusion in the carotid or subclavian arteries Medical treatment is aimed at preventing further attacks and stroke Cigarette smoking should be stopped, and cardiac sources of embolization, hypertension, diabetes mellitus, hyperlipidemia, arteritis, or hematologic disorders should be treated appropriately Weight reduction and regular physical activity should be encouraged when appropriate

Example A-55. One solution to Exercise 18-3

The tracheobronchial mucosa and conjunctiva may be involved in severe cases with resultant scarring Ophthalmologic consultation is required if ocular involvement is present

Erythema multiforme major (Stevens-Johnson syndrome) with extensive denudation of skin is best treated in a burn unit Otherwise, patients need not be admitted unless mucosal involvement interferes with hydration and nutrition Patients who begin to blister should be seen daily Immediate discontinuation of the inciting medication (before blistering occurs) improves prognosis and reduces the risk of death in erythema multiforme major

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