Imitadores de ataque cerebrovascular en pacientes de la Fundacion Cardioinfantil

Introducción: El Ataque Cerebrovascular (ACV) es una emergencia médica que requiere atención inmediata para instaurar intervenciones que ayuden a mejorar su desenlace. Su diagnóstico es clínico, pero se confirma y clasifica con la ayuda de neuroimágenes. No obstante, hasta un 30% de los pacientes qu...

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2023
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Universidad del Rosario
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Palabra clave:
Ataque cerebrovascular
Imitadores de ataque cerebrovascular
Epilepsia
Migraña
Delirum
Stroke
Stroke mimics
Epilepsy
Delirium
Migraine
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id EDOCUR2_ae17cc74bdf6b9722814d1abd76a46b3
oai_identifier_str oai:repository.urosario.edu.co:10336/41656
network_acronym_str EDOCUR2
network_name_str Repositorio EdocUR - U. Rosario
repository_id_str
dc.title.none.fl_str_mv Imitadores de ataque cerebrovascular en pacientes de la Fundacion Cardioinfantil
dc.title.TranslatedTitle.none.fl_str_mv Stroke mimics in patients from the Fundacion Cardioinfantil
title Imitadores de ataque cerebrovascular en pacientes de la Fundacion Cardioinfantil
spellingShingle Imitadores de ataque cerebrovascular en pacientes de la Fundacion Cardioinfantil
Ataque cerebrovascular
Imitadores de ataque cerebrovascular
Epilepsia
Migraña
Delirum
Stroke
Stroke mimics
Epilepsy
Delirium
Migraine
title_short Imitadores de ataque cerebrovascular en pacientes de la Fundacion Cardioinfantil
title_full Imitadores de ataque cerebrovascular en pacientes de la Fundacion Cardioinfantil
title_fullStr Imitadores de ataque cerebrovascular en pacientes de la Fundacion Cardioinfantil
title_full_unstemmed Imitadores de ataque cerebrovascular en pacientes de la Fundacion Cardioinfantil
title_sort Imitadores de ataque cerebrovascular en pacientes de la Fundacion Cardioinfantil
dc.contributor.advisor.none.fl_str_mv Romero Hernández, Camilo Andrés
Cruz Reyes, Danna Lesley
dc.subject.none.fl_str_mv Ataque cerebrovascular
Imitadores de ataque cerebrovascular
Epilepsia
Migraña
Delirum
topic Ataque cerebrovascular
Imitadores de ataque cerebrovascular
Epilepsia
Migraña
Delirum
Stroke
Stroke mimics
Epilepsy
Delirium
Migraine
dc.subject.keyword.none.fl_str_mv Stroke
Stroke mimics
Epilepsy
Delirium
Migraine
description Introducción: El Ataque Cerebrovascular (ACV) es una emergencia médica que requiere atención inmediata para instaurar intervenciones que ayuden a mejorar su desenlace. Su diagnóstico es clínico, pero se confirma y clasifica con la ayuda de neuroimágenes. No obstante, hasta un 30% de los pacientes que se presentan con déficits neurológicos focales, permanentes o transitorios, cursan con otras patologías diferentes al ACV. Estas condiciones se han agrupado bajo el término de imitadores de ACV. La identificación temprana de un imitador de ACV permitirá evitar los riesgos de las intervenciones y disminuirá el costo de la atención. Objetivo: Determinar la incidencia y las características demográficas, clínicas y radiológicas de los imitadores de ACV en pacientes con déficit neurológico, permanente o transitorio, de rápida instauración atendidos en la Fundación CardioInfantil durante el periodo 2021-2022. Métodos: Se realizó un estudio observacional, descriptivo, transversal que incluyó a pacientes que fueron interconsultados al servicio de neurología con sospecha de ACV durante el periodo de Enero de 2021 a mayo de 2022 y en los que finalmente se descartó el diagnóstico de ACV (considerados como imitadores de ACV). Se evaluaron las variables demográficas, clínicas y de imagen y se realizó un análisis de dichas variables. Resultados: De 793 pacientes con déficits neurológicos de aparición rápida que fueron consultados por sospecha de ACV, 188 (23,7%) eran imitadores de ACV. La mayoría eran mujeres, con una edad media de 66,1 años. En el 16,49% de los casos se activó el protocolo de código ACV. Los principales déficits fueron alteraciones del lenguaje (23,94%), disminución del estado de conciencia (21,28%) y compromiso motor (19,15%). En cuanto a la etiología de los imitadores de ACV en esta población, el diagnóstico más frecuente fue delirium 22,9% (43), seguido de epilepsia 17,6% (33) y migraña 12,8% (24). Ninguno de los pacientes que tuvieron síntomas de ACV fueron tratados con trombólisis intravenosa. Conclusiones: El delirio, la migraña y la epilepsia son imitadores frecuentes de ACV. La edad, factores de riesgo vascular, los síntomas o signos de focalización y la aplicación de escalas de neurológicas pueden ser elementos útiles para su rápida identificación y adecuado tratamiento. Es necesario el desarrollo de estudios multicéntricos en Colombia para conocer su prevalencia y describir sus factores predictores por subgrupos de ACV.
publishDate 2023
dc.date.accessioned.none.fl_str_mv 2023-11-14T17:36:33Z
dc.date.available.none.fl_str_mv 2023-11-14T17:36:33Z
dc.date.created.none.fl_str_mv 2023-11-09
dc.type.none.fl_str_mv bachelorThesis
dc.type.coar.fl_str_mv http://purl.org/coar/resource_type/c_7a1f
dc.type.document.none.fl_str_mv Trabajo de grado
dc.type.spa.none.fl_str_mv Trabajo de grado
dc.identifier.uri.none.fl_str_mv https://repository.urosario.edu.co/handle/10336/41656
url https://repository.urosario.edu.co/handle/10336/41656
dc.language.iso.none.fl_str_mv spa
language spa
dc.rights.*.fl_str_mv Attribution-NonCommercial-ShareAlike 4.0 International
dc.rights.coar.fl_str_mv http://purl.org/coar/access_right/c_abf2
dc.rights.acceso.none.fl_str_mv Abierto (Texto Completo)
dc.rights.uri.*.fl_str_mv http://creativecommons.org/licenses/by-nc-sa/4.0/
rights_invalid_str_mv Attribution-NonCommercial-ShareAlike 4.0 International
Abierto (Texto Completo)
http://creativecommons.org/licenses/by-nc-sa/4.0/
http://purl.org/coar/access_right/c_abf2
dc.format.extent.none.fl_str_mv 38 pp
dc.format.mimetype.none.fl_str_mv application/pdf
dc.publisher.none.fl_str_mv Universidad del Rosario
dc.publisher.department.none.fl_str_mv Escuela de Medicina y Ciencias de la Salud
dc.publisher.program.none.fl_str_mv Especialización en Neurología
publisher.none.fl_str_mv Universidad del Rosario
institution Universidad del Rosario
dc.source.bibliographicCitation.none.fl_str_mv 1. García-Alfonso C, Martínez Reyes A, García V, Ricaurte-Fajardo A, Torres I, Coral J. Actualización en diagnóstico y tratamiento del ataque cerebrovascular isquémico agudo. Univ. Med. 2019;60(3).
2. Coupland AP, Thapar Ankur, Qureshi MI, Jenkis H, Davies AH. The definition of stroke. J R Soc Med. 2017 Jan;110(1):9-12.
3. Hankey GJ. Stroke. Lancet. 2017 Feb;389(10069):641-654.
4. Amarenco P. Transient Ischemic Attack. N Engl J Med. 2020 May 14;382(20):1933-1941.
5. Gorelick PB. The global burden of stroke: persistent and disabling. Lancet Neurol. 2019 May;18(5):417-418.
6. GBD 2016 Stroke Collaborators. Global, regional, and national burden of stroke, 1990–2016: a systematic analysis for the Global Burden of Disease. Lancet Neurol. 2019 May;18(5):439-458.
7. Muñoz M. Enfermedad Cerebrovascular. Acta Neurol Colomb. 2010;26(2): 1-3.
8. Lioutas VA, Ivan CS, Himali JJ, Aparicio HJ, Leveille T, Romero JR, Beiser AS, Seshadri S. Incidence of Transient Ischemic Attack and Association With Long-term Risk of Stroke. JAMA. 2021 Jan 26;325(4):373-381.
9. Chugh C. Acute Ischemic Stroke: Management Approach. Indian J Crit Care med. 2019;23(Suppl 2):S140-S146.
10. Schrag M, Kirshner H. Management of Intracerebral Hemorrhage. J Am Coll Cardiol. 2020 Apr;75(15):1819-1831.
11. Emberson J, Lees KR, Lyden P, Blackwell L, Albers G, Bluhmki E, et al. Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomized trials. Lancet. 2014 Nov;384(9958):1929-1935.
12. Goyal M. Demchuk AM. Menon BK, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372:1019–30
13. Saver JL. Time is brain – quantified. Stroke. 2006 Jan;37(1):263-266.
14. Huang Q, Zhang J, Xu W, Wu J. Generalization of the right acute stroke promotive strategies in reducing delays of intravenous thrombolysis for acute ischemic stroke: A meta-analysis. Medicine (Baltimore). 2018 Jun;97(26):e11205.
15. Chen CH, Tang SC, Tsai LK, Hsieh MJ, Yeh SJ, Huang KY, Jeng JS. Stroke Code Improves Intravenous Thrombolysis Administration in Acute Ischemic Stroke. PLoS One. 2014;9(8):e10462.
16. Anathhanam S, Hassan A. Mimics and chameleons in stroke. Clin Med (Lond). 2017;17(2):156-160.
17. Nguyen PL, Chang JJ. Stroke Mimics and Acute Stroke Evaluation: Clinical Differentiation and Complications after Intravenous Tissue Plasminogen Activator. J Emerg Med. 2015 Aug;49(2):244-252.
18. Rowley H., Vagal A. Stroke and Stroke Mimics: Diagnosis and Treatment. In: Hodler J, Kubik-Huch R, von Schulthess G, editors. Diseases of the Brain, Head and Neck, Spine 2020–2023. Switzerland: IDKD Springer Series;2020. p 25-36.
19. Vilela P. Acute stroke differential diagnosis: Stroke mimics. Eur J Radiol. 2017 Nov;96:133-144.
20. Wippold II FJ. Focal Neurologic Deficit. AJNR Am J Neuroradiol. 2008 Nov;29(10):1998-2000
21. Peisker T, Koznar B, Stetkarova I, Widimsky P. Acute stroke therapy: A review. Trends Cardiovasc Med. 2017;27(1):59-66.
22. Sattin JA, Olson SE, Liu L, Raman R, Lyden PD. An Expedited Code Stroke Protocol Is Feasible and Safe. Stroke. 2006 Dec;37(12):2935-2939.
23. Winkler DT, Fluri F, Fuhr P, Wetzel SG, Lyrer PA, Ruegg S, et al. Thrombolysis in stroke mimics: frequency, clinical characteristics, and outcome. Stroke. 2009 Apr;40(4):1522-1525.
24. Nadarajan V, Perry RJ, Johnson J, et al. Transient ischaemic attacks: mimics and chameleons. Practical Neurology 2014;14:23-31.
25. Sadighi A, Abedi V, Stanciu A, El Andary N, Banciu M, Holland N, Zand R. Six-Month Outcome of Transient Ischemic Attack and Its Mimics. Front Neurol. 2019 Mar 27;10:294.
26. Keselman B, Cooray C, Vanhooren G, Bassi P, Consoli D, Nichelli P. Intravenous thrombolysis in stroke mimics: results from the SITS International Stroke Thrombolysis Register. Eur J Neurol. 2019 Aug;26(8):1091-1097.
27. Tsivgoulis G, Zand R, Katsanos AH, Goyal N, Uchino K, Chang J. Safety of intravenous thrombolysis in stroke mimics: prospective 5-year study and comprehensive meta-analysis. Stroke. 2015 May;46(5):1281-1287.
28. Goyal N, Male S, Wafai AA, Bellamkonda S, Zand R. Cost burden of stroke mimics and transient ischemic attack after intravenous tissue plasminogen activator treatment. J Stroke Cerebrovasc Dis. 2015 Apr;24(4):828-833.
29. Mouthon-Reignier C, Bonnaud I, Gaudron M, Vannier-Bernard S, Bodin JF, Cottier JP, et al. Impact of a direct-admission stroke pathway on delays of admission, care, and rates of intravenous thrombolysis. Rev Neurol (Paris). 2016 Dec;172(12):756-60.
30. Förster A, Griebe M, Wolf ME, Szabo K, Hennerici MG, Kern R. How to identify stroke mimics in patients eligible for intravenous thrombolysis? J Neurol. 2012 Jul;259(7):1347-53.
31. Moulin T, Sablot D, Vidry E, Belahsen F, Berger E, Lemounaud P. Impact of emergency room neurologists on patient management and outcome. Eur Neurol. 2003;50(4):207-214.
32. Arauz A, Ruiz-Franco A. Enfermedad vascular cerebral. Rev Fac Med Univ Nac Auton Mex. 2012;55(3):11-21.
33. Ojaghihaghighi S, Vahdati SS, Mikaeilpour A, Ramouz, A. Comparison of neurological clinical manifestation in patients with hemorrhagic and ischemic stroke. World J Emerg Med. 2017;8(1):34-43.
34. Adams HP, Davis PH, Leira EC, Chang KC, Bendixen BH, Clarke WR, et al. Baseline NIH Stroke Scale score strongly predicts outcome after stroke A report of the Trial of Org 10172 in Acute Stroke Treatment (TOAST). 1999;53(1):126-127.
35. Appelros P, Terént A. Characteristics of the National Institute of Health Stroke Scale: results from a population-based stroke cohort at baseline and after one year. Cerebrovasc Dis. 2004;17(1):21-27.
36. Kasner SE. Clinical interpretation and use of stroke scales. Lancet Neurol. 2006;5(7):603-612.
37. Montaner J, Alvarez-Sabín J. NIH stroke scale and its adaptation to Spanish. Neurologia. 2006;21(4):192-202.
38. Powers WJ. Acute Ischemic Stroke. N Engl J Med. 2020;383(3);252-260.
39. Badhiwala JH, Nassiri F, Alhazzani W, Selim MH, Farrokhyar F, Spears J. Endovascular Thrombectomy for Acute Ischemic Stroke: A Meta-analysis. JAMA. 2015;314(17:1832-1832-1843.
40. Rymer MM. Hemorrhagic Stroke: Intracerebral Hemorrhage. Mo Med. 2011;108(1):50-54.
41. Merino JG, Luby M, Benson R, Davis LA, Hsia AW, Latour LL, et al. Predictors of acute stroke mimics in 8,187 patients referred to a stroke service. J Stroke Cerebrovasc Dis. 2013;22(8):397-403.
42. Okano Y, Ishimatsu K, Kato Y, Yamaga J, Kuwahara K, Okumoto K, et al. Clinical features of stroke mimics in the emergency department. Acute Med Surg. 2018;5(3):241-248.
43. Gargalas S, Weeks R, Khan-Bourne N, Shotbolt P, Simblett S, Ashraf L, et al. Inicidence and outcome of functional stroke mimics admitted to a hyperacute stroke unit. J Neurol Neurosurg Psychiatry. 2015;0:1-5.
44. Hemmen TM, Meyer BC, McClean TL, D Lydep. Identification of Nonischemic Stroke Mimics Among 411 Code Strokes at the University of California, San Diego, Stroke Center. J Stroke Cerebrovasc Dis 2008;17(1):23-5.
45. Khathaami AMA, Alsaif SA, Al Bdah BA, Alhasson MA, Aldriweesh MA, Alluhidan EA, et al. Stroke mimics: Clinical characteristics and outcome. Neurosciences (Riyadh). 2020;25(1):38-42.
46. Vroomen PCAJ, Buddingh MK, Luijickx GJ, De Keyser J. The Incidence of Stroke Mimics Among Stroke Department Admissions in Relation to Age Group. J Stroke Cerebrovasc Dis. 2008;17(6):418-22.
47. Liberman AL, Prabhakaran S. Stroke Chameleons and Stroke Mimics in the Emergency Department. Curr Neurol Neurosci Rep. 2017;17(2), 15.
48. Faiz KW, Labberton AS, Thommessen B, Rønning OM, Dahl FA, Barra M. The Burden of Stroke Mimics: Present and Future Projections Stroke Cerebrovasc Dis. 2018 May;27(5):1288-1295.
49. Hansson PO, Andersson Hagiwara M, Herlitz J, Brink P, Wireklint Sundström B. Prehospital assessment of suspected stroke and TIA: An observational study. Acta Neurol Scand. 2019 Aug;140(2):93-99.
50. Sugii N, Zaboronok A, Fujimori H, Sato N, Fujita K, Ishikawa E, et al. Stroke Mimics and Accuracy of Referrals Made by Emergency Department Doctors in Japan for Patients with Suspected Stroke. J Stroke Cerebrovasc Dis. 2019 Apr;28(4):1078-1084.
51. Chtaou N, Bouchal S, Midaoui AEL, Souirti Z, Tachfouti N, Belahsen MF. Stroke Mimics: Experience of a Moroccan Stroke Unit. J Stroke Cerebrovasc Dis. 2020 May;29(5):104651.
52. Matuja SS, Khanbhai K, Mahawish KM, Munseri, P. Stroke mimics in patients clinically diagnosed with stroke at a tertiary teaching hospital in Tanzania: a prospective cohort study. BMC Neurol. 2020 Jul 7;20(1):270.
53. Brunser AM, Illanes S, Lavados PM, Muñoz P, Cárcamo D, Hoppe A, et al. Exclusion criteria for intravenous thrombolysis in stroke mimics: an observational study. J Stroke Cerebrovasc Dis. 2013 Oct;22(7):1140-5.
54. Avellaneda-Gómez C, Rodríguez Campello A, Giralt Steinhauer E, Gómez González A, Serra Martínez M, de Ceballos Cerrajería P, et al. Description of stroke mimics after complete neurovascular assessment. Neurologia (Engl Ed). 2019 Jan-Feb;34(1):7-13.
55. Alexandra ANM, Luis BSJ, Carlos RCE, Patricia JLS, Alexander MRB, Alexander AP, et al. Comparison between telestroke versus face-to-face thrombolysis models in stroke management in Colombia. Neurol Perspect. 2023;3(1):1-7.
56. Brunser AM, Hoppe A, Muñoz P, Lavados PM, Illanes S, Díaz V, et al. Trombolisis intravenosa en cuadros imitadores de isquemia cerebral: experiencia de un centro [Thrombolysis in stroke mimics: Experience in 10 cases]. Rev Med Chil. 2016 Oct;144(10):1266-1269. Español.
57. Kvistad CE, Novotny V, Næss H, Hagberg G, Ihle-Hansen H, Waje-Andreassen U, et al. Safety and predictors of stroke mimics in The Norwegian Tenecteplase Stroke Trial (NOR-TEST). Int J Stroke. 2019 Jul;14(5):508-516.
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spelling Romero Hernández, Camilo Andrésdcb2937d-4f9e-43e4-87a6-7a52127158ce-1Cruz Reyes, Danna Lesley1032415315600Ramirez Rodriguez, NataliaEspecialista en NeurologíaMaestríaFull time63e03cae-efc4-4b89-a1d5-0ab6c4f68beb-12023-11-14T17:36:33Z2023-11-14T17:36:33Z2023-11-09Introducción: El Ataque Cerebrovascular (ACV) es una emergencia médica que requiere atención inmediata para instaurar intervenciones que ayuden a mejorar su desenlace. Su diagnóstico es clínico, pero se confirma y clasifica con la ayuda de neuroimágenes. No obstante, hasta un 30% de los pacientes que se presentan con déficits neurológicos focales, permanentes o transitorios, cursan con otras patologías diferentes al ACV. Estas condiciones se han agrupado bajo el término de imitadores de ACV. La identificación temprana de un imitador de ACV permitirá evitar los riesgos de las intervenciones y disminuirá el costo de la atención. Objetivo: Determinar la incidencia y las características demográficas, clínicas y radiológicas de los imitadores de ACV en pacientes con déficit neurológico, permanente o transitorio, de rápida instauración atendidos en la Fundación CardioInfantil durante el periodo 2021-2022. Métodos: Se realizó un estudio observacional, descriptivo, transversal que incluyó a pacientes que fueron interconsultados al servicio de neurología con sospecha de ACV durante el periodo de Enero de 2021 a mayo de 2022 y en los que finalmente se descartó el diagnóstico de ACV (considerados como imitadores de ACV). Se evaluaron las variables demográficas, clínicas y de imagen y se realizó un análisis de dichas variables. Resultados: De 793 pacientes con déficits neurológicos de aparición rápida que fueron consultados por sospecha de ACV, 188 (23,7%) eran imitadores de ACV. La mayoría eran mujeres, con una edad media de 66,1 años. En el 16,49% de los casos se activó el protocolo de código ACV. Los principales déficits fueron alteraciones del lenguaje (23,94%), disminución del estado de conciencia (21,28%) y compromiso motor (19,15%). En cuanto a la etiología de los imitadores de ACV en esta población, el diagnóstico más frecuente fue delirium 22,9% (43), seguido de epilepsia 17,6% (33) y migraña 12,8% (24). Ninguno de los pacientes que tuvieron síntomas de ACV fueron tratados con trombólisis intravenosa. Conclusiones: El delirio, la migraña y la epilepsia son imitadores frecuentes de ACV. La edad, factores de riesgo vascular, los síntomas o signos de focalización y la aplicación de escalas de neurológicas pueden ser elementos útiles para su rápida identificación y adecuado tratamiento. Es necesario el desarrollo de estudios multicéntricos en Colombia para conocer su prevalencia y describir sus factores predictores por subgrupos de ACV.Background: Stroke is a medical emergency that requires immediate attention to establish interventions that help improve its outcome. Its diagnosis is clinical but is confirmed and classified with the help of neuroimaging. However, up to 30% of patients who present with focal, permanent, or transient neurological deficits have pathologies other than stroke. These conditions have been grouped under the term stroke mimics. Early identification of a stroke mimics will avoid the risks of interventions and reduce the cost of care. Objective: To determine the incidence and the demographic, clinical and radiological characteristics of stroke mimics in patients with rapid onset (permanent or transient) neurological deficit treated at the Fundación Cardioinfantil during 2021-2022. Methods: We carried out an observational, descriptive, cross-sectional study that included patients that were consulted to the neurology service with suspected stroke during the period from January 2021 to May 2022 and in whom the diagnosis of stroke was finally ruled out (stroke mimics). We evaluated and analyzed the demographic, clinical and imaging variables. Results: Out of 793 patients with rapidly appearing neurological deficits who were consulted for suspected stroke, 188 (23.7%) were stroke mimics. Most of them were women, with an average age of 66.1 years. In 16.49% of the cases, the stroke code protocol was activated. The main deficits were language alterations (23.94%), decreased state of consciousness (21.28%) and motor deficit (19.15%). Regarding the etiology of stroke mimics in this population, the most frequent diagnosis was delirium 22.9% (43), followed by epilepsy 17.6% (33) and migraine 12.8% (24). None of the patients who had stroke mimics were managed with IV thrombolysis. Conclusions: Delirium, migraine, and epilepsy are common stroke mimics. Age, vascular risk factors, focal symptoms or signs, and the application of neurological scales can be useful elements for rapid identification and appropriate treatment. It is necessary to develop multicenter studies in Colombia to know its prevalence and describe its predictive factors by stroke subgroups.38 ppapplication/pdfhttps://repository.urosario.edu.co/handle/10336/41656spaUniversidad del RosarioEscuela de Medicina y Ciencias de la SaludEspecialización en NeurologíaAttribution-NonCommercial-ShareAlike 4.0 InternationalAbierto (Texto Completo)EL AUTOR, manifiesta que la obra objeto de la presente autorización es original y la realizó sin violar o usurpar derechos de autor de terceros, por lo tanto la obra es de exclusiva autoría y tiene la titularidad sobre la misma.http://creativecommons.org/licenses/by-nc-sa/4.0/http://purl.org/coar/access_right/c_abf21. García-Alfonso C, Martínez Reyes A, García V, Ricaurte-Fajardo A, Torres I, Coral J. Actualización en diagnóstico y tratamiento del ataque cerebrovascular isquémico agudo. Univ. Med. 2019;60(3).2. Coupland AP, Thapar Ankur, Qureshi MI, Jenkis H, Davies AH. The definition of stroke. J R Soc Med. 2017 Jan;110(1):9-12.3. Hankey GJ. Stroke. Lancet. 2017 Feb;389(10069):641-654.4. Amarenco P. Transient Ischemic Attack. N Engl J Med. 2020 May 14;382(20):1933-1941.5. Gorelick PB. The global burden of stroke: persistent and disabling. Lancet Neurol. 2019 May;18(5):417-418.6. GBD 2016 Stroke Collaborators. Global, regional, and national burden of stroke, 1990–2016: a systematic analysis for the Global Burden of Disease. Lancet Neurol. 2019 May;18(5):439-458.7. Muñoz M. Enfermedad Cerebrovascular. Acta Neurol Colomb. 2010;26(2): 1-3.8. Lioutas VA, Ivan CS, Himali JJ, Aparicio HJ, Leveille T, Romero JR, Beiser AS, Seshadri S. Incidence of Transient Ischemic Attack and Association With Long-term Risk of Stroke. JAMA. 2021 Jan 26;325(4):373-381.9. Chugh C. Acute Ischemic Stroke: Management Approach. Indian J Crit Care med. 2019;23(Suppl 2):S140-S146.10. Schrag M, Kirshner H. Management of Intracerebral Hemorrhage. J Am Coll Cardiol. 2020 Apr;75(15):1819-1831.11. 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