Cerebrovascular disease

Cerebrovascular disease can present as stroke, transient ischaemic attack or amaurosis fugax, due to vaso-occlusive disease in the cerebral circulation, usually due to emboli from carotid atheroma plaques. Diagnosis is on clinical grounds +/- imaging and managment should focus on primary and secondary prevention as much as possible.

How long has the patient had diabetes?

Cerebrovascular disease is typically a relatively late complication of T1DM but in T2DM stroke can be a presenting feature or can antedate the onset of diabetes.

Are there additional risk factors?

The presence of smoking, hypercholesterolaemia, hypertension and a family history of premature ischaemic heart disease should all be enquired about.

Does the patient have other manifestations of macrovascular disease?

MI, angina pectoris, claudication and previous lower limb gangrene or ulceration should all be enquired about as atherosclerosis elsewhere increases the odds of the patient having cerebrovascular disease.

Previous history of stroke, transient ischaemic attack, or amaurosis fugax should also be elicited.

What are the presenting symptoms?

Transient unilateral weakness affecting some or all of face, arm, leg or speech is typical of TIA. If the same symptoms last more than 24 hours then by definition this is stroke. Transient loss of consciousness is a very rare presentation of TIA or stroke and these symptoms should prompt appropriate investigations for other pathologies (hypoglycaemia, cardiac arrhythmia, seizure activity, vaso-vagal episode and the like).

Transient monocular total or partial loss of vision is typical of amaurosis fugax. This requires careful history-taking to distinguish from homonymous visual symptoms.

Neither TIA nor amaurosis are benign symptoms, these should be taken very seriously and the patient referred for urgent investigation - and consideration of intervention - to prevent stroke

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