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8/2/2019 Assessment and Diagnosis of Stroke
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Assessment and
diagnosis in strokeNick Ward
DEPARTMENT OF HEADACHE, BRAIN INJURY, AND NEUROREHABILITATION
NATIONAL HOSPITAL FOR NEUROLOGY AND NEUROSURGERY
INSTITUTE OF NEUROLOGY
UNIVERSITY COLLEGE LONDON
8/2/2019 Assessment and Diagnosis of Stroke
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Objectives
You should know
1. The essential clinical features to be elicited2. The essential investigations to be performed
3. Understand some of the differential diagnosis
4. Understand the basic subtypes of strokePathology what?
Anatomy where?
Mechanism why?
You should be able to diagnose and
assess a patient with suspected stroke
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65 year old man
Found collapsed at home by wife
Not moving right side very well
Not speaking
nicotine stained fingers
bp 190/110
Positively diagnose stroke
CT normal
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IMMEDIATE CLINICAL APPROACH
ABC
Check blood sugar
Glasgow Coma Scale
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Clinical syndrome
Syndrome of focal neurological symptoms
and signs
Sudden onset
Symptoms maximal within minutes to hours
Predominantly negative symptoms
MAKE A POSITIVE DIAGNOSIS!
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History
Onset spread of symptoms?
Focal symptoms language/ motor/ sensory/ visual
Trauma, previous history, systemically unwell
Risk factors
Normal functional level
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Examination
Neurologic
standard cranium and limbs
status degree of consciousness GCS
swallow
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General
Cardiovascular
Pulse / BP / Murmurs / Bruits
Chest
Pneumonia
Examination
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Conditions that mimic acute stroke
411 patients initially diagnosed as having stroke
78 (19%) of these
eventually diagnosed as
some other condition
333 patients
confirmed tohave had
stroke
Seizure
(17%)Systemic infection
(17%)
Brain tumour (15%)
Toxic-metabolic (13%)
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Multidisciplinary
assessment
Nursing Functional disability
Communication Swallowing function
Movement disability Nutritional risk
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Objectives revisited
You should know
1. The essential clinical features to be elicited2. The essential investigations to be performed
3. Understand some of the differential diagnosis
4. Understand the basic subtypes of strokePathology what?
Anatomy where?
Mechanism why?
You should be able to diagnose and
assess a patient with suspected stroke
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Diagnosis Pathology
What?
80% ischaemic vs 20% haemorrhagic
No reliable clinical method Haemorrhage:
? GCS signs of ICP
headache?
on warfarin?
Neuroimaging - only way to be sure
i f ti h h ?
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Infarction Haemorrhage
infarction or haemorrhage ?
Answer.do scan
Diagnosis Anatomy
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Diagnosis Anatomy
Where?
8/2/2019 Assessment and Diagnosis of Stroke
15/34Brain cross section showin the arteries after in ection of contrast
A t
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Anatomy
Where?
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Diagnosis Mechanism
Why?
TOAST classification:
Lacunar (penetrating vessel occlusion)
Large vessel occlusion
Cardioembolic
Other (eg sickle cell disease)
Undetermined
Haemorrhage
EMBOLIC
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EMBOLIC
SOURCES
Platelet clots
Fibrin clots
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1: Penetrating vessel disease
Lacunar stroke
1. Pure hemiparesis2. Hemisensory loss
3. Ataxic Hemiparesis
4. Clumsy hand dysarthria syndrome
Absence of cortical features
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2: Large vessel - MCA
HemiparesisHemisensory loss
Visual field defect
Cortical signs
Dysphasia
Neglect
MCA stroke
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3: Large vessel PCA
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3: Large vessel - PCA
Nausea + VomitingDiplopia
Vertigo
Ataxia
Crossed signs
Visual field defect
Coma
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4 H h
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4. Haemorrhage
Conforms to this schema
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Infarction Haemorrhage
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Who to scan urgently
Those with a depressed level of
consciousness in whom neurosurgical
intervention would be considered
Patients on anticoagulants
Patients who may be suitable for
thrombolysis
Neuroimaging:
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Neuroimaging:
CT or MRI?
CT
Readily available
Cheap Better for blood
Can be used acutely May be only choice eg
pacemaker
New techniques
MRI
Less availability
Expensive Better anatomy
Better for posteriorfossa
Can be used acutely
(DWI)
Whichever is available urgently!
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Other investigations
FBC
U+E
Sugar
Cholesterol ECG / Echo
CXR Neuroimaging
Vascular imaging
Investigations
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Investigations
Help to answer questions
Where? What? Why?
e.g. which side/arterial territory?infarction or haemorrhage ?
lacunar or large vessel?
S
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Summary
Stroke is a clinical syndrome NOT a diagnosis
Need then to answer
What is it?
Where is it?
Why did it happen?
Urgent assessment should establish
Deficit
Risk factors + likely cause Complications
Multidisciplinary team
ASSESSMENT OF STROKE PATIENTS: SUMMARY
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History
Stroke clerking proforma
Identify risk factors
Pre-stroke function
Examination
Neurological assessment
Identify risk factors
Multidisciplinary
Nursing
Functional disability
Communication
Swallowing function
Movement disability
Nutritional risk
Clinical Investigations
Haemotology/biochemistry
Urinalysis
ECG
CXR
Investigations to consider
CT scan
Carotid doppler
Echocardiography
MRI
ISCHAEMIC STROKE HAEMORRHAGIC STROKE
MANAGEMENT
Obj ti R i it d
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Objectives Revisited
You should know
1. The essential clinical features to be elicited2. The essential investigations to be performed
3. Understand some of the differential diagnosis
4. Understand the basic subtypes of strokePathology what?Anatomy where?
Mechanism why?
You should be able to diagnose and
assess a patient with suspected stroke