Stroke

Viplav 080201048

My patient named Gopal, 59 years old, hailing from Kavoor carpenter by occupation came to GWH hospital with chief complaint of weakness of the right side of the body since 20 days.

History of presenting illnessPatient was apparently normal 20 days back when he developed weakness over right side of the body, when he was about to go to bathroom at 7 30 am, where he suddenly felt weak and could not move his right side. It was sudden in onset and evolution of paralysis was complete within 6 hours. Patient complained of deviation of angle of the mouth to left side during eating or speaking and slurring of speech. No history of loss of consciousness, No history of seizures, headache or vomiting. No history of previous neurodeficit which recover completely. No history of loss of bowel and bladder control.No history difficulty in swallowing and nasal regurgitation.No history of vertigo or diplopiaNo history of fever, breathlessness, chest pain and palpitation.

Past historyNo history of DM, hypertension or seizures.No history contact with tuberculosis.

Family historyNo significant family history.

Personal historyPatient consume mixed diet.Sleep and Appetite normal.Normal bowel and bladder habits.History of intake of 180 ml of alcohol per for 25 years.No history of any other addictions

General physical examinationPatient is conscious , cooperative, oriented with time, place and person.Afebrile at time of examination.No pallor, icterus, cyanosis, clubbing, lymphadenopathy and pedal edema.

VitalsPR: 70/min, normal rhythm, good volume, normal character, no vessel wall thickening, no radio-radial or radio-femoral delay. All peripheral pulses felt.RR: 17/min abdomino-thoracic.BP:130/84 mmHg, right arm supine position.JVP is not raised.

Central Nervous System Examination:

Higher mental function test1-Education: Patient is right handed, uneducated.2-Language: Good comprehension but slurring of speech is present. Able to name, repeat, read and write.3-Speech: Slurred speech4-Memory: All remote, intermediate and recent memory are intact.5-No delusion, hallucination and illusion.

Cranial nerve examination Right Left

Olfactory nerve normal normal

Optic nerve•Visual acuity•Visual field•Colour vision

Finger counting at 6m.Normalnormal

Finger counting at 6m.NormalNormal

Occulomotor, trochlear and abducens nerve•Movement of eyeball•Pupil-shape-position•Light reflex-direct-consensual•Accommodation reflex

Normal

NormalCentral

NormalNormalNormal

Normal

NormalCentral

NormalNormalNormal

Trigeminal nerve•Sensory•Motor-clenching of teeth-jaw against resistance•Reflex-corneal reflex -jaw jerk

NormalNormal Normal

Normal Normal

Normal

Cranial nerve examination Right Left

Facial nerve•No loss of nasolabial fold• Deviation angle of mouth to left side•Orbicularis oculi•Buccinator•Frontalis•Taste sensation of ant. 2/3 of tongue –

Normal Normal

Vestibulocochlear nerve•Rinne’s test•Weber’s test

AC > BCLateralized equally both sides

AC > BC

Glossopharyngeal and vagus nerve•Movement of uvula•Palatal movement•Gag reflex

CentralNormalNormal

Spinal accesory nerve•shrugging of shoulder•Movement of neck

NormalNormal

NormalNormal

Cranial nerve examination Right Left

Hypoglossal nerve•No wasting and fasciculation of tongue•No deviation of tongue

Motor system Right Left

Nutrition (bulk) No wasting No wasting

Tone•Upper limb•Lower limb

HypertonicHypertonic

NormalNormal

Power•Upper limb•Lower limb•Grip test

2/52/5Weak

5/55/5Normal

Coordination Could not be tested Normal

Reflexes Right Left

• Superficial- Corneal- Abdominal- Plantar

Present Present Extensor

Present Present Flexor

• Deep- Biceps- Triceps- Supinator- Knee- Ankle

ExaggeratedExaggeratedExaggeratedExaggeratedExaggerated

NormalNormalNormalNormalNormal

• Clonus- patella- ankle

Absent Present

AbsentAbsent

Sensory system Right • Left

• Superficial -pain-touch-temperature

• Deep-crude touch-fine touch-vibration-joint sense

-tactile localisation-tactile discrimination

-position sense

Normal

Normal

Normal

Normal

Normal

Normal

Gait : Not assessed

Involuntary movement :Absent

Skull and spine :Normal

Meningeal sign :No neck stiffness, Kernig’s and Brudzinki’s sign negative.

Cerebellar function :Within normal limit

Other system:•Respiratory system: normal vesicular breath sound, no added sound•Cardiovascular system: S1 S2 heard, no murmur•Abdominal: soft, non-tender, no organomegaly

Provisional Diagnosis: Right sided hemiplegia due to cerebrovasular accident most likely of the thrombotic type, with the lesion in the left internal capsule involving the left middle cerebral artery.

STROKE

Swasthik.K.S080201050

• TIA-Focal neurological deficit where complete recovery of SIGNS & SYMPTOMS within 24hrs.

• STROKE- lasts more than 24hrs.

RISK FACTOR• Gender: Male• Older age• Hypertension• Diabetes• Hyperlipidemia• Smoking• Carotid stenosis- Asymptomatic -Symptomatic

Stroke Subtypes

Ischemic stroke(85%)

Hemorrhage(15%)

Atrial fibrillation

Others(64%)

Carotid disease

Aneurysmal-SAH

Others (4%)

Hypertensive

Ischemic Stroke• Thrombosis- small vessel (lacunar stroke) -large vessel• Embolic- Artery to artery (m/c Carotid bifurcation) -Cardioembolism (m/c Atrial fibrillation)

Uncomman causes• Hypercoagulable disorders• Venous sinus thromosis• Vasculitis- Giant cell/ takayasus• Cardiogenic• Drugs: cocaine, amphetamine• Moyamoya disease

Middle cerebral artery

• M1 segment M2 segment Proximal MCA(Lenticulostriate artery) Superior Inferior -Frontal -Temporal -Parietal (sup) -Parietal(inf)

Foetal Posterior Cerebral artery??

Intracranial Hemorrhage

Intraparenchymal Subarachnoid-Trauma -Saccular/Berry-anticoagulant therapy-Hypertension Putamen-Cerebral amyloid angiopathy Thalamus-cocaine( common in Young) Cerebellum Pons• Inraventricular-RARE….

Clinical Features• Focal deficit worsens steadily over 30-90min. associated with- Diminishing Conscious level - ICP (Headache, vomiting)

• EMERGENCY- -BP -non-vasodilating iv drugs -STUPOROUS/COMA- dec ICP

• PUTAMEN - Hemiparesis (contralateral) -Eyes deviates (away from hemiparesis) -Respiration (deep, irregular) -Pupil- fixed & dilated

• Thalamic Motor- hemiplegia Sensory deficit Visual field defect- Homonymous Aphasia ( dominant thalamus) Constructional Apraxia (non-dominant thalamus)

Pontine Cerebellum• Decerebrate rigidity - Occipital headache• Pin-point pupil - Vomiting• Pyrexia - Ataxic• Dolls eye movement - Vertigo impaired - Conjugate lateral gaze• Hyperapnea

Subarahnoid hemorrhage• C/F: Thunderclap headache + Vomiting + loss of consciousness on onset• Examination: Irritable, neck rigidity, Lateral gaze.

INVESTIGATION

Nora Fariza Hamzah 080201051

IMAGING STUDIES

• CT SCANS– identify or exclude hemorrage – Imaging modality of choice in acute stroke-

because of its speed and wide availability– Identify other conditions:

• Extraparenchymal hemorrages• Neoplasm• abscesses

– Ct scans obtained in the first several hours after an infarction generally shows no abnormality

– Contrast enhanced CT scans : • showing contrast enhancement of subacute infarct• Allow visualisation of venous structures

– CT angiography (CTA) may visualised :• Cervical and intracranial arteries• Intracranial veins• Aortic arch• Coronary arteries• Intracranial aneurysm

• MRI– Documents the extent and location of infarction – Less sensitive than CT for detecting acute blood– MR perfusion studies (gadolinium contrast iv)– MR angiography is sensitive for stenosis of

extracranial internal carotid arteries and of large intracranial vessels

• Cerebral angiography– X ray cerebral angiography is the gold standard for

• identifying and quantifying artherosclerotic stenoses of the cerebral arteries

• Characterising aneurysm,vasospasm,intraluminal thrombi, fibromuscular dysplasia,arteriovenous fistula, vasculitis

– Endovascular technique• To deploy stents within delicate intracranial vessels• To perform balloon angioplasty of stenotic lesions• To treat intracranial aneurysm by embolisation• To open occluded vessels in acute stroke with mechanical

thrombotic devices

• Ultrasound– Duplex ultrasound (combination of B-mode

ultrasound image with a doppler ultrasound assestment of flow velocity)

• Can identified stenosis at the origin of internal carotid artery

– Transcranial doppler (TCD)• Can detect stenotic lesion in the large intracranial

arteries• Assist thrombolysis• Improve large artery recanalisation following rtPA

administration

• Perfusion techniques– Both xenon techniques (principally xenon CT) and

PET can quantify cerebral blood flow.– CT perfusion

• Increase sensitivity for detecting ischemia• Can measure the ischemic penumbra

– MR diffusion & MR perfusion combination• Identify the ischemic penumbra

Treatment of ischemic stroke

080201049

• The first goal is to prevent or reverse brain injury.

Medical Support.

Intravenous Recombinant Tissue Plasminogen Activator (rtPA)

Indications:- Clinical diagnosis of stroke.- Onset of symptoms to time of

administration ≤ 3 hours.- CT scan showing no h’hage or

edema of >1/3 of the MCA territory.

- Age ≥ 18 years.- Consent by patient or surrogate.

Contraindications- Sustained BP >185/110 mmHg

despite treatment.- Platelets <100,000 ; HCT <25% ;

glucose <50 or > 400 mg/dl.- Used of heparin within 48 hrs

and prolonged PTT or elevated INR.

- Rapidly improving symptoms.- Prior stroke or head injury

within 3 mnths ; prior intracranial h’hage.

- Major Sx in preceding 14days.- Minor stroke symptoms.- GI bleeding in preceding 21

days.- Recent MI- Coma or stupor.

Preventions.

Treatment of intracerebral haemorrhage (ICH)

THANK YOU!!