assessment and diagnosis of stroke

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


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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



4. Understand the basic subtypes of strokePathology what?

Anatomy where?

Mechanism why?




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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?


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



4. Understand the basic subtypes of strokePathology what?Anatomy where?

Mechanism why?



assessment and diagnosis of stroke

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