Assessment and diagnosis in stroke

Nick WardDEPARTMENT OF HEADACHE, BRAIN INJURY, AND NEUROREHABILITATION

NATIONAL HOSPITAL FOR NEUROLOGY AND NEUROSURGERY

INSTITUTE OF NEUROLOGYUNIVERSITY COLLEGE LONDON

Objectives

• You should know1. The essential clinical features to be elicited2. The essential investigations to be performed3. Understand some of the differential diagnosis4. Understand the basic subtypes of stroke

Pathology – what?Anatomy – where?Mechanism – why?

• You should be able to diagnose and assess a patient with suspected stroke

•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

IMMEDIATE CLINICAL APPROACHABC

Check blood sugar

Glasgow Coma Scale <12 consider nasal airway

<8 consider intubation

Pyrexia, neck stiffness

Oxygen

IV access

RAPID neurological assessment motor

speech

visual

sensory

Clinical syndrome

• Syndrome of focal neurological symptoms

and signs

• Sudden onset

• Symptoms maximal within minutes to hours

• Predominantly negative symptoms

MAKE A POSITIVE DIAGNOSIS!

History

• Onset – spread of symptoms?

• Focal symptoms – language/ motor/ sensory/ visual

• Trauma, previous history, systemically unwell

• Risk factors

• Normal functional level

Examination

• Neurologic

– “standard” cranium and limbs

– status – degree of consciousness – GCS

– swallow

• General

– Cardiovascular

• Pulse / BP / Murmurs / Bruits

– Chest

• Pneumonia

Examination

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 to have had stroke

Seizure (17%)

Systemic infection (17%)

Brain tumour (15%)

Toxic-metabolic (13%)

Multidisciplinaryassessment

• Nursing• Functional disability• Communication• Swallowing function• Movement disability• Nutritional risk

Objectives revisited

• You should know1. The essential clinical features to be elicited2. The essential investigations to be performed3. Understand some of the differential diagnosis4. Understand the basic subtypes of stroke

Pathology – what?Anatomy – where?Mechanism – why?

• You should be able to diagnose and assess a patient with suspected stroke

Diagnosis – PathologyWhat?

• 80% ischaemic vs 20% haemorrhagic

• No reliable clinical method– Haemorrhage:

• ? ↓ GCS• signs of ↑ ICP• headache?• on warfarin?

• Neuroimaging - only way to be sure

Infarction Haemorrhage

infarction or haemorrhage ?Answer……………….do scan

Diagnosis – AnatomyWhere?

Brain cross section showing the arteries after injection of contrast

Anatomy –Where?

Arterial territories and clinical presentations

• Anterior circulation – carotid + branches– Ophthalmic - amaurosis fugax

– MCA - Hemiparesis,hemisensory loss cortical signs

– ACA – Hemiparesis (Leg > Arm), no/mild sensory deficit, frontal lobe signs

• Posterior circulation – vertebrobasilar – PICA/AICA/PCA – Cranial nerve and long tract signs,

N+V, diplopia, Vertigo, ataxia, coma

Diagnosis – MechanismWhy?

• TOAST classification:– Lacunar (penetrating vessel occlusion)– Large vessel occlusion – Cardioembolic– Other (eg sickle cell disease)– Undetermined

• Haemorrhage

EMBOLIC SOURCES

Platelet clots

Fibrin clots

1: Penetrating vessel disease

Lacunar stroke

1. Pure hemiparesis2. Hemisensory loss3. Ataxic Hemiparesis4. Clumsy hand –

dysarthria syndrome

Absence of cortical features

2: Large vessel - MCA

HemiparesisHemisensory lossVisual field defectCortical signs

– Dysphasia– Neglect

MCA stroke

3: Large vessel - PCA

Nausea + VomitingDiplopiaVertigoAtaxia‘Crossed’ signsVisual field defectComa

4. HaemorrhageConforms to this schema

Infarction Haemorrhage

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: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 posterior

fossa• Can be used acutely

(DWI)

Whichever is available urgently!

Other investigations

• FBC• U+E• Sugar• Cholesterol• ECG / Echo• CXR• Neuroimaging• Vascular imaging

Investigations

• Help to answer questions– Where? What? Why?

• e.g. which side/arterial territory?infarction or haemorrhage ?lacunar or large vessel?

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

HistoryStroke clerking proforma

Identify risk factors

Pre-stroke function

ExaminationNeurological assessment

Identify risk factors

MultidisciplinaryNursing

Functional disability

Communication

Swallowing function

Movement disability

Nutritional risk

Clinical InvestigationsHaemotology/biochemistry

Urinalysis

ECG

CXR

Investigations to considerCT scan

Carotid doppler

Echocardiography

MRI

ISCHAEMIC STROKE HAEMORRHAGIC STROKE

MANAGEMENT

ASSESSMENT OF STROKE PATIENTS: SUMMARY

Objectives Revisited

• You should know1. The essential clinical features to be elicited2. The essential investigations to be performed3. Understand some of the differential diagnosis4. Understand the basic subtypes of stroke

Pathology – what?Anatomy – where?Mechanism – why?

• You should be able to diagnose and assess a patient with suspected stroke