Cerebrovascular disease (CVA / Stroke)

Cerebrovascular disease (CVA, Stroke) Submitted to AskTheNeurologist.Com in 2007 Author Anon.

What is a stroke / CVA ?

Acute onset of deficit

Persists > 24 hours ( see TIA definition)

Result of disturbance of vascular system

TIA’s

Current definition is based on duration less than 24 hours

Most last minutes

Always ischaemic….hence “I”

Warn of impending stroke

CVA Epidural Ischaemic Haemorrhagic Subdural SAH Intracerebral Thrombosis Embolus Carotid / VB Cardiac Aortic arch

Bleed vs Ischaemia Clear vascular territory No obvious territory Herniation rare / late Early signs of herniation Consciousness relatively preserved ( variable) Consciousness usually impaired if large Moderate / no headache Severe headache Acute or hyperacute Hyperacute Ischaemia Bleed

Clinical features of CVA’s

Depend on part of brain involved

Very variable

Common syndromes vs very rare

Common Features of CVA

Hemiparesis

Face asymmetry

Gaze deviation

Dysphasia / aphasia

Dysarthria

Limb incoordination

Ataxia ( +/- vertigo)

One sided sensory symptoms

Features very unlikely to be due to CVA

General weakness

Isolated headache

Isolated vertigo

General confusion

Memory disturbance

Isolated fall

Bilateral complaints

Gradual deterioration in consciousness

When to think of a CVA in a patient with decreased consciousness

Hyperacute sustained loss of consciousness with no evidence of cardiorespiratory disturbance

Unequal pupils ( if no past surgery!)

Reacts to pain only on one side

Gaze deviation

Other causes are more common and usually much more treatable

The old stroke that got worse

A past stroke is a significant risk factor for a future stroke

Patients usually improve following stroke

Deterioration common with fever or other metabolic / haemodynamic disturbance

Common differential diagnoses

SOL

Seizure

Metabolic condition especially hypoglycaemia

Blood pressure following CVA

Rise in BP following stroke is protective

Rarely want to decrease BP in acute phase

Very high BP may be the cause or the effect!

Basic work-up

PMH ( especially risk factors, old strokes)

Drugs ( risk factors, “ blood thinning” )

Vital signs including temperature!

ECG

Bloods for CBC, Biochemistry ( esp. glucose), ESR

? INR ? X-match

Diagnosis

Clinical is most important

CT

MRI in selected cases

Following diagnosis of ischaemic stroke

Some patients receive immediate treatment with thrombolysis / stenting

Some with suspected embolus may be started on heparin

Most started on aspirin alone

Important issues following stroke

Physiotherapy

Family support

Identify and treat depression

Prevent common complications

DVT

Infections ( aspiration)

Pressure sores

Searching for a treatable cause

Carotid duplex

Cardiac echo

Angiography

Secondary prevention

Reduce risk factors

Anticoagulants / antiplatelets

Neurological follow-up

Case 55 year old man with negligible risk factors for cerebrovascular disease Presented to Hadassah Ein Kerem ER with acute, progressive left-sided weakness and right-sided headache 2 days prior to admission felt sudden onset of sharp, right – sided headache associated with left arm numbness and mild articulation difficulty; resolved spontaneously over minutes On morning of admission, recurrence of sharp, severe right sided headache (without pulsatile characteristics) associated with left arm numbness and articulation difficulty

Examination Fully conscious & orientated, no neck stiffness Speech Dysarthric Left central facial weakness - Cranial nerves otherwise intact Mild right upper limb global weakness (4/5) Power preserved in lower limbs Reflexes symmetrical with no pyramidal signs Hypoaesthesia left arm Rest of neurological examination unremarkable with no evidence of neglect

Diffusion Perfusion Mismatch On MRI Diffusion MRI Perfusion MRI

Absent RICA on MRA

Pre-Stent Angiography String Sign Parenchymography phase

Angioplasty and Stenting Post angioplasty - aneurysm After 1st stent After 3rd stent

Comparison of pre and post –stent Angiogram

Progress in ER Over period of 2 hours deterioration with marked exacerbation of dysarthria and facial weakness, exacerbation of left arm weakness to 3/5 and appearance of left leg weakness 4-/5 with a left Babinski sign

Following procedure Immediately following procedure noticeable improvement in dysarthria and left sided weakness Treatment commenced with LMW heparin, aspirin and clopidogrel. On following morning neurological examination had returned to that noted on arrival to ER: Mild dysarthria with left facial weakness Left arm 4/5 Left leg in tact

Follow – up Patient discharged on Aspirin 325mg, Clopidogrel 75mg Trans-cranial Doppler and follow-up MRA revealed patency and normal flow in all cervical arteries Follow-up MRI revealed no progression of infarct Patient responded well to rehabilitation and recovered all function being left with mild dysarthr i a, left arm sensory complaints and facial weakness

Submitted to AskTheNeurologist.Com in 2007 Author Anon.