Assessment and
 diagnosis in stroke
                      Nick Ward
DEPARTMENT OF HEADACHE, BRAIN INJURY, AND NEUROREHABIL...
Objectives
•    You should know
    1.   The essential clinical features to be elicited
    2.   The essential investigati...
•65 year old man
•Found collapsed at home by wife
•Not moving right side very well
•Not speaking
•nicotine stained fingers...
IMMEDIATE CLINICAL APPROACH
ABC
Check blood sugar
Glasgow Coma Scale        <12 consider nasal airway
                    ...
Clinical syndrome

• Syndrome of focal neurological symptoms
  and signs
• Sudden onset
• Symptoms maximal within minutes ...
History

• Onset – spread of symptoms?

• Focal symptoms – language/ motor/ sensory/ visual

• Trauma, previous history, s...
Examination
• Neurologic

  – “standard” cranium and limbs

  – status – degree of consciousness – GCS

  – swallow
Examination

• General

  – Cardiovascular

    • Pulse / BP / Murmurs / Bruits

  – Chest

    • Pneumonia
Conditions that mimic acute stroke
        411 patients initially diagnosed as having stroke


333 patients
confirmed to
 ...
Multidisciplinary
              assessment
•   Nursing
•   Functional disability
•   Communication
•   Swallowing function...
Objectives revisited
•    You should know
    1.   The essential clinical features to be elicited
    2.   The essential i...
Diagnosis – Pathology
                    What?
• 80% ischaemic vs 20% haemorrhagic

• No reliable clinical method
  – Hae...
infarction or haemorrhage ?
  Answer……………….do scan




Infarction           Haemorrhage
Diagnosis – Anatomy
      Where?
Brain cross section showing the arteries after injection of contrast
Anatomy –
 Where?
Arterial territories and clinical
             presentations
• Anterior circulation – carotid + branches
  – Ophthalmic - ...
Diagnosis – Mechanism
            Why?

• TOAST classification:
  – Lacunar (penetrating vessel occlusion)
  – Large vesse...
EMBOLIC
  SOURCES



Platelet clots




Fibrin clots
1: Penetrating vessel disease

                               Lacunar stroke

                               1.   Pure hem...
2: Large vessel - MCA

            MCA stroke


           Hemiparesis
           Hemisensory loss
           Visual field...
3: Large vessel - PCA




             Nausea + Vomiting
             Diplopia
             Vertigo
             Ataxia
  ...
4. Haemorrhage
Conforms to this schema
Infarction   Haemorrhage
Who to scan urgently

• Those with a depressed level of
  consciousness in whom neurosurgical
  intervention would be cons...
Neuroimaging:
                 CT or MRI?
           Whichever is available urgently!

              CT                   ...
Other investigations

•   FBC
•   U+E
•   Sugar
•   Cholesterol
•   ECG / Echo
•   CXR
•   Neuroimaging
•   Vascular imagi...
Investigations

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


• e.g. which side/arterial territory?
       infarction...
Summary
• Stroke is a clinical syndrome NOT a diagnosis
  – Need then to answer
       • What is it?
       • Where is it?...
ASSESSMENT OF STROKE PATIENTS: SUMMARY
          History                         Examination                         Multi...
Objectives Revisited
•    You should know
    1.   The essential clinical features to be elicited
    2.   The essential i...
Assessment and diagnosis in stroke
Assessment and diagnosis in stroke
Assessment and diagnosis in stroke
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Assessment and diagnosis in stroke

  1. 1. Assessment and diagnosis in stroke Nick Ward DEPARTMENT OF HEADACHE, BRAIN INJURY, AND NEUROREHABILITATION NATIONAL HOSPITAL FOR NEUROLOGY AND NEUROSURGERY INSTITUTE OF NEUROLOGY UNIVERSITY COLLEGE LONDON
  2. 2. Objectives • You should know 1. The essential clinical features to be elicited 2. The essential investigations to be performed 3. Understand some of the differential diagnosis 4. 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
  3. 3. •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
  4. 4. IMMEDIATE CLINICAL APPROACH ABC 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
  5. 5. Clinical syndrome • Syndrome of focal neurological symptoms and signs • Sudden onset • Symptoms maximal within minutes to hours • Predominantly negative symptoms MAKE A POSITIVE DIAGNOSIS!
  6. 6. History • Onset – spread of symptoms? • Focal symptoms – language/ motor/ sensory/ visual • Trauma, previous history, systemically unwell • Risk factors • Normal functional level
  7. 7. Examination • Neurologic – “standard” cranium and limbs – status – degree of consciousness – GCS – swallow
  8. 8. Examination • General – Cardiovascular • Pulse / BP / Murmurs / Bruits – Chest • Pneumonia
  9. 9. Conditions that mimic acute stroke 411 patients initially diagnosed as having stroke 333 patients confirmed to 78 (19%) of these have had eventually diagnosed as stroke some other condition Seizure (17%) Systemic infection (17%) Brain tumour (15%) Toxic-metabolic (13%)
  10. 10. Multidisciplinary assessment • Nursing • Functional disability • Communication • Swallowing function • Movement disability • Nutritional risk
  11. 11. Objectives revisited • You should know 1. The essential clinical features to be elicited 2. The essential investigations to be performed 3. Understand some of the differential diagnosis 4. 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
  12. 12. 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
  13. 13. infarction or haemorrhage ? Answer……………….do scan Infarction Haemorrhage
  14. 14. Diagnosis – Anatomy Where?
  15. 15. Brain cross section showing the arteries after injection of contrast
  16. 16. Anatomy – Where?
  17. 17. 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
  18. 18. Diagnosis – Mechanism Why? • TOAST classification: – Lacunar (penetrating vessel occlusion) – Large vessel occlusion – Cardioembolic – Other (eg sickle cell disease) – Undetermined • Haemorrhage
  19. 19. EMBOLIC SOURCES Platelet clots Fibrin clots
  20. 20. 1: Penetrating vessel disease Lacunar stroke 1. Pure hemiparesis 2. Hemisensory loss 3. Ataxic Hemiparesis 4. Clumsy hand – dysarthria syndrome Absence of cortical features
  21. 21. 2: Large vessel - MCA MCA stroke Hemiparesis Hemisensory loss Visual field defect Cortical signs – Dysphasia – Neglect
  22. 22. 3: Large vessel - PCA Nausea + Vomiting Diplopia Vertigo Ataxia ‘Crossed’ signs Visual field defect Coma
  23. 23. 4. Haemorrhage Conforms to this schema
  24. 24. Infarction Haemorrhage
  25. 25. 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
  26. 26. Neuroimaging: CT or MRI? Whichever is available urgently! CT MRI • Readily available • Less availability • Cheap • Expensive • Better for blood • Better anatomy • Can be used acutely • Better for posterior • May be only choice eg fossa pacemaker • Can be used acutely • New techniques (DWI)
  27. 27. Other investigations • FBC • U+E • Sugar • Cholesterol • ECG / Echo • CXR • Neuroimaging • Vascular imaging
  28. 28. Investigations • Help to answer questions – Where? What? Why? • e.g. which side/arterial territory? infarction or haemorrhage ? lacunar or large vessel?
  29. 29. 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
  30. 30. ASSESSMENT OF STROKE PATIENTS: SUMMARY History Examination Multidisciplinary Stroke clerking proforma Neurological assessment Nursing Identify risk factors Identify risk factors Functional disability Pre-stroke function Communication Swallowing function Movement disability Nutritional risk Clinical Investigations Investigations to consider Haemotology/biochemistry CT scan Urinalysis Carotid doppler ECG Echocardiography CXR MRI ISCHAEMIC STROKE HAEMORRHAGIC STROKE MANAGEMENT
  31. 31. Objectives Revisited • You should know 1. The essential clinical features to be elicited 2. The essential investigations to be performed 3. Understand some of the differential diagnosis 4. 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
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