How to manage patient with limb weakness? animated guide with comments. for medical students and teachers. algorithm based. Davidson Macleod step up to medicine. neurology emergency neurology lecture.

1. Limb Weakness
STROKE: APROACH AND MANAGEMENT
BY DR. MUSTAFA F. AL BAGHDADI

2. Approach

3. Approach

4. Assess power, ask
about pre-existing
weakness & measure
glucose.
Immobilize the cervical spine
Disk prolapse, pathological
fracture & Spinal stroke (severe
back pain)
Increase tone, Brisk reflexes,
extensor planter response
Suggest myelopathy
Do MRI

5. syringomyelia,
glioma, abscess
post-radiation
myelopathy, sub-
acute combined
degeneration of the
cord, transverse
myelitis, & ALS.
Signs of raised ICP, LP for
CSF, brain MRI, serum B12,
autoimmune & infective
screen
Guillain–Barré, diabetic neuropathy, acute
intermittent porphyria, chronic inflammatory
demyelinating polyneuropathy, & hereditary
sensorimotor neuropathy.
Sensory loss pattern, Nerve conduction
studies, LP, vital capacity,
Suggest myelopathy
Do MRI

6. Ocular and bulbar involvement (ptosis,
diplopia, voice weakening), +ve
tendon reflex, AChRAb,& chest CT.
myopathies
Stop statins, exclude other drugs,&
antibody screen(anti-jo1).
UMN or LMN ‘patchy’ pattern of weaknessa
lumbosacral plexopathy, malignant,
vasculitic or infiltrative disorder

7. Compare pulses, color,
temperature,& capillary refill.
Limb x-ray, CK, ask about
seizure,& previous stroke.
Assess the risk
of impending
stroke

8. Assessing the risk of impending stroke
Admit if ABCDD score ≥4
Or >1 TIA
Otherwise
 consider discharge with
appropriate secondary prevention
and specialist follow-up within a
week.
 Arrange neuroimaging prior to
discharge in any patient taking
warfarin.
 carotid Doppler USS

9. Compare pulses, color,
temperature,& capillary refill.
Limb x-ray, CK, ask about
seizure,& previous stroke.
Assess the risk
of impending
stroke

10. Further assessment
of stroke
Step 1 Assess eligibility for
thrombolysis
 Potentially disabling stroke.
 Less than 3 hours
 immediate CT brain to exclude
hemorrhagic stroke.

11. Step 2 Classify stroke
according to clinical
and radiological findings
Perform a CT brain urgently if:
• the patient is eligible for thrombolysis
• coagulation is impaired
• ↓GCS
• symptoms include a severe headache
• there is a rapidly progressive
neurological deficit
• cerebellar hemorrhage is suspected (to
exclude obstructive hydrocephalus).
Otherwise, perform CT within 24 hours

12. Acute treatment & Prevention
 Acute Supportive treatment (airway protection, oxygen,
IV fluids) is initiated.
 Aspirin is best if given within 24 hours of symptom onset.
 Assess the patient’s ability to protect his or her airway,
keep NPO, and elevate the head of the bed 30°.
 Do not give antihypertensive agents unless one of the
following three:
 Prevention according to the cause:
• atherosclerosis of the carotid arteries (Aspirin, Control
HTN, DM, smoking, hypercholesterolemia, obesity,
Surgery carotid endarterectomy in Symptomatic
patients)
• embolic disease anticoagulation (aspirin), reduction of
atherosclerotic risk factors
• lacunar strokes—control of hypertension
So if patient presents
within 3 hours of stroke
onset, thrombolytics are
indicated.
If after 3 hours, give
aspirin. If patient cannot
take aspirin, give
clopidogrel.
1- BP is very high >220/>120.
2- medical indication for
antihypertensive(MI, HF)
3- receiving thrombolytic
therapy

13. Step 3 Evaluate for risk factors/
underlying cause
Suspect a cardiac source if :
• evidence of AF or MI
• features suggesting
endocarditis ,e.g. fever & new
murmur
• ≥2 cerebral infarcts
• systemic emboli e.g. lower
limb
Investigate for an unusual cause
of stroke in younger patients
without vascular risk factors:
• thrombophilia screen.
• echocardiography
• Consider MRA

14. Complications of Stroke
 1. Progression of neurologic insult
 2. Cerebral edema occurs within 1 to 2 days and
can cause mass effects for up to10 days.
Hyperventilation and mannitol may be needed to
lower intracranial pressure.
 3. Hemorrhage into the infarction—rare
 4. Seizures—fewer than 5% of patients

15. Compare pulses, color,
temperature,& capillary refill.
Limb x-ray, CK, ask about
seizure,& previous stroke.
Assess the risk
of impending
stroke

16. If no result
do LP ± MRIfever, meningism, purpuric
rash, or features of shock
blood cultures, give empirical
IV treatment
Slowly progressive suddenExclude
spinal cord
Or sensory
level
If you can’t do brain CT or MRI if
cranial nerve or cerebellar signs +ve
Single peripheral n.MRI spine
Still possible so we should do CT

17. References
DAVISON’S PRINCIPLES
MACLEOD’S CLINICAL DIAGNOSIS
STEP UP TO MEDICINE

18. Thank you
FOR YOUR ATTENTION