HOW CAN I BE SURE THIS IS A STROKE ?

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• HOW CAN I BE SURE THIS IS A STROKE ?
• DR. INDIRA NATARAJAN
• LOCUM CONSULTANT
• UNIVERSITY HOSPITAL OF NORTH STAFFRODSHIRE

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WHO DEFINITION

• rapidly developing clinical signs (at times
  global) disturbance of cerebral function, lasting
  more than 24 hours or leading to death with no
  apparent cause other than that of vascular
  origin
• This definition includes signs and symptoms of
  suggestive of
• - ischaemic stroke
• - haemorrhages (intracerebral or subarachanoid)

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IS THIS A STROKE?
History - sudden onset of focal symptoms, risk
factors for stroke, relevant past medical
history Examination - neurological signs
consistent with story
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Diagnostic Dilemma

• Stroke Mimics or Stroke Syndrome
• 10 - 15 of patients referred with possible
  stroke have something else
• Some uncertainty is inevitable

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How to approach?

• Focus on the event
• Onset whether sudden or gradual
• Try to get the sequence of events
• Previously fit and well
• Preceding illness
• Similar episodes
• Risk factors

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Pattern Recognition

• FACE
• SPEECH
• ARM
• LEG

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Stop and Think!

• Drowsy and Delirious
• Patient with headache
• Drowsiness, confusion and headache

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Drowsiness / Delirium

• SEIZURES
• METABOLIC / TOXIC
• SUBDURAL HAEMATOMA

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Seizures

• Commonest cause of misdiagnosis
• Eye witness
• Look for Ictal features loss of consciousness,
  convulsion, incontinence, tongue biting
• Post Ictal features sleepiness and confusion

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METABOLIC

• Hypoglycaemia
• Alcohol and drugs
• Hyponatraemia
• Hypocalcaemia
• Hepatic encephalopathy
• Wernick-Korsakoff syndrome
• Hyperglycaemia

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Subdural Haematoma

• Usually in the elderly
• Recurrent fallers
• If significant will cause drowsiness
• Sometimes headache, confusion, hemiplegia or
  dysphasia
• Features may fluctuate
• Diagnosis CT scan

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Headache

• VENOUS THROMBOSIS
• MIGRAINE
• CEREBRAL VASCULITIS
• ARTERIAL DISSECTION

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Venous Thrombosis

• Most have headache
• Half have raised ICP
• Some have neurological signs
• Prothrombotic state
• D - Dimer
• CSF if often abnormal high protein and raised
  pressure
• MR or CT venography diagnostic

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Migraine

• Visual aura
• Visual phenomenon
• Sensory symptoms
• Dysphasia can occur
• Headache

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Cerebral Vasculitis

• Unwell prior to the event
• Look for clues
• Results in infarcts or bleeds
• ESR can be raised
• MRI and CSF abnormal
• Check auto antibodies

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Arterial Dissection

• History of Neck Trauma
• Pain - Face and around eye
• Unilateral Headache
• Unilateral Neck pain Carotid artery
• Occipital pain Vertebral artery
• Ipsilateral Horners Syndrome
• Ipsilateral Cranial nerve lesion and
  contralateral pyramidal tract lesion
• CT MAY BE NORMAL DISCUSS WITH RADIOLOGIST

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HEADACHE AND DROWSINESS

• CEREBRAL TUMOUR
• ENCEPHALITIS
• CEREBRAL ABSCESS

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Cerebral Tumours

• Onset is slower than stroke
• Signs of Raised ICP headache, vomiting,
  drowsiness, papilloedema
• CT Scan confirms diagnosis
• Sometimes further imaging needed

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Encephalitis

• Usually fit and well
• Acute Confusional State
• Mild preceding febrile illness, headache and
  drowsiness
• Sometimes fits, and gradual onset coma
• 15 of patients have focal signs
• CT scan usually normal
• CSF usually abnormal

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Cerebral Abscess

• Subacute onset
• Usually spread from sinuses or ear
• Headache usual
• Signs of sepsis
• Later drowsiness, vomiting, delirium
• Dysphasia, visual field defects and facial
  weakness more common
• Avoid LP
• CT Scan

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• ALSO LOOK OUT FOR ATYPICAL CLINICAL
• PRESENTATIONS

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Transient Global amnesia

• Middle aged or elderly people
• Sudden onset
• Loss of memory for a period of time
• No loss of personal identity
• May have headache
• Good recovery

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Old Stroke with increased weakness

• Old neurological signs often worse during
  intercurrent illness
• Rapid return to previous level of function is
  usual with appropriate treatment

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Syncopal episodes

• Loss of consciousness
• Light headedness with diminishing loss of vision

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Hysteria / Functional

• Young patient
• Focal neurology not fitting with examination
• Similar events in the past
• Mental health issues
• Hyperventilation

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FACIAL PALSY

• Bells Palsy
• Low NIHSS score

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To Summarise..

• Sudden onset
• Risk factors for vascular event
• Clear pattern of weakness
• It is a Stroke

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Features prompting caution.

• Atypical pattern of weakness
• Drowsy/ Delirium
• Headache
• Pyrexia
• Malaise or prodromal illness
• Gradual progression over days
• Features of raised ICP
• Young age or absence of risk factors

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• THE EYES DO NOT SEE WHAT THE MIND DOES NOT
  KNOW

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• THANK YOU