Transcript HOW CAN I BE SURE THIS IS A STROKE ? LOCUM CONSULTANT

HOW CAN I BE SURE
THIS IS A STROKE ?
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DR. INDIRA NATARAJAN
LOCUM CONSULTANT
UNIVERSITY HOSPITAL OF NORTH
STAFFRODSHIRE
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)
IS THIS A STROKE?
History - sudden onset of focal
symptoms, risk factors for stroke,
relevant past medical history
Examination - neurological signs
consistent with story
Diagnostic Dilemma
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“ Stroke Mimics ” or “ Stroke
Syndrome ”
10% - 15% of patients referred with
possible stroke have something else
Some uncertainty is inevitable
How to approach?
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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
Pattern Recognition
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FACE
SPEECH
ARM
LEG
Stop and Think!
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Drowsy and Delirious
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Patient with headache
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Drowsiness, confusion and headache
Drowsiness / Delirium
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SEIZURES
METABOLIC / TOXIC
SUBDURAL HAEMATOMA
Seizures
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Commonest cause of misdiagnosis
Eye witness
Look for Ictal features – loss of
consciousness, convulsion,
incontinence, tongue biting
Post Ictal features – sleepiness and
confusion
METABOLIC
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Hypoglycaemia
Alcohol and drugs
Hyponatraemia
Hypocalcaemia
Hepatic encephalopathy
Wernick-Korsakoff syndrome
Hyperglycaemia
Subdural Haematoma
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Usually in the elderly
Recurrent fallers
If significant will cause drowsiness
Sometimes headache, confusion,
hemiplegia or dysphasia
Features may fluctuate
Diagnosis : CT scan
Headache
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VENOUS THROMBOSIS
MIGRAINE
CEREBRAL VASCULITIS
ARTERIAL DISSECTION
Venous Thrombosis
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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
Migraine
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Visual aura
Visual phenomenon
Sensory symptoms
Dysphasia can occur
Headache
Cerebral Vasculitis
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Unwell prior to the event
Look for clues
Results in infarcts or bleeds
ESR can be raised
MRI and CSF abnormal
Check auto antibodies
Arterial Dissection
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History of Neck Trauma
Pain - Face and around eye
Unilateral Headache
Unilateral Neck pain – Carotid artery
Occipital pain – Vertebral artery
Ipsilateral Horner’s Syndrome
Ipsilateral Cranial nerve lesion and contralateral
pyramidal tract lesion
CT MAY BE NORMAL – DISCUSS WITH
RADIOLOGIST
HEADACHE AND DROWSINESS
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CEREBRAL TUMOUR
ENCEPHALITIS
CEREBRAL ABSCESS
Cerebral Tumours
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Onset is slower than stroke
Signs of Raised ICP – headache,
vomiting, drowsiness, papilloedema
CT Scan confirms diagnosis
Sometimes further imaging needed
Encephalitis
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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
Cerebral Abscess
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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
ALSO LOOK OUT FOR
ATYPICAL CLINICAL
PRESENTATIONS
Transient Global amnesia
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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
Old Stroke with increased
weakness
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Old neurological signs often worse
during intercurrent illness
Rapid return to previous level of
function is usual with appropriate
treatment
Syncopal episodes
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Loss of consciousness
Light headedness with diminishing
loss of vision
Hysteria / Functional
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Young patient
Focal neurology not fitting with
examination
Similar events in the past
Mental health issues
Hyperventilation
FACIAL PALSY
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Bell’s Palsy
Low NIHSS score
To Summarise…..
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Sudden onset
Risk factors for vascular event
Clear pattern of weakness
It is a Stroke
Features prompting caution….
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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
THE EYES DO NOT SEE
WHAT THE MIND
DOES NOT KNOW
THANK YOU