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    Assessment and Diagnosis of Stroke

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    Mohd Khateeb
    This document provides guidance on assessing and diagnosing patients with suspected stroke. It outlines the essential steps to take in the initial clinical approach and examination. Key aspects include eliciting a history of symptoms and risk factors, performing a neurological examination, and considering differential diagnoses that can mimic stroke. Important investigations include blood tests, ECG, imaging studies like CT or MRI to determine if the stroke is ischemic or hemorrhagic, and the location and likely cause. A multidisciplinary team approach is needed to evaluate factors like functional ability, communication, swallowing and provide appropriate management.

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    Assessment and Diagnosis of Stroke

    Uploaded by

    Mohd Khateeb
    160 views34 pages
    This document provides guidance on assessing and diagnosing patients with suspected stroke. It outlines the essential steps to take in the initial clinical approach and examination. Key aspects include eliciting a history of symptoms and risk factors, performing a neurological examination, and considering differential diagnoses that can mimic stroke. Important investigations include blood tests, ECG, imaging studies like CT or MRI to determine if the stroke is ischemic or hemorrhagic, and the location and likely cause. A multidisciplinary team approach is needed to evaluate factors like functional ability, communication, swallowing and provide appropriate management.

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    This document provides guidance on assessing and diagnosing patients with suspected stroke. It outlines the essential steps to take in the initial clinical approach and examination. Key aspects include eliciting a history of symptoms and risk factors, performing a neurological examination, and considering differential diagnoses that can mimic stroke. Important investigations include blood tests, ECG, imaging studies like CT or MRI to determine if the stroke is ischemic or hemorrhagic, and the location and likely cause. A multidisciplinary team approach is needed to evaluate factors like functional ability, communication, swallowing and provide appropriate management.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    160 views34 pages

    Assessment and Diagnosis of Stroke

    Uploaded by

    Mohd Khateeb
    This document provides guidance on assessing and diagnosing patients with suspected stroke. It outlines the essential steps to take in the initial clinical approach and examination. Key aspects include eliciting a history of symptoms and risk factors, performing a neurological examination, and considering differential diagnoses that can mimic stroke. Important investigations include blood tests, ECG, imaging studies like CT or MRI to determine if the stroke is ischemic or hemorrhagic, and the location and likely cause. A multidisciplinary team approach is needed to evaluate factors like functional ability, communication, swallowing and provide appropriate management.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 34

    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

    Objectives
    You should know
    1. 2. 3. 4. The essential clinical features to be elicited The essential investigations to be performed Understand some of the differential diagnosis 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

    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

    IMMEDIATE CLINICAL APPROACH


    ABC Check blood sugar Glasgow Coma Scale Pyrexia, neck stiffness Oxygen IV access RAPID neurological assessment motor speech visual <12 consider nasal airway <8 consider intubation

    Clinical syndrome
    Syndrome of focal neurological symptoms and signs Sudden onset Symptoms maximal within minutes to hours Predominantly negative symptoms

    MAKE A POSITIVE DIAGNOSIS!

    History
    Onset spread of symptoms? Focal symptoms language/ motor/ sensory/ visual Trauma, previous history, systemically unwell Risk factors Normal functional level

    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 have had stroke

    78 (19%) of these eventually diagnosed as some other condition

    Seizure (17%) Systemic infection (17%) Brain tumour (15%) Toxic-metabolic (13%)

    Multidisciplinary assessment
    Nursing Functional disability Communication Swallowing function Movement disability Nutritional risk

    Objectives revisited
    You should know
    1. 2. 3. 4. The essential clinical features to be elicited The essential investigations to be performed Understand some of the differential diagnosis 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

    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

    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 - 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

    Diagnosis Mechanism Why?


    TOAST classification: Lacunar (penetrating vessel occlusion) Large vessel occlusion Cardioembolic Other (eg sickle cell disease) Undetermined

    Haemorrhage

    EMBOLIC SOURCES

    Platelet clots

    Fibrin clots

    1: Penetrating vessel disease


    Lacunar stroke
    1. 2. 3. 4. Pure hemiparesis Hemisensory loss Ataxic Hemiparesis Clumsy hand dysarthria syndrome

    Absence of cortical features

    2: Large vessel - MCA


    MCA stroke
    Hemiparesis Hemisensory loss Visual field defect Cortical signs
    Dysphasia Neglect

    3: Large vessel - PCA

    Nausea + Vomiting Diplopia Vertigo Ataxia Crossed signs Visual field defect Coma

    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 considered Patients on anticoagulants Patients who may be suitable for thrombolysis

    Neuroimaging: CT or MRI?
    Whichever is available urgently! CT Readily available Cheap Better for blood Can be used acutely May be only choice eg pacemaker New techniques MRI Less availability Expensive Better anatomy Better for posterior fossa Can be used acutely (DWI)

    Other investigations
    FBC U+E Sugar Cholesterol ECG / Echo CXR Neuroimaging Vascular imaging

    Investigations
    Help to answer questions
    Where? What? Why?

    e.g. which side/arterial territory? infarction or haemorrhage ? lacunar or large vessel?

    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

    ASSESSMENT OF STROKE PATIENTS: SUMMARY


    History
    Stroke clerking proforma Identify risk factors Pre-stroke function

    Examination
    Neurological assessment Identify risk factors

    Multidisciplinary
    Nursing Functional disability Communication Swallowing function Movement disability Nutritional risk

    Clinical Investigations
    Haemotology/biochemistry Urinalysis ECG CXR

    Investigations to consider
    CT scan Carotid doppler Echocardiography MRI

    ISCHAEMIC STROKE

    HAEMORRHAGIC STROKE

    MANAGEMENT

    Objectives Revisited
    You should know
    1. 2. 3. 4. The essential clinical features to be elicited The essential investigations to be performed Understand some of the differential diagnosis 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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