HOW CAN I BE SURE THIS HOW CAN I BE SURE THIS IS A STROKE ?IS A STROKE ?

- DR. INDIRA NATARAJANDR. INDIRA NATARAJAN

LOCUM CONSULTANTLOCUM CONSULTANT

UNIVERSITY HOSPITAL OF NORTH UNIVERSITY HOSPITAL OF NORTH STAFFRODSHIRESTAFFRODSHIRE

WHO DEFINITIONWHO DEFINITION

“ “ rapidly developing clinical signs (at times rapidly developing clinical signs (at times global) disturbance of cerebral function, global) disturbance of cerebral function, lasting more than 24 hours or leading to lasting more than 24 hours or leading to death with no apparent cause other than death with no apparent cause other than that of vascular origin”that of vascular origin”

This definition includes signs and symptoms This definition includes signs and symptoms of suggestive ofof suggestive of

- ischaemic stroke- ischaemic stroke - haemorrhages (intracerebral or - haemorrhages (intracerebral or

subarachanoid)subarachanoid)

IS THIS A STROKE?IS THIS A STROKE?

History - sudden onset of focal History - sudden onset of focal symptoms, risk factors for stroke, symptoms, risk factors for stroke,

relevant past medical historyrelevant past medical history

Examination - neurological signs Examination - neurological signs consistent with storyconsistent with story

Diagnostic DilemmaDiagnostic Dilemma

“ “ Stroke Mimics ” or “ Stroke Stroke Mimics ” or “ Stroke Syndrome ”Syndrome ”

10% - 15% of patients referred with 10% - 15% of patients referred with possible stroke have something elsepossible stroke have something else

Some uncertainty is inevitableSome uncertainty is inevitable

How to approach?How to approach?

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

Pattern RecognitionPattern Recognition

FACE FACE SPEECHSPEECH ARMARM LEGLEG

Stop and Think!Stop and Think!

Drowsy and DeliriousDrowsy and Delirious

Patient with headachePatient with headache

Drowsiness, confusion and headacheDrowsiness, confusion and headache

Drowsiness /Drowsiness / DeliriumDelirium

SEIZURESSEIZURES METABOLIC / TOXICMETABOLIC / TOXIC SUBDURAL HAEMATOMASUBDURAL HAEMATOMA

SeizuresSeizures

Commonest cause of misdiagnosisCommonest cause of misdiagnosis Eye witnessEye witness Look for Ictal features – loss of Look for Ictal features – loss of

consciousness, convulsion, consciousness, convulsion, incontinence, tongue bitingincontinence, tongue biting

Post Ictal features – sleepiness and Post Ictal features – sleepiness and confusionconfusion

METABOLICMETABOLIC

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

Subdural HaematomaSubdural Haematoma

Usually in the elderlyUsually in the elderly Recurrent fallersRecurrent fallers If significant will cause drowsinessIf significant will cause drowsiness Sometimes headache, confusion, Sometimes headache, confusion,

hemiplegia or dysphasiahemiplegia or dysphasia Features may fluctuateFeatures may fluctuate Diagnosis : CT scanDiagnosis : CT scan

HeadacheHeadache

VENOUS THROMBOSISVENOUS THROMBOSIS MIGRAINEMIGRAINE CEREBRAL VASCULITISCEREBRAL VASCULITIS ARTERIAL DISSECTIONARTERIAL DISSECTION

Venous ThrombosisVenous Thrombosis

Most have headacheMost have headache Half have raised ICPHalf have raised ICP Some have neurological signsSome have neurological signs Prothrombotic stateProthrombotic state D - DimerD - Dimer CSF if often abnormal – high protein and CSF if often abnormal – high protein and

raised pressureraised pressure

MR or CT venography diagnosticMR or CT venography diagnostic

MigraineMigraine

Visual auraVisual aura Visual phenomenonVisual phenomenon Sensory symptomsSensory symptoms Dysphasia can occurDysphasia can occur Headache Headache

Cerebral VasculitisCerebral Vasculitis

Unwell prior to the eventUnwell prior to the event Look for cluesLook for clues Results in infarcts or bleedsResults in infarcts or bleeds ESR can be raisedESR can be raised MRI and CSF abnormalMRI and CSF abnormal Check auto antibodiesCheck auto antibodies

Arterial DissectionArterial Dissection

History of Neck TraumaHistory of Neck Trauma Pain - Face and around eyePain - Face and around eye Unilateral HeadacheUnilateral Headache Unilateral Neck pain – Carotid arteryUnilateral Neck pain – Carotid artery Occipital pain – Vertebral arteryOccipital pain – Vertebral artery Ipsilateral Horner’s SyndromeIpsilateral Horner’s Syndrome Ipsilateral Cranial nerve lesion and contralateral Ipsilateral Cranial nerve lesion and contralateral

pyramidal tract lesionpyramidal tract lesion

CT MAY BE NORMAL – DISCUSS WITH CT MAY BE NORMAL – DISCUSS WITH RADIOLOGISTRADIOLOGIST

HEADACHE AND DROWSINESSHEADACHE AND DROWSINESS

CEREBRAL TUMOURCEREBRAL TUMOUR ENCEPHALITISENCEPHALITIS CEREBRAL ABSCESSCEREBRAL ABSCESS

Cerebral TumoursCerebral Tumours

Onset is slower than strokeOnset is slower than stroke Signs of Raised ICP – headache, Signs of Raised ICP – headache,

vomiting, drowsiness, papilloedemavomiting, drowsiness, papilloedema CT Scan confirms diagnosisCT Scan confirms diagnosis Sometimes further imaging neededSometimes further imaging needed

EncephalitisEncephalitis

Usually fit and well Usually fit and well Acute Confusional StateAcute Confusional State Mild preceding febrile illness, headache Mild preceding febrile illness, headache

and drowsinessand drowsiness Sometimes fits, and gradual onset comaSometimes fits, and gradual onset coma 15% of patients have focal signs15% of patients have focal signs CT scan usually normalCT scan usually normal CSF usually abnormalCSF usually abnormal

Cerebral AbscessCerebral Abscess

Subacute onsetSubacute onset Usually spread from sinuses or earUsually spread from sinuses or ear Headache usualHeadache usual Signs of sepsisSigns of sepsis Later drowsiness, vomiting, deliriumLater drowsiness, vomiting, delirium Dysphasia, visual field defects and facial Dysphasia, visual field defects and facial

weakness more commonweakness more common Avoid LP Avoid LP CT ScanCT Scan

ALSO LOOK OUT FOR ALSO LOOK OUT FOR ATYPICAL CLINICALATYPICAL CLINICAL

PRESENTATIONSPRESENTATIONS

Transient Global amnesiaTransient Global amnesia

Middle aged or elderly peopleMiddle aged or elderly people Sudden onsetSudden onset Loss of memory for a period of timeLoss of memory for a period of time No loss of personal identityNo loss of personal identity May have headacheMay have headache Good recoveryGood recovery

Old Stroke with increased Old Stroke with increased weaknessweakness

Old neurological signs often worse Old neurological signs often worse during intercurrent illnessduring intercurrent illness

Rapid return to previous level of Rapid return to previous level of function is usual with appropriate function is usual with appropriate treatmenttreatment

Syncopal episodesSyncopal episodes

Loss of consciousnessLoss of consciousness Light headedness with diminishing Light headedness with diminishing

loss of visionloss of vision

Hysteria / FunctionalHysteria / Functional

Young patientYoung patient Focal neurology not fitting with Focal neurology not fitting with

examinationexamination Similar events in the pastSimilar events in the past Mental health issuesMental health issues HyperventilationHyperventilation

FACIAL PALSYFACIAL PALSY

Bell’s PalsyBell’s Palsy Low NIHSS scoreLow NIHSS score

To Summarise…..To Summarise…..

Sudden onsetSudden onset Risk factors for vascular eventRisk factors for vascular event Clear pattern of weaknessClear pattern of weakness

It is a Stroke It is a Stroke

Features prompting caution….Features prompting caution….

Atypical pattern of weaknessAtypical pattern of weakness Drowsy/ DeliriumDrowsy/ Delirium HeadacheHeadache PyrexiaPyrexia Malaise or prodromal illnessMalaise or prodromal illness Gradual progression over daysGradual progression over days Features of raised ICPFeatures of raised ICP Young age or absence of risk factorsYoung age or absence of risk factors

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

THANK YOUTHANK YOU