HOW CAN I BE SURE THIS IS A STROKE ? - DR. INDIRA NATARAJAN LOCUM CONSULTANT LOCUM CONSULTANT UNIVERSITY HOSPITAL OF NORTH STAFFRODSHIRE 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) - 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 “ Stroke Mimics ” or “ Stroke Syndrome ” “ Stroke Mimics ” or “ Stroke Syndrome ” 10% - 15% of patients referred with possible stroke have something else 10% - 15% of patients referred with possible stroke have something else Some uncertainty is inevitable Some uncertainty is inevitable

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

Pattern Recognition FACE FACE SPEECH SPEECH ARM ARM LEG LEG

Stop and Think! Drowsy and Delirious Drowsy and Delirious Patient with headache Patient with headache Drowsiness, confusion and headache Drowsiness, confusion and headache

Drowsiness / Delirium SEIZURES SEIZURES METABOLIC / TOXIC METABOLIC / TOXIC SUBDURAL HAEMATOMA SUBDURAL HAEMATOMA

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

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

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

Headache VENOUS THROMBOSIS VENOUS THROMBOSIS MIGRAINE MIGRAINE CEREBRAL VASCULITIS CEREBRAL VASCULITIS ARTERIAL DISSECTION ARTERIAL DISSECTION

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

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

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

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

HEADACHE AND DROWSINESS CEREBRAL TUMOUR CEREBRAL TUMOUR ENCEPHALITIS ENCEPHALITIS CEREBRAL ABSCESS CEREBRAL ABSCESS

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

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

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

ALSO LOOK OUT FOR ATYPICAL CLINICAL PRESENTATIONS

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

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

Syncopal episodes Loss of consciousness Loss of consciousness Light headedness with diminishing loss of vision Light headedness with diminishing loss of vision

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

FACIAL PALSY Bell’s Palsy Bell’s Palsy Low NIHSS score Low NIHSS score

To Summarise….. Sudden onset Sudden onset Risk factors for vascular event Risk factors for vascular event Clear pattern of weakness Clear pattern of weakness It is a Stroke

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

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

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