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Neurology Part 1: Stroke Delivered by: Dr Aisha Abdelrahman Delivered by: Amir Sharif BSc (Hons) , Fifth year MBChB StudentDisclaimer BIDA SW teaching is led by students with supervision of junior doctors and consultants across the UK. These teachings are created to support students’ learning but should not replace your local Medical School teaching material.Stroke • Stroke is a clinical syndrome characterized by rapidly developing signs of focal or global disturbance of cerebral functions which lasts longer than 24 hours or leads to death. • Transient ischaemic attack (TIA) is a transient (less than 24 hours) neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without evidence of acute infarction • The etiology of stroke can be classified into hemorrhagic and ischemic • Hemorrhagic strokes can be further classify into two main groups: 1) intracerebral 2) subarachnoid 1Ischemic stroke •for 85% of stroke cases (1) common type of stroke approximately accounting •Ischemic stroke etiology : Vascular Cardiac HematologicalIschemic stroke Risk factors (2): Age Hypertension Diabetes Smoking Hypercholesterolaemia AFIschemic stroke •Clinical features (3): 1) The sign and symptoms are dependent on the location of the stroke 2) Bamford classification 3) FAST for quick screen(4)Ischemic stroke Territories 1) Anterior cerebral artery stroke 2) posterior cerebral artery stroke 3) Middle cerebral artery stroke 4) Basilar artery stroke 5) Midbrain infarct ( Weber's syndrome ) 6) posterior inferior cerebral artery Case 1 •78 years old woman presented to ED with difficulties in her moving and speech. On neurological examination the right side of her both upper and lower limb reveal normal strength. On the left side the strength on upper limb is 1/5 and on lower limb is 3/5. she is unable to see objects on the left side of both her left and right eyes. Sensation is lost in both upper and lower limb on the left side. ❖ Where is the most likely lesion?Case 2 •A 67-year-old female patient visits the emergency department with a complaint of a vision disturbance that occurred suddenly 20 minutes ago. She reports difficulty in identifying objects on her right side. The patient has a medical history of type 2 diabetes mellitus and hypertension. Upon examination, the doctor observes right-sided homonymous hemianopia with macular sparing, while the patient's speech and limb power are normal. ❖ The probable location of the lesion causing the patient's symptoms would be where?Case 3 A 54-year-old woman visits an outpatient clinic because of recurrent palpitation. She has no relevant PMH. Her 12-lead ECG is shown below. ECHO shows findings consistent with hypertrophic cardiomyopathy. CHA DS -VASc score is calculated to be 1. 2 2 6 months later she presents to the ER with severe expressive aphasia, right hemiplegia, and right hemi-sensory loss. There are no visual defects . [6]. ❖ What is the main risk factor for stroke in this case? ❖ Where is the lesion likely to be? ❖ Is this a TACS?Case 4 A 57-year-old gentleman with diabetes, hypertension, and chronic smoking, presented with acute onset double vision and left eyelid ptosis for 3 days. There was no associated weakness, sensory changes, speech changes, or swallowing difficulties. His blood pressure on arrival was 198/117 mm Hg. His examination was remarkable for left eyelid ptosis and impaired left eye adduction and upward gaze. Both pupils were of normal size, equal, and reactive to light. There were no further cranial nerve deficits. There[7]. very mild right arm and leg dystaxia but no motor or sensory deficit . ❖ Where is the lesion?Case 5 65F presents to the ED with right-sided hemiparesis, aphasia, and mouth deviation. On neurological examination power is 2 / 5 in the upper limb and 3/ 5 in the lower limb. There is associated sensory loss in both the upper and lower right limbs. There is no visual field defects .. His CT scan is shown to the right ❖ Where is the lesion?Ischemic stroke Investigations: CT head (first line) MRI CTA Carotid doppler ultrasound ECG 5Ischemic • Management : Time dependent • Management based on onset of symptoms: Aspirin 300 mg Thrombolysis Thrombectomy ● Secondary prevention No atrial fibrillation- antiplatelet monotherapy Standard treatment is clopidogrel 75mg daily 1Hemorrhagic stroke Rapidly developing neurological dysfunction due to a focal collection of blood from within the brain parenchyma or ventricular system or bleeding into the arachnoid space that is not caused by trauma About 15% of strokes which occur are haemorrhagicCase 6 A 55-year old woman presents to the ER after a severe headache with subsequent collapse. She is unconscious and not following commands. Her right pupil is dilated. Her current VS are RR 24,SpO2 92% with 15L nonrebreather mask, BP 170/90, HR 122. She is sent for a stat CT head [1.]. ❖ What symptoms in this case suggest a hemorrhagic as opposed to ischemic stroke? ❖ What are the 2 main types of hemorrhagic stroke?Classification Hemorrhagic stroke Intracerebral Subarachnoid Intrapaalnchym IntraventricularCase 7 A 23-year-old primigravida presents at 32 weeks 6 days gestation with sudden onset of right-sided hemiplegia associated with aphasia and blood pressure (BP) of 200/120. CT scan confirms a left frontoparietal lobe parenchymal hemorrhage with intraventricular extension. Emergency Cesarean delivery was done followed by leftl decompression craniotomy with intracranial hemorrhage (ICH)’s evacuation. She recovered completely without any neurological deficit .11]. ❖ What are the risk factors of hemorrhagic stroke in this case? ❖ What is the appropriate BP target for acute ICH?Risk factors • Lifestyle factors • Cardiovascular disease • Other medical conditions such migraine, diabetes mellitus and hypercoagulable disorders • Factors such as age, male sex, history of TIA/stroke and the use of anticoagulationCauses ● Intracerebral haemorrhage occur most commonly due to hypertension induced changes such as hyaline arteriosclerosis in small cerebral blood vessels ● Other causes include microaneurysms, AV malformation rupture and conditions such as vasculitis, hemangiomas and amyloid angiopathy ● Rarer causes include carotid artery dissection and cerebral venous thrombosisSecondary causes ● May also be secondary to ischemic stroke ● Reperfusion to endothelial cells in ischemic tissues which causes rupture and hemorrhage ● Hemorrhagic conversion Case 8 A 21-year-old right-handed male, with a past medical history significant for asthma and Attention Deficit Disorder (ADD), treated with methylphenidate, who was found in a gym bathroom with left sided weakness and urinary incontinence shortly after lifting weights. Upon arrival to the emergency department (ED), he was following commands with left hemiparesis. He complained of severe headache. Initial laboratory studies[12].aled a normal platelet count, coagulation profile, and negative toxicology screen Emergent non-contrast head CT revealed a right frontal intracranial hemorrhage ❖ What clinical features of this case suggest a secondary cause of ICH? ❖ What imaging could visualise the cause of the ICH in this case?Events Rupture of artery Blood pools Tissue damage Intracranial pressure + Oxygen deprivationSymptoms ● Sudden numbness or weakness, vision changes, dysarthria, loss of balance and coordination- remember FAST symptoms ● Sudden severe headache, vomiting, nuchal rigidity, vertigo, confusionCase 9 60m presents with sudden onset dense left hemiparesis and loss haemorrhage. CT is done within 2 hours of the onset of symptoms and is shown below [13]. ❖ Where is the lesion likely to be found?Management(16) Case 10 77m presents with sudden change in awareness. CT shows the below [14]. ❖ What is shown in the CT? ❖ What is a complication of raised ICP demonstrated in this scan? ❖ What is the mainstay of treatment in hemorrhagic stroke?Treatment Mainly supportive- stop anticoagulants and antiplatelets Drugs to relieve intracranial pressure- antihypertensives Surgical management- ● Craniotomy or CT guided aspiration stereotactic aspiration ● Decompressive craniectomy ● Endovascular repairKey points ● Stroke is a clinical diagnosis guided by imaging ● Remember to exclude common conditions which may mimic stroke symptoms such as seizure, hypoglycaemia and complicated migraine ● Minimum work up includes focused history and examination, checking blood glucose levels to rule out hypoglycaemia and CT head to rule out intracerebral haemorrhage ● Time is brain- the aim is to restore cerebral blood flow as fast as possibleReferences 1. Royal College of Physicians. National Clinical Guideline for Stroke 2. BMJ Best Practice. Epidemiology. 3. Classification and natural history of clinically identifiable subtypes of cerebral infarction. 4. https://radiopaedia.org/articles/anterior-cerebral-artery-aca-infarct 5. Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: a prospective comparison. 6. https://www.saem.org/about-saem/academies-interest-groups-affiliates2/cdem/for-students/online-education/m4-curriculum/group-m4-neurology/ischemic-stroke 7. https://www.ahajournals.org/doi/10.1161/STROKEAHA.120.0305 8. https://radiopaedia.org/cases/ischaemic-stroke-1?lang=gb 9. NICE guideline: Stroke and transient ischemic attack in over 16s: diagnosis and management 10. https://www.studocu.com/en-us/document/city-colleges-of-chicago/advanced-medical-surgical/neuro-case-study-2-hemorrhagic-stroke/24911300 11. https://www.jsafog.com/doi/JSAFOG/pdf/10.5005/jp-journals-10006-1929 12. https://www.thoracic.org/professionals/clinical-resources/clinical-cases/07-12-intracerebral-hemorrhage-in-a-young-adult-male-patient.php 13. https://radiopaedia.org/cases/haemorrhagic-stroke-1 14. https://radiopaedia.org/cases/acute-haemorrhagic-stroke?lang=gb 15. Brighton & Sussex University hospitals NHS trust: Guidelines for the management of stroke 16. BMJ Stroke and Vascul ar Neurology: Current management of spontaneous intracerebral haemorrhageFOR FEEDBACK AND QUERIES: Email @ info@bidasw.com