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Brain attack is it a stroke l.jpg

Brain attack! Is it a Stroke?

Dr Richard I Lindley

Consultant Geriatrician

Part-time Senior Lecturer

[email protected]


How accurate is the diagnosis of stroke typically made by the doctor in the emergency room l.jpg
How accurate is the diagnosis of stroke typically made by the doctor in the Emergency Room?

  • 50%

  • 60%

  • 70%

  • 80%

  • 90%

  • 95%


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How accurate is the diagnosis of stroke typically made by the doctor in the Emergency Room?

  • 50%

  • 60%

  • 70%

  • 80%

  • 90%

  • 95%


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1991 to 1992 WGH Series the doctor in the Emergency Room?

350 patients referred to stroke team

54 did not have stroke

85% accuracy

Mimics

3% Tumour

1% Seizures

1% Previous stroke and new intercurrent illness


Other mimics l.jpg

Migraine the doctor in the Emergency Room?

TIA

Wernicke’s encephalopathy

Myelopathy

Hyponatraemia

Labyrinthitis

Septicaemia

Delirium

Hysteria

Spinal cord stroke

Chest pain!

Lung cancer

Phenytoin toxicity

Spinal cord compression

Other mimics


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Dr Peter Hand 2000-2001 the doctor in the Emergency Room?

Assessed 350 patients

(92% admitted through ARU)

18.6% were stroke mimics

4% Seizure

3% Tumour

2% Sepsis

2% Toxic/metabolic


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Syncope the doctor in the Emergency Room?

Delirium

Vestibular dysfunction

Mononeuropathy

Medically unexplained

Dementia

Migraine

Parkinson’s Disease

Spinal Cord Lesion

SAH

Transient global amnesia

Stroke Mimics 2000


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What are the key components to identify definite stroke from stroke mimic?

Need to reflect on the definition of stroke and TIA


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Stroke stroke mimic?

A clinical syndrome characterized by rapidly developing clinical symptoms and/or signs of focal, and at times global (applied to patients in deep coma and those with subarachnoid haemorrhage), loss of cerebral function, with symptoms lasting more than 24 hours, or leading to death, with no apparent cause other than that of vascular origin.

Hatano 1976


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Transient ischaemic attack (TIA) stroke mimic?

A clinical syndrome characterized by an acute loss of focal cerebral or monocular function with symptoms lasting less than 24 hours and which is thought to be due to inadequate cerebral or ocular blood supply as a result of low blood flow, arterial thrombosis or embolism associated with diseases of the arteries, heart or blood.

Hankey & Warlow 1994


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  • Advantages of stroke and TIA definitions stroke mimic?

  • Allows stroke incidence to be compared around the world (epidemiology)

  • Ensures a common language (clinicians)

  • Helps clinician identify certain non-stroke pathology (guides differential diagnosis)


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  • Disadvantages of definitions of stroke and TIA stroke mimic?

  • The invention of CT scanning (1970’s) emphasised the heterogeneity of stroke (syndrome can be due to cerebral infarction, cerebral haemorrhage or subarachnoid haemorrhage)

  • In the era of “time is brain” what do we call an attack, which has not resolved, assessed within 24 hours of onset?

  • They are based on clinical assessment and in the era of modern technology have we not got a better objective method of assessment?


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TIA: Ischaemic stroke continuum stroke mimic?

Anything which causes a TIA, will, if prolonged cause a stroke.

Quantitatively, not qualitatively, different


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Duration of attack and percentage of patients with a relevant infarct on CT

Koudstaal et al 1992 JNNP;55:95


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The History relevant infarct on CT

Strokes are common in old people with vascular disease

How old are they?

If young (<60 years old) have they premature vascular disease or have they an unusual cause of stroke (e.g. a right to left shunt from patent foramen ovale)

Have they got vascular disease?

Previous heart attacks, diabetes, hypertension, previous stroke or TIA, high cholesterol?

Were they previously well?


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The History: exclude mimics relevant infarct on CT

  • Transient loss of consciousness suggests seizure or cardiac disease

  • Dementia makes all diagnoses difficult

  • Have you got a source of history from another person?


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The Examination relevant infarct on CT

  • Have they got signs of vascular disease (e.g. lost pulses, heart murmurs, carotid bruits, hypertension)?

  • Have they got focal neurological deficits?

  • Have they got sustained global neurological deficit e.g. coma?


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Acute brain attack relevant infarct on CT

Exclude: fits/migraine

Hypo-hyperglycaemia

Other metabolic causes

Exclude tumour /structural lesion

CT Scan

Non-stroke pathology

Exclude:

intracranial bleed

Confirmed ischaemic

brain attack

PICH, SAH, Subdural


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Stroke relevant infarct on CTIS an Emergency!

  • Stroke is a “Brain Attack”

  • Brain Attack is an emergency

  • “Time is Brain”


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AMBULANCE relevant infarct on CT

AMBULANCE

The Brain Attack Team: the need for investment

Ambulance Service

Casualty Dept

Radiology/Neuroradiology/

Physicians/Radiographers

Acute stroke units

Pharmacy & Laboratory

Large RCT’s

Admissions

Administration

Public Relations/Community

Education


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Confirmed ischaemic relevant infarct on CT

brain attack

Yes

Are the symptoms/signs resolving rapidly?

TIA

No

No

Are the symptoms/signs disabling?

Treat like TIA

Yes

Consider more intensive treatment


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Summary relevant infarct on CT

Definitions of TIA and Stroke a bit out of date

The new paradigm of Brain Attack may be useful

There are many non-cerebrovascular causes of brain attack


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Question 1 relevant infarct on CT

Mrs X 78 years old

Perfectly well until day of presentation

Wife noticed that he was “not himself”

Collapsed and brought into A&E dept

Was noted to be aphasic (language problem) and right sided weakness

Then had an epileptic fit

CT scan


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CT scan relevant infarct on CT

Showed a problem in the appropriate hemisphere

Interpreted as being early ischaemia

Admitted to stroke unit

Developed status epilepticus

Is this a stroke?


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CT scan reviewed relevant infarct on CT

Odd swollen appearance

Possibly herpes simplex encephalitis

Despite anticonvulsants, and anti-viral therapy, patient died.

Post mortem showed...


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Post mortem examination relevant infarct on CT

Gliomatosis cerebri

Brain tumour cells found throughout entire brain

Did eventual tumour mass cause electrical instability?

Lesson

A common mimic of “stroke” in emergency medicine is brain tumour (a cause of about 3-5% of all initial “stroke” diagnoses).

Clues: CT scan appearance very atypical for stroke

Status epilepticus rare after acute stroke


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Question 2: Mr Y relevant infarct on CT

A 72 year old lady with known bladder cancer (transitional cell carcinoma) presents with mild left sided weakness.

CT scan


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What’s the diagnosis? relevant infarct on CT


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What’s the diagnosis? relevant infarct on CT

Right frontal lesion is a primary intracerebral haemorrhage stroke

The left frontal lesion is an incidental meningioma

Lessons

Stroke affects older people and co-morbidity is common

About 10% of all stroke is due to primary intracerebral haemorrhage


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Pathology of stroke can now be reliably established by CT scanning done within hours/days of the event

Cerebral infarction 80%

Primary intracerebral haemorrhage 10%

Subarachnoid haemorrhage 5%

Unknown 5%

Sudlow & Warlow 1997

Systematic review of world-wide incidence studies


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Question 3 scanning done within hours/days of the event

64 year old man was driving his car and he suddenly lost power in his right arm and leg

He had no headache

No loss of consciousness

Called for help and son brought him to casualty

No significant medical history


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On examination scanning done within hours/days of the event

Looked well

Blood pressure 200/120 mmHg

Normal language

Slurred speech

Complete weakness affecting his right face, arm and leg

No hemianopia


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Is this a stroke? scanning done within hours/days of the event


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Yes! Due to a Lacunar Infarction scanning done within hours/days of the event


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Question 4: 85 year old lady scanning done within hours/days of the event

Presents with a sudden onset of dizziness and headache

On examination she had nystagmus

Six hours after admission started to complain of worsening headache

24 hours later was unconscious

Is this a stroke?


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Yes! A cerebellar haemorrhage with acute hydrocephalus scanning done within hours/days of the event


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Question 5 scanning done within hours/days of the event

Mrs X 69 years old

Developed Right hemiparesis and aphasia during breakfast (9am)

Husband called GP and sent immediately to A & E department


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Severe (0/5) right face, arm and leg weakness scanning done within hours/days of the event

Dyspraxia (disorganised movement of body)

Aphasic (no understanding or expression of language)


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Is this a stroke? scanning done within hours/days of the event


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Is this a stroke? scanning done within hours/days of the event

Dense MCA sign indicating thrombus in the left MCA

Yes!


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