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Slides and explanatory notes available on www.dcn.ed.ac.uk/studentnotes. Aims of today’s symposium. What is stroke? Why is it important? How can be recognise/diagnose it? How do we investigate it? How can we localise the brain lesion? How to distinguish different pathological types?

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Slides and explanatory notes available on www dcn ed ac uk studentnotes l.jpg
Slides and explanatory notes available on www.dcn.ed.ac.uk/studentnotes


Aims of today s symposium l.jpg
Aims of today’s symposium

What is stroke?

Why is it important?

How can be recognise/diagnose it?

How do we investigate it?

How can we localise the brain lesion?

How to distinguish different pathological types?

How can we treat it?


Aims of today s symposium4 l.jpg
Aims of today’s symposium

Also:

some epidemiological principles

incidence, prevalence, prognosis

simple, clinically relevant neuroanatomy

cerebral localisation

basics of evidence based medicine

randomised trials


Stroke cerebrovascular accident cva l.jpg
Stroke Cerebrovascular Accident (CVA)

Definition

A syndrome characterised by:

  • rapidly developing symptoms and/or signs of focal loss of cerebral function

  • symptoms last more than 24 hours or lead to death

  • no apparent cause other than a vascular origin


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Transient Ischaemic Attack (TIA)

  • A “stroke” where the symptoms completely resolve within 24 hours

  • An arbitrary concept which has some value in clinical practice and research

    • may act as a warning

    • different differential diagnosis to stroke

    • more difficult to diagnose with certainty therefore if excluded from “stroke” makes the latter a more homogenous group.

  • Don’t bother with other terms e.g. RIND


Why is stroke important l.jpg
Why is stroke important?

  • It is common

  • It is often fatal

  • Many survivors remain disabled

  • It has major cognitive and psychological effects

  • It accounts for about 5% of all NHS resources

  • It has a huge impact on families etc


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Stroke is common

  • Incidence (no. new cases/unit pop/yr)

    • about 200/100,000/yr

    • 120,000/yr in UK

  • Prevalence (no. cases in population at a single point in time)

    • about 800/100,000


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Stroke is often fatal

  • Case fatality is

    • 20% by 30 days

    • 30% by 6 months

  • 3rd most common cause of death (after coronary heart disease and cancer)

  • 70,000 deaths per year in UK


The bath principle l.jpg

Incidence

Prevalence

Case fatality

The Bath Principle


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Other consequences

  • Impairments

    • weak limbs, absent speech, loss of vision, depression

  • Disabilities

    • cannot walk, dress, feed themselves etc

  • Handicap

    • cannot fulfil role in society e.g. breadwinner, grand parent


How do we diagnose a stroke l.jpg
How do we diagnose a stroke?

  • Listen to the patient’s story (the history)

    • where were they?

    • what were they doing?

    • what did they first notice wrong?

    • how did their symptoms progress?


Common symptoms of stroke l.jpg

Focal

weak/clumsy arm, leg or both

(mono/hemi paresis/plegia)

loss of feeling or sensation

loss of speech

(dysarthria, dysphasia)

loss of balance

General

Headache

Vomiting

Common symptoms of Stroke



Blocked blood vessels l.jpg
Blocked blood vessels which artery is affected


Remember l.jpg
Remember which artery is affected

In stroke

  • the symptoms come on rapidly

  • the symptoms depend on which part of the brain is affected



Why do the symptoms come on rapidly the relationship of blood flow and neuronal function l.jpg
Why do the symptoms come on rapidly? which artery is affectedthe relationship of blood flow and neuronal function


Extension of infarction l.jpg
Extension Of Infarction which artery is affected


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How do we diagnose a stroke? which artery is affected

If the patient’s story suggests a stroke

  • Is the patient the sort of person to have had a stroke?

    • are they elderly?

    • have they got vascular disease elsewhere?

      • angina, heart attacks, bad circulation in the legs

    • have they got vascular risk factors?

      • High blood pressure, smoking, diabetes, high cholesterol


What is a risk factor l.jpg
What is a “risk factor” which artery is affected

  • Somebody with the characteristic or “risk factor” has a greater risk of developing the disease

  • The “importance” of a risk factor is reflected by:

    • how common it is in the population

    • the strength of its association (relative risk)

    • the absolute risk of the person

  • It may or may not be on the causal pathway


Causal pathways l.jpg
Causal Pathways which artery is affected

Hypertension

Atrial Fibrillation

Disease of

cerebral vessels

Clots in the atrium

Embolism to the brain

Stroke


A typical story l.jpg
A typical story which artery is affected

  • A 75 year old woman wakes up and tries to get out of bed

  • She falls over and can’t get up

  • She tries to speak to her husband but cannot find the words

  • She cannot move her right arm or leg

  • When she arrives at hospital the weakness has improved a bit.


A typical story26 l.jpg
A typical story which artery is affected

  • Her husband tells us:

  • she has been on treatment for high blood pressure

  • she has angina and diabetes

  • she smoked until recently


How do we diagnose a stroke27 l.jpg
How do we diagnose a stroke? which artery is affected

We examine the patient looking for:

  • signs compatible with focal damage to the brain - ones search is guided by the history

  • evidence of underlying vascular problems

    • irregular pulse, high blood pressure, heart murmurs, bruits over arteries.

    • signs of other diseases which may cause strokes


How do we diagnose a stroke28 l.jpg
How do we diagnose a stroke? which artery is affected

  • Having made a diagnosis of a stroke based on the story and examination we assess our certainty that we are right.

  • We carry out tests to confirm the diagnosis, to identify risk factors and to screen for or diagnose rare causes.

  • The number of tests we do depends on how able we are to answer the following questions.


Important questions to answer when assessing a patient with a probable stroke l.jpg
Important questions to answer when assessing a patient with a probable stroke

  • How likely is it to be a stroke?

  • Which part of the brain is affected

  • What sort of stroke is it?

    • Ischaemic (blocked blood vessel)

    • Haemorrhagic (burst blood vessel)

  • What is the likely cause?

  • What problems has this caused?



Tests laboratory investigations l.jpg
Tests (Laboratory Investigations) a probable stroke

  • Full Blood Count tell us:

    • how many red cells (erythrocytes)

      • too many - polycythaemia

      • too few - anaemia

    • how many white and type of white cells

      • might indicate infection, leukaemia

    • how many platelets (sticky bits which form clot)

      • too many - thrombocythaemia

      • too few - thrombocytopenia


Tests laboratory investigations32 l.jpg
Tests (Laboratory Investigations) a probable stroke

Erythrocyte Sedimentation Rate (ESR)

  • reflects the fibrinogen level in the blood and is a non specific indicator of “inflammation”

  • Blood glucose will identify

    • too low (hypoglycaemia)

    • too high (hyperglycaemia) - diabetes

  • Cholesterol

  • Urea & Electrolytes (renal function and hydration)


Other tests l.jpg
Other tests a probable stroke

  • Electrocardiogram - ECG

    • Is the heart rhythm normal (e.g. AF)?

    • Has the patient had a heart attack?

    • Is there evidence of prolonged high blood pressure?

  • Echocardiogram

    • Is there a structural abnormality in the heart which could be a source of embolism to the brain?


Brain imaging l.jpg
Brain imaging a probable stroke

  • Computerised Tomography (CT)

    • Is there another pathology causing the symptoms (e.g. brain tumour)?

    • Are there signs of a stroke?

    • Is the stroke ischaemic or haemorrhagic?

  • Magnetic resonance imaging


Computerised tomography ct l.jpg
Computerised Tomography (CT) a probable stroke


A cortical infarct l.jpg
A cortical infarct a probable stroke


An ischaemic stroke l.jpg
An ischaemic stroke a probable stroke


An haemorrhagic stroke l.jpg
An haemorrhagic stroke a probable stroke



Haemorrhage into an infarct l.jpg
Haemorrhage into an infarct a probable stroke


Bilateral subdural haematoma l.jpg
Bilateral subdural haematoma a probable stroke


A brain tumour l.jpg
A brain tumour a probable stroke


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Imaging the blood vessels a probable stroke

  • Carotid and Vertebral artery Ultrasound

    • can show atheroma and occlusions of vessels in neck

  • Transcranial Doppler (TCD)

    • can show flow (or lack of flow) in large intracerebral vessels

  • Magnetic resonance angiography

    • can show extra and intra cranial blood vessels

  • Catheter angiography


Carotid duplex l.jpg
Carotid Duplex a probable stroke


Carotid duplex45 l.jpg
Carotid Duplex a probable stroke


Carotid angiography l.jpg
Carotid a probable strokeAngiography



Aims of today s symposium48 l.jpg
Aims of today’s symposium a probable stroke

What is stroke? 

Why is it important? 

How can be recognise/diagnose it? 

How do we investigate it? 

How can we localise the brain lesion?

How to distinguish different pathological types?

How can we treat it?


Aims of today s symposium49 l.jpg
Aims of today’s symposium a probable stroke

Also:

some epidemiological principles 

incidence, prevalence, prognosis

simple, clinically relevant neuroanatomy

cerebral localisation

basics of evidence based medicine

randomised trials


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