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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
Slides and explanatory notes available on www.dcn.ed.ac.uk/studentnotes
aims of today s symposium
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
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
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
transient ischaemic attack tia
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
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
stroke is common
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
stroke is often fatal
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
Incidence

Prevalence

Case fatality

The Bath Principle
other consequences
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
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
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
remember
Remember

In stroke

  • the symptoms come on rapidly
  • the symptoms depend on which part of the brain is affected
how do we diagnose a stroke22
How do we diagnose a stroke?

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
What is a “risk factor”
  • 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
Causal Pathways

Hypertension

Atrial Fibrillation

Disease of

cerebral vessels

Clots in the atrium

Embolism to the brain

Stroke

a typical story
A typical story
  • 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
A typical story
  • 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
How do we diagnose a stroke?

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
How do we diagnose a stroke?
  • 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
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
Tests (Laboratory Investigations)
  • 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
Tests (Laboratory Investigations)

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
Other tests
  • 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
Brain imaging
  • 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
imaging the blood vessels
Imaging the blood vessels
  • 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
aims of today s symposium48
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 symposium49
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

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