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Stroke. Stroke. Sudden in onset Focal neurologic deficit Involvement of the blood vessels. Temporal profiles of neurologic deficits that point to the underlying pathologic cause. -Mayo Clinic. Types of Stroke. DIFFERENTIAL DIAGNOSIS. Clinical Types of Stroke in the PHILIPPINES

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  • Sudden in onset
  • Focal neurologic deficit
  • Involvement of the blood vessels

Temporal profiles of neurologic deficits that point to the underlying pathologic cause.

-Mayo Clinic

differential diagnosis
  • Clinical Types of Stroke in the PHILIPPINES
  • 61.39% Ischemic
  • 38.6% Hemorrhagic
hemorrhagic stroke
Hemorrhagic Stroke
  • Primary Intracerebral hemorrhage
    • Inside the brain
    • defective artery in the brain bursts
    • Bleed in the substance of the brain --. Basal ganglia (60% recurrence) 10 % recurrence at the different lobes, 10% at the cerebellum, 10% recurrence a
    • Secondary to hypertension
  • Subarchanoid Hemorrhage –
    • Outside the brain
    • a blood vessel on the brain's surface ruptures and bleeds
    • annuerysm, AVM
hemorrhagic stroke1
Hemorrhagic Stroke
  • intracerebral > subarachnoid hemorrhage
  • Occur during stress or exertion
  • Focal deficits rapidly evolve
  • Confusion, coma or immediate death
hemorrhagic stroke2
Hemorrhagic Stroke
  • Classic: sudden onset headache, vomiting, elevated BP
  • Focal neurologic deficits that progress over minutes
  • May present with agitation and lethargy but progresses to stupor or coma
ischemic stroke
Ischemic Stroke
  • Thrombus forms and blocks blood flow in an artery bringing blood to part of the brain
ischemic stroke1
Sudden onset of a non-convulsive, FND due to CVD

Embolic strokes

Deficit reaches its peak almost at once

Reverses itself within a few hours or days

Thrombotic strokes

Evolve more slowly over a period of several min/hrs and occasionally days

Improve gradually over weeks or months

Cerebral Hemorrhage

There is severe deficit of rapid but not necessarily instantaneous onset

Ischemic Stroke
ischemic stroke thrombotic
Ischemic Stroke: Thrombotic
  • Local Origin of Clot
  • Usually develops at night during sleep
  • Symptoms perceived in the morning
  • Suspect in history of atherosclerosis, hypercoaguable states and collagen vascular disorders
  • 1/3 of ischemic strokes, occlude large cerebral arteries (lCA, MCA, basilar), small penetrating arteries (lacunar strokes), cerebral veins, and venous sinuses.
  • Symptoms evolve over minutes to hrs.
  • Often preceded by TIA in same territory causing similar deficits.
ischemic stroke embolic
Ischemic Stroke: Embolic
  • Proximal origin of clot
  • Occurs at any time
  • Frequently during periods of vigorous activity
  • History of AF, valvular vegetations, thromboembolism from MI, ulcerated plaques in carotid system
  • Seizures in 20% of cases
  • 2/3 of ischemic strokes, from thrombus in heart, aortic arch, large cerebral artery or medium sized branches of brain a.
  • In anterior circulation usually effect MCA , in posterior circulation usually effect branch point of basilar or PCA.
  • Produce maximal neurological deficit at onset.
  • When TIAs precede, symptoms vary because emboli lodges in different places.
ischemic stroke2
Ischemic Stroke
  • Classic: sudden onset of headache, vomiting,  BP
  • Focal neurological deficits progress over minutes
  • May present with agitation & lethargy but progresses to stupor & coma
  • Lacunar—small vessel disease
  • Clinical Presentation
  • Neuroimaging/neurosonology
  • Establish mechanism/s
clinical presentation
Clinical Presentation
neuroimaging neurosonology
  • NeuroImaging
  • Cranial CT Scan – to differentiate infarct vs hemorrhage
  • Timing of the test  important when to do the imaging
  • Cerebral Infarction  1st 6 hour normal
  • Bleeds  abnormal at the start
    • Cranial MRI  transmission weighted imaging
      • Infarct  early changes (DW1)
      • Diffusion-perfusion mismatch


    • Carotid Duplex Examination
      • Carotid Artery, Vertebral Artery, IMT (thickening)
    • Stenosis
  • Obstruction
    • Transcranial Doppler Examination
      • Blood vessels inside the brain
      • Intracranial stenosis or occlusion
  • non-invasive, can be repeated, accurate
mechanism of stroke
Mechanism of stroke
nih stroke scale
NIH Stroke Scale
  • The National Institute of Health (NIH) stroke scale (NIHSS) is a standardized method used by physicians and other health care professionals to measure the level of impairment caused by a stroke.
  • Assessment of whether or not the degree of disability caused by a given stroke merits treatment with tPA
nih stroke scale1
NIH Stroke Scale
  • The NIH stroke scale measures several aspects of brain function, including consciousness, vision, sensation, movement, speech, and language.
  • A certain number of points are given for each impairment uncovered during a focused neurological examination.
nih stroke scale2
NIH Stroke Scale
  • A maximal score of 42 represents the most severe and devastating stroke. Current guidelines as of 2008 allow strokes with scores greater than 4 points to be treated with tPA.
  • 0= no stroke
  • 1-4= minor stroke
  • 5-15= moderate stroke
  • 15-20= moderate/severe stroke
  • 21-42= severe stroke
nih stroke scale3
NIH Stroke Scale
  • Level of Consciousness (LOC)
  • 0-Alert
  • 1-Drowsy
  • 2-Stuporous
  • 3-Coma
  • Best Gaze
  • 0-Normal
  • 1-Partial gaze palsy
  • 2-Forced deviation
  • Best Motor Arm
  • 0-No drift
  • 1-Drift
  • 2-Can't resist gravity
  • 3-No effort against gravity
  • LOC Answers Two Questions
  • (Pt. asked two questions)
  • 0-Answers correctly
  • 1-Answers one correctly
  • 2-Answers none
  • LOC Commands
  • (Patient given two commands)
  • 0-Obeys both correctly
  • 1-One correctly
  • 2-Incorrect
  • Pupillary response
  • 0-Both react
  • 1-One reactive
  • 2-Neither reactive
  • Best Visual
  • 0-No loss
  • 1-Partial hemianopia
  • 2-Complete hemianopia
  • Facial Palsy
  • 0-Normal
  • 1-Minor
  • 2-Partial
  • 3-Complete
  • Best Motor Leg
  • 0-No drift
  • 1-Drift
  • 2-Can't resist gravity
  • 3-No effort against gravity
  • Plantar Reflex
  • 0-Normal
  • 1-Equivocal
  • 2-Extensor
  • 3-Bilaterally extensor
  • Limb Ataxia
  • 0-None
  • 1-Lower or upper
  • 2Both
  • Sensory
  • 0-Normal
  • 1-Partial loss
  • 2-Dense loss
  • Neglect
  • 0-None
  • 1-Partial
  • 2-Complete
  • Dysarthria
  • 0-Normal articulation
  • 1-Mild/moderate
  • 2-Near unintelligible
  • Best Language
  • 0-No aphasia
  • 1-Mild/moderate
  • 2-Severe
  • 3-Mute
  • Change From Previous Exam
  • same/better/worse
  • Change From Baseline
  • same/better/worse