Describe the methods and findings for techniques used to investigate arterial disease,

to include Doppler pressure measurements, Arteriograms and Duplex

scanning. Describe the methods and findings for investigations used to investigate
venous disease and lymphatic disease.

Doppler Pressure Measurements
Finds blood pressure by using a Doppler probe
The blood pressure cuff is inflated proximal to the artery in question and the Doppler is used
on a distal artery
Same as normal blood pressure but a Doppler probe instead of stethoscope
Systolic blood pressure on lower limb of <50mmHg indicates critical ischaemia

Arterial/Brachial Pressure Index (ABPI)
It is a measurement of the cuff pressure at which blood flow is detectable by a hand held
Doppler in the posterior tibial or anterior tibial arteries compared to the brachial artery.
Blood pressure cuff is applied to the calf and the pressure where you hear the Doppler as you
release the cuff is the value
Normally the ABPI should be more than 1.0 and systolic pressure in the ankle being equal or
greater than the pressure in the arm
The ratio decreases if severity is worse

No peripheral arterial disease >1.0
Mild to moderate (intermittent claudication) 0.5-0.9
Severe (critical limb ischemia) <0.5

The sensitivity of the test may be improved with a fall in ABPI after exercise.
If the arteries are heavily calcified and incompressible i.e. in renal or diabetic disease the ABPI may
be falsely elevated. In these patients, a toe pressure value is more sensitive.

Duplex ultrasound
Uses B-mode ultrasound and colour Doppler
Useful for mapping out both arterial and venous flow
Provides an accurate anatomical map of the lower limbs with sensitivity of 87% and specificity
of 94% compared to angiography but this is operator dependent

Arteriography (Angiography)
X-ray Digital Subtraction Angiography (DSA)
MRI Magnetic Resonance Angiography (MRA)
CT Computed Tomographic Angiography (CTA)

Digital subtraction angiography (DSA)
Provides an arterial map
But requires peripheral arterial cannulation and exposes the patient to iodinated contrast
This should be reserved for patients immediately prior to intervention
3-D contrast enhanced MR angiography (MRA)
Provides excellent imaging of both legs with a single contrast injection without exposure to
ionizing radiation
Sensitivity of 97% and specificity of 96%
CT angiography (CTA)
Effective alternative to MRA although extensive calcification may obscure stenosis
CTA requires ionizing radiation and iodinated contrast media

What are the main stroke mimics and how do you differentiate them from true
cerebrovascular disease

Ischaemic Stroke
Symptoms occur suddenly
Patients would not exhibit GI symptoms or headache typically
CT or MRI for an ischaemic infarct would appear as a hypoattenuation (darkness) many do
not appear for many hours after stroke onset

Intracerebral Haemorrhage
No symptoms or signs reliably distinguish haemorrhagic stroke from ischaemic stroke
Haemorrhagic stroke is more often associated with reduced level of consciousness and signs of
increased intracranial pressure than ischaemic stroke
CT or MRI demonstrates haemorrhage with hyperattenuation (brightness)

Transient Ischaemic Attack
Neurological symptoms last less than 24 hours with no evidence of acute infarct
CT or MRI may be normal or may reveal evidence of older infarcts


Complicated Migraine
Repetitive history of similar events preceding aura, headache in a marching pattern
differentiates complicated migraine
Stroke often presents with negative symptoms (e.g. visual loss, numbness or weakness)
Positive symptoms (e.g. marching paraesthesias, visual hallucinations and abnormal motor
manifestations) are more likely with complicated migraine
MRI shows no evidence of infarction

Conversion and Somatisation Disorders
Mental factors that cause physical or neurological symptoms
Neurological signs and symptoms do not fit a vascular territory
No cranial nerve deficits
Conversion disorder usually displays multiple signs that are neurologically inconsistent
CT or MRI shows no evidence of infarction or haemorrhage

Seizure (Todds Palsy) and Postictal Defects
Postictal defect An altered state of consciousness after an epileptic seizure
Todds Palsy Weakness and paralysis (commonly of face and arms) following a seizure and can last
up to 48 hours.
History of seizures or a witnessed seizure followed by postictal deficits (e.g. drowsiness,
tongue biting)
Wrong way eye deviation (i.e. gaze deviates away form the side of the brain lesion, towards
the hemiparetic side) should consider seizure but can also occur with stroke affecting the
pons or thalamus
EEG results may identify seizure activity
MRI shows no evidence of infarction

Hypertensive Encephalopathy
A neurological dysfunction induced by malignant hypertension caused by sudden and sustained
severe elevation of arterial blood pressure
Combination of headache, cognitive abnormalities or decreased level of consciousness and
HTN significantly above patients baseline BP
Other signs/symptoms include visual changes or loss, or signs of increased intracranial
pressure
Less frequently these patients present with focal abnormalities in neurological examination
CT or MRI shows cerebral oedema

Multiple Sclerosis
Chronic disease that affects the CNS (it is thought to be autoimmune). The immune system
produces antibodies that attack myelin.
Sudden onset of generalised or focal neurological deficit resembling a TIA is often the first
presentation of multiple sclerosis
Symptoms are short in duration and occur progressively frequently

Trauma
Can present with neurological deficit
No vascular pattern
Inconsistencies
No findings of investigations

Structural Lesions

Subdural Haematoma
Collection of clothing blood that forms in the subdural space
o Acute SDH
o Subacute SDH (begins 3-7 days after initial injury)
o Chronic SDH (begins 2-3 weeks after initial injury)

Brain Tumour
Symptoms and signs are more likely to have been on-going
May be history of cancer if it is due to metastatic lesion
CT head demonstrates lesion or lesions

Metabolic/toxic Syndromes

Sepsis
General symptoms of nausea, vomiting, lethargy
Symptoms of infection: fever, tachycardia, tachypnoea etc.
Neurological deficit
Important especially in the elderly to take a good history and blood tests can rule this out

Hypoglycaemia
Low blood sugar
There may be a history of diabetes with use of insulin or insulin secretagogues
Sweating tremor, hunger, confusion and decreased level of consciousness
Low serum glucose at time of symptoms

Hyponatraemia
Sodium deficiency
If a drop in sodium levels is sudden it can cause significant symptoms
o Mild: Anorexia, headache, nausea, vomiting, lethargy
o Moderate: Personality change, muscle cramps and weakness, confusing, ataxia
o Severe: Drowsiness
Neurological signs include cognitive impairment, focal or generalised seizures, decreased lelve
of consciousness
Serum sodium can rule this out

Hypocalcaemia
Low calcium levels
A rapid fall in levels can cause severe form of symptoms
o Paraesthesia (usually fingers, toes and around mouth)
o Tetany (seizure)
o Dementia and confusing with prolonged hypocalcaemia
Take fasting blood specimens to determine if patient is truly hypocalcaemic

Wernickes Encephalopathy
Neurological symptoms caused by biochemical lesions of the CNS, after exhaustion of B-vitamin
reserves particularly thiamine
History of alcohol abuse
Irritability, confusion and delirium are common presenting features
Decreased blood thiamine level and successful therapeutic trial of thiamine

Alcohol and Drugs
Slurring of words
Confusion