Stroke

Dr. Rob Peck

Consultant / Senior Lecturer
Internal Medicine / Pediatrics
 Preview for Stroke Lecture
• Case and Review
• Stroke
– Definition
– Epidemiology
– Types and Differential Diagnosis
– Presentation – symptoms and signs
– Diagnosis
– Treatment
CC: right sided weakness x 1/7

HPI: A 50 year old female with a history of hypertension (not on

medications) presents with right sided weakness. She was previously
well until she suddenly developed right sided weakness 24 hours ago.
The weakness is associated with an inability to talk and drooling from
the right sound of the mouth. She has also become increasingly
confused over the last several hours. When she did not improve her
family brought her to the hospital.

Review of Systems: The family denies any fever, weight loss, headache,
vomiting, chest pain, cough, shortness of breath, or rash.

Past Medical History: She was diagnosed with hypertension in 2003 and
was prescribed medication but immediately stopped taking this
medication.
Medications: None. The patient is not taking any local helps.

Social/Family History: The family says that the patient does not smoke or
drink alcohol. There is no family history of diabetes, hypertension or
blood clots.
Physical Examination:
General exam: Lethargic. Obese. But no palor, jaundice, thrush,
lymphadenopathy, cyanosis/clubbing, rashes or edema.
BP: 180/100 HR: 100 RR: 16 RBG 14 mmol/L
Neurologic exam:
1. Higher Centers: Lethargic with a Glascow Coma Scale – 10 (3 Eyes, 1
Verbal, 6 Motor). The patient has an expressive (Broca’s) aphasia but
follows commands. Memory could not be assessed.
2. Cranial Nerves - Mouth deviates to the left with sternal rub. The brain
stem reflex are intact. Other cranial nerves could not be assessed.
3. There are no signs of meningismus.
4. Motor – Bulk is normal but tone is decreased in the right arm and leg.
There is grade 0/5 Power on the right upper and lower limbs, 5/5 Power
in left upper and lower limbs; Reflexes – DTRs are grade 1 (diminished)
in the right upper and lower limbs but grade 2 (normal) on the left. The
Babinski’s test is normal on both sides.
5. Sensation / Coordination, Gait and Balance – Could not be assessed
Cardiovascular / Pulmonary / Abdominal Examinations: normal
• What is your impression (be as specific as possible)?
• Which other differentials would you consider in this case?
• Which investigations would you request on this patient?
• Which treatments would you consider?
• What is the prognosis for this patient?
 Neurological History
In neurology, as with many medical sub-specialities, the
pattern of symptoms can give a clue about the underlying
etiology of the problem

Pattern of Symptoms Associated pathology

Acute Traumatic, vascular, psychogenic
Acute on Chronic Excerbation of existing pathology
Subacute Infection, Inflammation
Chronic progressive Tumors (malignant)
Chronic indolent Benign tumors, degenerative diseases,
genetic neurological conditions
Relapsing-remitting Inflammatory, infection
Stepwise Vasculitic, inflammatory, CVA
Previous episodes Inflammatory, psychogenic
 Neurologic Examination
• With every neurologic examination, you
should complete and report 6 parts:
1. Higher Centers
2. Cranial Nerves
3. Meningeal Signs
4. Motor/Reflexes
5. Sensory
6. Coordination, Gate and Balance
 Neurological Exam:
#1 Higher Centers
1) Assess the level of consciousness
– Is patient awake, alert, and oriented to person
place and time (A+Ox3)?
– If not, is the patient:
• Alert – eyes open spontaneous
• Lethargic – eyes open in response to voice
• Obtunded – eyes open only in response to pain
• Comatose – no response to voice or pain
– If the patients is not A+Ox3, you should also
describe the patient’s Glascow Coma Scale
(GCS)
Neurologic Examination –
#1 Higher Centers
The Glascow Coma Scale
(for adults and children > 5 years)
 Neurologic Examination –
#1 Higher Centers
2. Speech/language
– Is the patient speaking fluently or is there:
• Not speaking due to coma.
• Dysarthria – difficulty articulating words
• Expressive (Broca’s) Aphasia – difficulty
initiating speech
• Receptive (Wernicke’s) Aphasia – fluent but
nonsensical speech due to inability to
understand
 Neurologic Examination –
How to assess the cranial nerves
• With practice, you will be able to exam the all 12
cranial nerves quickly and accurately.
• As usual, practice doing it the same way every time.
• If the patient does not follow commands, cranial
nerves cannot be assessed and you should test for
brain stem reflexes including:
– Pupillary reflex (tests CN II and III)
– Corneal reflex (tests CN V and VII)
– Oculocephalic reflex (tests CN III, IV, VI and VIII)
• Also called “Dolls Eyes”
– Gag reflex (tests CN IX and X)
 Neurologic Examination –
#4 Motor
• First test for bulk and tone in all limbs by inspecting and
moving all 4 limbs
– The bulk can be either normal or decreased
– The tone can be either increased, normal or decreased
• Then test for strength in both upper and lower extremities
by moving each joint in both directions and testing each
muscle group.
• Power can be graded as:
• Grade 0 - complete paralysis
• Grade 1 - slight contraction or fasciculation but no movement
• Grade 2 – can move along a surface but not against gravity
• Grade 3 - can oppose gravity but not examiner’s resistance
• Grade 4 - can oppose gravity and some but not all resistance
• Grade 5 - normal power
 Neurologic Examination –
#4 Reflexes
• Deep tendon reflexes (DTRs) should be tested for the
triceps, biceps, brachioradialis, patellar and ankle jerk
(achilles).
– Each reflex tests a certain nerve root and it is important know which
nerves are tested by each DTR
• Superficial reflexes should also be tested for
abdominal and cremasteric reflexes
– Again, each reflex tests a certain nerve so you should know which
nerve is tested with each reflex
• Reflexes can be grades as:
• Grade 0 – Absent
• Grade 1 - Present but decreased
• Grade 2 - Normal
• Grade 3 - Increased
• Grade 4 - Clonus
 UPPER vs LOWER MOTOR
NEURON

CLINICAL SIGN UPPER MOTOR NEURON LOWER MOTOR NEURON

Power Weak Weak
Wasting None Yes (later)
Fasiculations None Yes (later)
Tone Increased/spastic (later) Flaccid
Reflexes Increased Decreased/absent
Plantar response (babinski) Extensor Flexor
Coordination Reduced by weakness Reduced by weakness
 Stroke - Definition
Stroke is defined as “a rapidly developing
syndrome of focal (or global)
disturbance of cerebral function of
sudden onset with no apparent cause
other than that of vascular origin lasting
> 24 hours.”
 Stroke - Definition
• Transient Ischemic Attack (TIA) is
defined as a stroke where the
symptoms last < 24 hours.
• TIA is a risk factor for stroke (5%/yr)
and death due to thromboembolic
events such as stroke or MI (10%/yr)
 Stroke - Pathophysiology
• Stroke is due to neuronal injury in the
brain due to either:
1) decreased blood supply that causes
ischemia and then infarction or
2) bleeding in the brain that causes
neuronal injury by either compression or
compromised blood supply.
 Types of Stroke
1. Ischemic (80%)
– Thrombotic
– Embolic
2. Hemorrhagic (20%)
– Intracranial Hemorrhage
– Subarachnoid Hemorrhage
 Stroke - Epidemiology
• The incidence of stroke is increasing
rapidly in Sub-Saharan Africa,
particularly in urban centers
• Stroke is the #2 most common
cardiovascular disease after Congestive
Cardiac Failure (CCF) in Sub-Saharan
Africa
• At BMC, stroke is the #2 cause of death
(after HIV) on adult wards
 Risk Factors
• #1 Risk Factor in Africa: Hypertension
• Other common risk factors: Diabetes
Mellitus, Age > 65yo, Alcohol, Atrial
Fibrillation, Rheumatic Heart Disease,
Obesity, Cholesterol, Smoking, Prior
TIA/stroke
• Rare Risk Factors: Carotid stenosis,
Sickle Cell Disease, HIV, Atrial Septal
Defects, high red and white blood cell
counts
 Risk Factors
• Understanding the risk factors for stroke
is important because:
– It helps us to determine the likelihood of
stroke in a patient
– Stroke can be prevented through the
prevention of risk factors
 Symptoms
• Unilateral Weakness - most common
• Difficulty in Speaking
• Confusion
• Headache/Vomiting/Sudden Loss of
Consciousness
– More common with hemorrhagic stroke.
 Signs
• Depressed Mental Status
• Dysarthria or Aphasia
– Expressive, Receptive and Global
• Hemiparesis/Hemiplegia
• Cranial Nerve Abnormalities (III, IV, VI, VII,
XII)
• Decreased then Increased Tone
• Decreased then Increased Reflexes
– **Neuronal Shock** (1-2 week)
 UPPER vs LOWER MOTOR
NEURON

CLINICAL SIGN UPPER MOTOR NEURON LOWER MOTOR NEURON

Power Weak Weak
Wasting None Yes (later)
Fasiculations None Yes (later)
Tone Increased/spastic (later) Flaccid
Reflexes Increased Decreased/absent
Plantar response (babinski) Extensor Flexor
Coordination Reduced by weakness Reduced by weakness
 Note:
Hemiplegia vs. Paraplegia
• Remember *paresis = decreased power
and *plegia = no power
• Hemiparesis and hemiplegia are
typically a sign of brain injury like stroke
• Paraparesis and paraplegia are typically
a sign of thoracic or lumbar spinal cord
injury
• Quadraparesis and quadraplegia are
typically a signs of cervical spinal injury
 Differential Diagnosis of Stroke
and Altered Mental Status
1. Vital Sign Abnormality
– Hypertension, Hypoxia…
2. Toxic/Metabolic
– Alcohol, Hyponatremia, Hypoglycemia…
3. Infection
– Mengingitis, Encephalitis, Abcess…
4. Structural Lesion
– Subdural Hematoma, Brain Cancer…
5. Seizures
6. Psychiatric
– Hysteria
 Investigations
• Urgent CT Scan of Brain (if possible)
• ECG
• CXR
• Full Blood Picture (FBP)
• Malaria Smear (MPS)
• Creatinine/Electrolytes
• Cholesterol
• HIV Test
 Diagnosis
• The diagnosis of stroke can be made by
history and physical examination but is
confirmed by:
– CT of brain showing ischemia or
hemorrhage or
– MRI
• In our setting, many diagnoses of stroke
are unconfirmed but this is OK as stroke
can be a clinical diagnosis
CT Brain without Contrast –
Right MCA Ischemic Stroke
CT Brain without Contrast –
Moderate Sized Left Parietal Hemorrhagic Stroke
Originating from Internal Capsule
CT of Brain with IV Contrast
MRI of Brain
 Treatment - Immediate
• Stabilize the Patient First (ABC’s)
• Check Random Blood Glucose (RBG)
and treat if necessary
• If Febrile, treat with Paracetamol
• Give Ranitidine to Prevent Stress Ulcers
 Treatment – Blood Pressure
(BP) Management
• If Ischemic Stroke - allow BP to be high
and come down on its own
– Cerebral Perfusion Pressure = Mean
Arterial Pressure – Intracranial Pressure
• If Hemorrhagic Stroke – quickly
decrease BP to prevent further bleeding
– goal SBP 140-160
Treatment of Ischemic Stroke
• Start Aspirin
– Continue low dose aspirin for life for
secondary prophylaxis
• Subcutaneous Heparin to prevent DVT
– Continue until the patient can get out of
bed
• Thrombolytics if < 4-6 hours after stroke
– Very rarely done in our setting
Treatment of Hemorrhagic Stroke

• Same as ischemic stroke but don’t give

aspirin or heparin
• Neurosurgery to remove blood if
massive bleeding or risk of herniation
 Treatment of Ischemic Stroke

Most patients with stroke don’t die of the

stroke itself, most die from
complications including:
1.Aspiration Pneumonia
2.Decubitus Ulcers
3.Deep Vein Thrombosis
4.Stress Gastric Ulcers
 Treatment - After 48 hours
• **Physical Therapy** - patient need to start
Physical Therapy as soon as possible and
this should be done several times every day
• The Head of Bed should be raised to greater
than 45 degrees to prevent aspiration
pneumonia
• If unable to get out of bed, the patient’s
position should be changed at least every 4-6
hours
 Prognosis
• Ischemic Stroke
– 10% mortality in first 48 hours
– 30% mortality between Hospital Days 2-30
• Hemorrhagic Stroke
– 30% mortality in first 48 hours
– If pt survive first 48 hours they are more
likely to survive and recover function
Data from Bugando

Total (n=39) Ischemic (n=22) Hemorrhagic

(n=17)
Diagnosis 90% 56% 33%
Survival 46% 45% 38%
Days to Death 7 10 3
Female Sex 59% 67% 36%
Average Age 61 65 52
Risk Factors
Hypertension 72% 81% 64%
HTN treated? 21% 25% 21%
Diabetes Mellitus 18% 33% 0%
Prior TIA/Stroke 23% 29% 21%
Alcohol Use 13% 5% 21%
Data from Bugando
Total (n=39) Ischemic (n=22) Hemorrhagic
(n=17)
Presentation
Hemiplegia 87% 91% 77%
Mental Status Change 54% 55% 62%
Average GCS 11.8 12.6 9.9
Aphasia 33% 41% 23%
Headache 18% 18% 15%
Vomiting 8% 9% 0%
Systolic BP 170 154 198
Diastolic BP 101 91 114
Management
Days to hospital 1.93 2.01 1.17
Days in hospital 8.82 10.43 5.62
Days to CT scan 1.05 1.11 0.95
Investigations
LVH by ECG 50% 53% 43%
RBG 8.4 9.0 7.7
Cholesterol 4.9 4.9 5.1
Creatinine 96.8 95.9 105
HIV + 0% 0% 0%
Malaria Smear + 17% 18% 0%
CC: right sided weakness x 1/7

HPI: A 50 year old female with a history of hypertension (not on

medications) presents with right sided weakness. She was previously
well until she suddenly developed right sided weakness 24 hours ago.
The weakness is associated with an inability to talk and drooling from
the right sound of the mouth. She has also become increasingly
confused over the last several hours. When she did not improve her
family brought her to the hospital.

Review of Systems: The family denies any fever, weight loss, headache,
vomiting, chest pain, cough, shortness of breath, or rash.

Past Medical History: She was diagnosed with hypertension in 2003 and
was prescribed medication but immediately stopped taking this
medication.
Medications: None. The patient is not taking any local helps.

Social/Family History: The family says that the patient does not smoke or
drink alcohol. There is no family history of diabetes, hypertension or
blood clots.
Physical Examination:
General exam: Lethargic and confused. Obese. But no palor, jaundice,
thrush, lymphadenopathy, cyanosis/clubbing, rashes or edema.
BP: 180/100 HR: 100 RR: 16 RBG 14 mmol/L
Neurologic exam:
1. Higher Centers: Lethargic and confused with a Glascow Coma Scale –
10 (3 Eyes, 1 Verbal, 6 Motor). Speech and memory could not be
assessed.
2. There are no signs of meningismus.
3. Cranial Nerves - Mouth deviates to the left with sternal rub. The brain
stem reflex are intact. Other cranial nerves could not be assessed.
4. Motor – Bulk is normal but tone is decreased in the right arm and leg.
There is grade 0/5 Power on the right upper and lower limbs, 5/5 Power
in left upper and lower limbs.
5. Reflexes – DTRs are grade 1 (diminished) in the right upper and lower
limbs but grade 2 (normal) on the left. The Babinski’s test is normal on
both sides.
6. Sensation / Coordination, Gait and Balance – Could not be assessed
Cardiovascular / Pulmonary / Abdominal Examinations: normal
• What is your impression (be as specific as possible)?
• Which other differentials would you consider in this case?
• Which investigations would you request on this patient?
• Which treatments would you consider?
• What is the prognosis for this patient?
 Review for Stroke Lecture
• Case & Review
• Stroke
– Definition and Pathophysiology
– Epidemiology
– Types and Differential Diagnosis
– Presentation – symptoms and signs
– Diagnosis
– Treatment
 Take Home Points
• Stroke is a syndrome with sudden onset of focal or
global neurologic deficit which can be diagnosed
clinically
• Stroke can be either ischemic or hemorrhagic and the
presentation/treatment of each type of stroke is
different
• Hypertension is the #1 risk factor for stroke in
Tanzania and stroke prevention and treatment should
focus on early diagnosis and treatment of
hypertension