COMMON

NEUROLOGICAL
DISORDER
PRESENTERS
DR WAN NUR AFIFAH BINTI WAN IBRAHIM

SUPERVISOR : DR SALZIYAN BADRIN

CASE 1
NAMe: Mr MN Past medical 1. Hypertension
history: 2. Diabetes Mellitus
Age: 61 3. CKD stage 3
4. history of CVA in 2018
GENDER : Male
- no residual weakness

• Complained of sudden onset right sided body weakness, slurred

speech, facial asymmetry for 1 days
• Associated with headache, dizziness and unsteadiness
• No head injury, no fitting/ jerking episode
• No visual, hearing disturbances
• No fever, no URTI symptoms
• Denied COVID19 contact
o/e : alert, conscious GCS E4V5M6, pupil unequal 2mm/3mm, not tachypneic
BP : 167/79 mmHg GM : 17.2 mmol/L (blood ketone 0.6)
HR 110 (irregularly irregular)
RR : 18
Spo2 : 97% RA
Temp : 37˚C

Lungs : clear, equal air entry

CVS : S1S2, soft pansystolic murmur loudest at mitral, grade 3/6
Per abdomen : soft, non tender

CNS : Right Left

Cerebellar examination : UL LL UL LL
- dysdiadochokinesia
over right side, Tone hypertonia hypertonia normal Normal
- Past pointing and Power 4/5 4/5 5/5 5/5
intention tremors over
Reflex Brisk Brisk normal Normal
right Side
- no nystagmus
sensation Reduced Reduced Intact intact
- unable to assess gait
Clonus Present Absent
Babinski Upgoing equivocal
ECG
INVESTIGATIONS
FBC : TWBC 9.3 Hb 10.6 PLT 304
RFT : urea 10, creat 232 , Na 132 , K 3.61, Cl 111
ALP 50 , AST 30, ALT 24
INR 0.92 , aPTT 28.5 sec , PT 12.6 sec
RTK COVID 19 : negative

Bedside ECHO : EF 40%, hypokinetic at apical region,

LVH, dilated LA, RA
no MR/ no MS/ no AS
MR, small intracardiac clot seen,
no vegetation seen
NCCT brain :
- fairly ill defined hypodensity at left corona radiata, left
external capsule and left cerebellar peduncle extending into
left cerebellum suggestive of recent infarctions.

Diagnosis : Cardioembolic stroke with Left PACI + left POCI

NIHSS 13
However, on Day 4 of admission, he complained of worsening right sided body
weakness

o/e: alert, conscious, GCS E4V5M6, pupil unequal, not tachypneic

BP : 162/90 mmHg
HR : 88 bpm
RR : 20 breaths/min
SpO2 : 98% RA
GM : 8.8mmol/L
CNS :
Right Left
Upper limb Lower limb Upper limb Lower limb
Tone hypertonia hypertonia normal Normal
Power 3/5 2/5 5/5 5/5
Reflex Brisk Brisk normal Normal
sensation Reduced Reduced Intact intact
Clonus Present Absent
Babinski Upgoing equivocal
Repeat NCCT brain :
- the recent infarct involving the left
cerebellar, left cerebellar peduncle and
left side of pons is more conspicuous.
- Multiple foci of hyperdensities within the
infarcted area suggestive of hemorrhagic
transformation

Diagnosis :
Extensive CVA secondary to
cardioembolic event
- left POCI + PACI involvement
- with haemorrhagic transformation
NIHSS 15
Ischaemic STROKE
01 DEFINITION, STATISTICS

02 Classifications of ischemic stroke

03 investigations

04 Management

05 prevention
 Stroke : 3rd cause of death in Malaysia

2020
• Total Death Medically Certified
Death : 109,155
• Death due to Cerebrovascular
Disease : 9,060 (8.3%)
• Every day 24 people died of
Stroke in our country

Source : statistics on cause of death Malaysia ,2021, Department of Statistics Malaysia

 principal causes of death for males

Race :
Malay 85%
Chinese 9%
Indian 3%
Others 3%
principal causes of death for females

Source : 1) statistics on cause of death Malaysia ,2021, Department of Statistics Malaysia

2) Annual Report on Malaysia National Stroke Registry (2009-2016), National Neurology Registry
MODIFIED RANKIN
SCALE FOR
NEUROLOGIC
DISABILTY
STROKE
Stroke is defined as a clinical syndrome characterized by
rapidly developing clinical symptoms and/or signs of focal, and
at times global, loss of cerebral function, with symptoms
lasting more than 24 hours or leading to death, with no
apparent cause other than that of a vascular origin.

Strokes may be classified and timed as:

I. Early hyperacute (a stroke that is 0–6 hours)
II. Late hyperacute (6–24 hours)
III. Acute (24 hours to 7 days)
IV. Subacute (1–3 weeks)
V. Chronic (more than 3 weeks)

Source : Clinical Practice Guideline Management of Ischaemic Stroke, 3rd edition 2020
 TRANSIENT ISCHAEMIC ATTACK (TIA)

Old-definition (clinically based)

- brief episode of neurologic dysfunction < 24 hours resulting
from focal temporary cerebral ischemia

New definition (tissue- based)

- transient episode of neurologic dysfunction caused by focal
brain, spinal cord or retinal ischemia, without acute infarction

Source : Clinical Practice Guideline Management of Ischaemic Stroke, 3rd edition 2020
• 80% of stroke
• Brain’s blood vessels become narrowed
or blocked
• Caused by fatty deposits that build up
in blood vessels or by blood clots
• Blood vessels in the brain ruptures
• Factors :
- uncontrolled hypertension
- overtreatment with anticoagulants
- aneurysms
- trauma
- cerebral amyloid angiopathy
- ischemic stroke leading to
hemorrhage
 PRINCIPAL CAUSES OF
ISCHAEMIC STROKE

Large artery
Penetrating artery Cryptogenic
atherosclerosis Embolism (20%) Other causes (5%)
disease (25%) (20-40%)
(20%)

-Lipohyalinosis - Atrial fibrillation - Dissection

-Atherothrombosis - Microatheroma - valvular disease - Vasculitis
-hypoperfusion - Fibrinoid - Vasospasm
necrosis - Inherited
disorder

Source : Clinical Practice Guideline Management of Ischaemic Stroke, 3rd edition 2020
 CLASSIFICATION
1. The Oxford Community Stroke Project (OCSP)
- developed based on clinical findings especially neurological symptoms

2. The Trial of Org 10172 in Acute Stroke Treatment (TOAST)

- further subclassified to Stop-Stroke Study TOAST (SSS-TOAST)

3. The Causative Classification Systems (CCS) is a web-based system

4. ASCO - A-S-C-O acronym: Atherosclerosis, Small-vessel disease,

Cardiac source, and Other causes.

5. Chinese Ischaemic Stroke Classification (CISS)

Source : Clinical Practice Guideline Management of Ischaemic Stroke, 3rd edition 2020
(TACI)

(PACI)

(POCI)

(LACI)
NIH Stroke Scale (NIHSS)

NIHSS Stroke Severity

0 No stroke
symptoms
1-4 Minor stroke
5 - 15 Moderate stroke
16 – 20 Moderate to
severe stroke
21 –42 Severe stroke
Stroke Recognition is the
Important First Step !
INVESTIGATIONS
1. Confirm the diagnosis
2. Determine the stroke
mechanism
3. Rule out stroke mimics
4. Risk stratification and
prognostication
5. Identify potentially
treatable large
obstructive lesion of the
cerebrovascular
circulation
IMAGING
ACA territory MCA territory PCA territory lacunar infarct

HEMORRHAGIC
ISCHEMIC
STROKE
STROKE

Subarachnoid intracerebral
haemorrhage hemorrhage
WHAT IS STROKE CARE?

STROKE IS A MULTIDISCIPLINARY EFFORT

 REPERFUSION THERAPY
intravenous
thrombolysis (IVT)
For patient with onset
of symptoms within 4.5
hours of presentation
• IV Alteplase (0.9mg/kg)
maximum 90mg over 60
minutes
• IV Tenecteplase (0.25mg/kg)
maximum 25mg
endovascular
thrombectomy (EVT)
For large vessel occlusion
(LVO) could be offered
Up to 24 hours using
Advanced imaging such as
CT/MR perfusion scan
Source : Clinical Practice Guideline
Management of Ischaemic Stroke, 3rd edition
2020
 Intravenous thrombolysis
Intravenous rt-PA can be given only if the following available
- a physician with expertise in diagnosis and
management of stroke
- appropriate neuroimaging test available 24hours a day
- capability to manage the complications of thrombolysis
particularly intracranial hemorrhage

Onset Within 4.5

hours
Tips to know the exact onset :
- The exact time of “ last seen well”

nihss
- What is the patient doing during the onset?
- Where does the patient stay?
NIHSS 6 – 22 - Challenge the eye witness regarding the time
 CANDIDATE FOR THROMBOLYSIS
• Clinical diagnosis of acute stroke at presentation
• Acute disabling stroke within 4.5hours of presentation or last
known/ seen well
• Wake up stroke or stroke of unknown onset- onset 4.5 to 9 hours
(not eligible for EVT), IVT may be consider if the lesion not larger
that 1/3 of MCA territory (CT perfusion/ MRI)
• NCCT or MRI brains shows no hemorrhage or established large
infarct core
• No contraindication for thrombolytic therapy
• Blood pressure SBP < 185mmHg and/or DBP < 100mmHg
• The patient or family understand the potential risks and benefits
from treatment

Source : Clinical Practice Guideline Management of Ischaemic Stroke, 3rd edition 2020
ABSOLUTE Contraindications
● Pre treatment SBP > 185mmHg , DBP > 110mmHg
● Blood glucose < 2.7mmol/L
● Current use of LMWH within 24 hours or previous 24H
with prolonged aPTT
● PT >15 seconds, aPTT > 40s or INR > 1.7
● Platelet < 100

Relative contraindications
● Serious head injury / stroke in previous 3 months
● Recent myocardial infarction within 8 weeks
● GIT / urinary bleeding within 21 days
● Major surgery within preceeding 14 days
● Seizure at the onset of stroke
● Premorbid mRS >= 4
● Peritoneal dialysis/ haemodialysis
● Pregnancy, up till 10 days postpartum, or breastfeeding mother
 endovascular
thrombectomy (EVT)
STROKE ENDOVASCULAR THERAPY STANDARD PRACTICE
 Alberta stroke programme early CT score
(ASPECTS)
• is a 10-point quantitative topographic CT
scan score used for patients with middle
cerebral artery (MCA) stroke.
• It has also been adjusted for the posterior
circulation

CT brain showed ASPECT 2

 IN EMERGENCY DEPARTMENT
IMMEDIATELY,
• Determine if patient candidate
for reperfusion therapy
•Activate Stroke Notification
•Essential neurological examination,
NIHSS score
•Basic blood investigation
(blood glucose, FBC, CE, INR/PTT, RP), ECG
•Cranial Imaging (NCCT, CTA)
 ACUTE MANAGEMENT OF ISCHEMIC STROKE
Factors Recommendations

Airway and breathing • Ensure clear airway and adequate oxygenation

• Elective intubation min patient with severely increase ICP, or poor GCS
Blood pressure • Do not treat hypertension if SBP < 220mmHg or DBP < 120mmHg
• Mild hypertension is desirable at 160-180/90-100mmHg
• Blood pressure reduction should not be drastic
Blood Glucose • Treat hyperglycemia (RBS > 11mmol/L) with insulin
• Treat hypoglycemia (RBS < 3mmol/L) with glucose infusion
• Keep blood glucose level 6.0 – 10.0 mmol/L
Nutrition • Perform swallow test
• Insert nasogastric tube if fail swallow test
Infection • Search for source of infection and treat accordingly with appropriate antibiotic

Raised intracranial • Hyperventilation lower the intracranial pressure

pressure • IV Mannitol (0.25 to 0.5g/kg) lowers ICP
• If hydrocephalus present, drainage of CSF via Intraventricular catheter
• Hemicraniectomy and surgical decompressive therapy within 48hours , to control ICP and
prevent herniation (in very large infarct cases)
Source : Clinical Practice Guideline Management of Ischaemic Stroke, 3rd edition 2020
 PROGNOSIS
• Prognosis depends on the type of stroke, size and location
of the lesion.
• Hemorrhagic stroke has higher mortality
• Brainstem infarction, large hemispheric infarction and
cardioembolic stroke carry as poor prognosis
• Lacunar infarct has lowest mortality rates
• Recurrent rates are :
- 3-4% (in the first month)
- 12% in the first year
- 4-5% per year
- 26.4-30% by 5 years
- up to 40% recurrent stroke at 10 years
Source : Clinical Practice Guideline Management of Ischaemic Stroke, 3rd edition 2020
 National Stroke Registry (2009-2016)
Countries Malaysia Singapore Thailand India China USA UK
Mean age 62.5 67 65 63 66.4 69.2 74.2
(years)

CV risk factors
Prevalence
Hypertension 69.9%
Diabetes Mellitus 41.4%
Smoking 26.3%
Hyperlipidaemia 24.0%
Ischaemic Heart Disease 10.8%
Family history 5.8%
Atrial Fibrillation 3.5%

Source : Annual Report on Malaysia National Stroke Registry (2009-2016), National Neurology Registry
 Most cases of strokes are attributable to potentially
modifiable risk factors
MODIFIABLE NON- MODIFIABLE
BEHAVIOURAL
Cigarette smoking or secondhand Older age
smoke exposure
Ethnicity
High alcohol consumption
Gender
Unhealthy diet
Low physical activity
MEDICAL

METABOLIC Existing CVD, including heart failure,

heart defects, heart infection or
abnormal heart rhythm, such as atrial
Hypertension
fibrillation
Diabetes Mellitus
Family history of premature CVD
Hypercholesterolemia
Obesity COVID 19 infection
 STRATEGIES OF PRIMARY PREVENTION
Factors Recommendations
Hypertension • Self BP monitoring recommended
• Risk stratification based on CVD risk, target organ damage
and complication are recommended for optimizing therapy
• Lifestyle changes if systolic BP between 130-139mmHg
and/or diastolic BP is between 80-89mmHg (3-6 monthly
review)
• Treat medically if SBP > 140mmHg and/or DBP > 90mmHg
• Hypertension should be treated in the very elderly
(age > 80) to reduce risk of stroke
Diabetes Mellitus • Strict blood glucose control
• More intensive HbA1c control target (<6.5%) for optimal
ischemic stroke prevention
• Target BP for DM is SBP < 130mmHg and DBP < 80mmhg,
preferably < 120mmHg if tolerated
Source : Clinical Practice Guideline Management of Ischaemic Stroke, 3rd edition 2020
 STRATEGIES OF PRIMARY PREVENTION
Factors Recommendations
Smoking • Cessation of smoking
Aspirin therapy • Not recommended for primary prevention of stroke in the elderly,
diabetic or other high risk group
Post menopausal • Oestrogen- based HRT is not recommended for primary stroke
hormone prevention
replacement therapy

Source : Clinical Practice Guideline Management of Ischaemic Stroke, 3rd edition 2020
 Factors Recommendations
Hyperlipidaemia • Treatment of dyslipidaemia stratified based on risk
• Very high risk group : lowering LDL < 1.8mmol/L
• Intermediate and low risk : keep LDL < 3.4mmol/L
• No risk : keep LDL < 4.2mmol/L

Source :Clinical Practice Guideline Management of Dyslipidaemia, 5th edition 2017

 STRATEGIES OF PRIMARY PREVENTION
Factors Recommendations
Alcohol • Avoid heavy alcohol consumption or limit to < 1 drink per
day
Physical activity • Physical activity (occupational and leisure time) is
recommended for all group of patients
• Physical activity > 30 mins/day or > 150mins/week
Diet • Dietary Action to Stop Hypertension (DASH) diet

Source : Clinical Practice Guideline Management of Ischaemic Stroke, 3rd edition 2020
 SECONDARY PREVENTION OF STROKE
Factors Recommendations
Antiplatelets • Aspirin : 75mg to 325mg OD
• Alternatives :
- clopidogrel : 75mg OD
- Ticlopidine 250mg BD
- Triflusal : 600mg OD
- Cilostazol : 100mg BD

Double therapy • Clopidogrel and Aspirin in patient with minor ischemic stroke and
high risk TIA for 21 days
(NIHSS < 5 , ABCD2 > 2)

Source : Clinical Practice Guideline Management of Ischaemic Stroke, 3rd edition 2020
 SECONDARY PREVENTION OF STROKE
Factors Recommendations
Antihypertensive • ACE inhibitor should be used to reduce
treatment recurrent stroke in normotensive and
hypertensive patients
• (2 weeks or more after stroke)
Lipid lowering • LDL target < 1.8mmol/L is recommended in all
patients with previous ischemic stroke

Diabetic control • Patients should maintain a good glycemic

control
Smoking • All smoker should stop smoking

Source : Clinical Practice Guideline Management of Ischaemic Stroke, 3rd edition 2020
 Stroke and CARDIOEMBOLISM
Major Risk Factors Recommendations
Atrial fibrillation Primary prevention
(CHA2Ds2-VASC score) • OAC to prevent cardioembolic stroke in all NVAF, with CHAD2Ds2-VASC >= 2 (male),
- Male : >= 2 >= 3 female (level 1, Grade A)
- Female >= 3 • Valvular AF , mechanical heart valves – consider Vitamin K antagonist (Warfarin)
(Level I, Grade A)

Secondary prevention
• DOACs are preferred compared to (VKA) warfarin or aspirin in AF patient with previous
stroke (level I, Grade A)
• Aspirin could be consider before initiation of OAC after AF patient suffer from ischemic
stroke (Level III, Grade C)
• initiation of OAC is recommended using 1-3-6-12 rule after rule out hemorrhagic
transformation
• After intracranial hemorrhage, OAC could be re-initiated after 4-8 weeks in NVAF with
high CHA2DS2-VASC score if the underlying cause and risk factors of the bleeding
have been treated

Source : Clinical Practice Guideline Management of Ischaemic Stroke, 3rd edition 2020
References
1. Clinical Practice Guideline Management of Ischaemic Stroke, 3rd edition 2020
2. Clinical Practice Guideline Management of Dyslipidaemia, 5th edition 2017
3. Statistics on cause of death Malaysia, 2021, Department of Statistics Malaysia
https://www.dosm.gov.my/v1/index.php?r=column/cthemeByCat&cat=401&bul_id=R3VrRUhwSXZ
DN2k4SGN6akRhTStwQT09&menu_id=L0pheU43NWJwRWVSZklWdzQ4TlhUUT09
4. Annual Report on Malaysia National Stroke Registry (2009-2016), National Neurology Registry
https://www.neuro.org.my/assets/guideline/Stroke%20registry%20report%202009-2016.pdf