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Approach
to
stroke
pa-ent!

Surat
Tanprawate,
MD,
FRCPT(T)

Northern
Neuroscience
Center

Chiangmai
University!

www.neurologycoffeecup.com
Outline
approach
to
pa-ent!
Sudden
onset
of

Localiza-on
of
lesion! neurological
deficit! Suspected
stroke!

Stroke
mimicker

Stroke
VS
Stroke
 Tumor

mimicker!
Infec-on
!

Stroke
type!

Ischemic
stroke! Hemorrhagic
stroke!

Stroke
subtype
by
 Primary
VS

TOAST
 Secondary

classifica-on
 Hemorrhagic
stroke!
Stroke
mimicker!
Unrecognized
 Confusion
state! Syncope
!
seizure!

13%
ini-ally
diagnos-c

stroke


was
stroke
mimicker


Toxic
and
 Subdural

hematoma! Tumor
!
metabolic

disorder!

Misdiagnosis
of
stroke:
Lancet,
1982;1:328‐331!
“stroke
localiza.on:

vascular
distribu.on
of

the
ischemic
lesion”!

Anterior
VS
posterior
circula-o
stroke!
Anterior
circula-on
stroke!
Posterior

circula-on

stroke!
Infarc-on
VS
Hemorrhage!
•  Some
clues
from
Hx.
And
PE

•  ICH

– Coma
on
arrival

– Vomi-ng

– Severe
headache

– Current
warfarin
therapy

– SBP>220
mmHg

– Glucose
level>170
mg/dL
in
non‐diabe-c
pa-ent

Stroke
1981;12:
288‐293

Arch
Intern
Med
1985;145:1800‐1803!
Classifica-on
of
ischemic
stroke

“TOAST
classifica-on”!
1. Large
artery
atherosclerosis

2. Cardioembolism

3. Small
vessel
occlusion

4. Stroke
of
other
determined
e-ology

5. Stroke
of
undetermined
e-ology!
Problem list

1.  Acute onset quadriparesis with urinary incontinence


2.  Previous episode of transient right hemiparesis
3.  Decreased bilateral carotid pulsations
4.  Bilateral frontal lobe signs
5.  Left parietal cortical impairement
(astereognosis, agraphia)
6.  Right UMN VII
7.  Bilateral pyramidal weakness
8.  Bilateral babinski response
Old R frontal lobe infarction Anterior watershed infarction at
left frontal and parietal lobes
Normal

Border-zone ischemia

Ischemia at center of bl supply

Anterior watershed

Subcortical watershed

Posterior watershed
Anterior Watershed Infarction
Moyamoya-“like” disease = “Puff-Of-Smoke”!
Bilateral occlusion of internal carotid arteries
⇒  Fine collateral arteries

Children ⇒ Alternating hemiplegia


Adults ⇒ Subarachnod haemorrhage !
Thank
you
for
your
aden-on


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