STROKE & TRANSIENT

ISCHAEMIC ATTACKS
 STROKE
Acute onset of focal neurological deficit of vascular origin which lasts
for › 24hrs.

1. ISCHAEMIC (80%):
 Thrombosis secondary to atherosclerosis, HTN & arteritis
 Cerebral embolism.
 Acute hypoperfusion.

2. HAEMORRHAGIC (20%):
 HTN.
 SAH.
 Bleeding disorders.
 IC Tumours.
BLOOD SUPPLY TO BRAIN
 PRESENTATION
F- FACE DROOPING.
A- ARM WEAKNESS.
S- SPEECH DIFFICULTY.
T- TIME IS BRAIN!!!!!
 APART FROM FAST, WE SHOULD LOOK FOR:

 SUDDEN NUMBNESS OR WEAKNESS OF FACE, ARM OR

LEG.
 SUDDEN CONFUSION, TROUBLE SPEAKING OR
UNDERSTANDING SPEECH.

 SUDDEN TROUBLE SEEING IN ONE OR BOTH EYES.

 SUDDEN TROUBLE WALKING, DIZZINESS, LOSS OF

BALANCE OR COORDINATION.
 SUDDEN SEVERE HEADACHE WITH NO KNOWN CAUSE.
 CLINICAL FEATURES OF STROKE
ACCORDING TO ARTERIAL TERRITORY

MIDDLE CEREBRAL ART. ANTERIOR CEREBRAL

ART.

1. Contralateral motor 1. Disinhibition.

deficit. Face& Arm>Leg 2. Speech preservation.
2. Contralateral sensory 3. Altered mental status.
deficit.
4. Contralateral motor
3. Gaze deviated towards
deficit. Leg>Arm
side of lesion.
4. Dominant Hemisphere- 5. Contralateral cortical
Receptive/ Expressive sensory deficit (Gait
Dysphasia. Apraxia)
5. Non- Dominant-
Neglect/Inattention.
 CLINICAL FEATURES OF STROKE ACCORDING TO
ARTERIAL TERRITORY

POSTERIOR CEREBRAL
VERTEBROBASILAR ART.
ART.
1. Visual disturbance. 1. Cerebellar signs.
2. Contralateral 2. Vertigo.
homonymous 3. Visual field defects,
hemianopia. diplopia.
3. Impaired memory. 4. Syncope.
5. Ipsilateral cranial
nerve deficits.
6. Contralateral motor
deficits.
 ROSIER SCORE
FACIAL WEAKNESS 1
ARM WEAKNESS 1
LEG WEAKNESS 1
SPEECH DISTURBANCE 1
VISUAL FIELD DEFECT 1
LOSS OF CONSCIUOSNESS / SYNCOPE -1
SEIZURE -1

 STROKE UNLIKELY IF SCORE ZERO / LESS

 INVESTIGATIONS
FBC
Blood glucose
U&E
ECG
CXR
ABG if SpO2 < 94%
PT/INR
CT BRAIN
 EMERGENCY CT SCAN TO BE DONE WHEN

1. Presented with symptoms under 4hrs of Duration.

2. On Warfarin, Heparin or other Anticoagulants.
3. Known case of Bleeding Disorder.
4. GCS < 13.
5. Unexplained Progressive or Fluctuating
symptoms.
6. Papilloedema, Neck Stiffness or Fever.
7. Presented with Severe Headache at the onset of
symptoms.
CT SCAN IMAGES
MRI IMAGES
 MANAGEMENT
Assess and protect Airway if required.
Correct Blood Glucose levels if required.
BP should be controlled cautiously.
O2 supplementation if SpO2 < 95%.
Perform a Swallow Test.
If CT is indicative of no bleed, 300mg Aspirin
should be given immediately.
Thrombolysis with Alteplase if within the Window
Period.
 BLOOD PRESSURE CONTROL PROTOCOL

Persistently increased BP in acute stroke can lead to

hemorrhage, cerebral edema or raised ICP.
Sudden reduction can lead to hypo perfusion or
increase in cerebral ischemia.
In fact, raised BP is a systemic reflex to cope up with
the reduction in cerebral perfusion.
Hence BP should be controlled in a very cautious way.
In any neurological event, there will be a Reflex
increase in BP to maintain the CPP.
IMPORTANT POINTS TO REMEMBER

BP remains elevated for the next 7days after the onset of
Stroke.
10days later, most of them become normotensive.
In a stroke, the dense ischemic zone is surrounded by
neurons that are nonfunctional but viable and can be salvaged
by proper reperfusion. This region is called as Ischemic
Penumbra.
A decrease in MAP of >15% is not recommended.
A MAP of 140-145 should be maintained to maintain the
Penumbra viable.
If BP is not maintained at or below 185/110mmHg, do not
thrombolyse.
 ANTIHYPERTENSIVE DRUGS OF CHOICE

Drugs to be avoided:
1. Nitroprusside
2. Nitroglycerine.
3. Hydralazine.

Drugs that are recommended:

1. Labetalol.
2. B-Blockers.
3. ACEIs
4. Clonidine.
 DOSAGES
Inj. Labetalol 5-10mg IV over 2mins. Can be
repeated till the target BP has been achieved to a
maximum dose of 300mg.

Tab Captopril 12.5 – 25mg.

 THROMBOLYSIS
Drug of choice is ALTEPLASE.

0.9mg/kg body weight total dose.

10% of the total dose as Bolus

Remaining 90% over 1hr Infusion

 CHECK LIST FOR THROMBOLYSIS

 Onset of symptoms >4.5hr or unclear time of onset.

 Head trauma or prior stroke in previous 3 mon.
 Symptoms suggestive of SAH. IC Bleed. Seizures at onset of
stroke.
 Arterial puncture in a non compressible site in previous 7days.
 H/O previous IC Bleed.
 BP > 185/11ommHg.
 Evidence of active bleeding on examination.
 Platelets <100,000, INR >1.7, PT >15sec.
 GRBS <50mg/dl.
 CT showing multilobular infarction, >1/3 cerebral hemisphere.
(Severe Stroke NIHSS >25)
 Age <18 or >80yrs.
STROKE MIMICS-Unusual manifestations of nonvascular
conditions that may resemble acute stroke syndrome

Metabolic Problems:  Abscess

 Hypoglycemia  Intracranial tumors
 Hyperglycemia  Primary CNS metastatic
 Hepatic encephalopathy  Hypertensive
Psychiatric Problems: encephalopathy
 Factitious disorders  Multiple sclerosis
CNS Problems:
 Seizure / Postictal state.
 Hemiplegic Migraine.
 SDH.
 STROKE MIMICS from initial diagnostic
impressions in the Emergency Department

 Seizure and Postictal state Multiple Sclerosis

 Systemic Infection
 Brain Tumor
 Toxic-Metabolic
 Positional Vertigo
 Cardiac Syncope
 Trauma
 Subdural Hematoma
 Herpes Encephalitis
 Transient Global Amnesia
Demyelinating Disease
Cervical Spine Fracture
Myasthenia Gravis
Parkinsonism
Hypertensive
Encephalopathy
Conversion Disorder
Dementia
 STROKE MIMICS from ED admission diagnosis following
initial neuroimaging and laboratory work

Paresthesia or Numbness of Unknown Cause

Seizure
Complicated Migraine
Peripheral Neuropathy
Cranial Nerve Neuropathy
Psychogenic Paralysis
 STROKE MIMICS identified following history, physical, laboratory
work, CT scanning, with advanced MR techniques likely failing to show
ischemic changes

Migraine
Seizures
Functional Disorder
Transient Global Amnesia
Brain Tumor
 TRANSIENT ISCHEMIC ATTACK (TIA)

An episode of transient focal neurological deficit of

vascular origin lasting < 24hrs, but usually resolves
within an hour.
Its usually a sign of impending stroke.
It is also defined as a transient episode of neurologic
dysfunction caused by focal brain, spinal cord, or
retinal ischemia, without acute infarction.
Ischemic stroke is defined as an episode of
neurologic dysfunction caused by focal cerebral,
spinal, or retinal infarction.
 PRESENTATION
VERTEBROBASILAR
CAROTID TERRITORY
TERRITORY

1. Unilateral weakness 1. Blackouts.

or sensory changes. 2. Bilateral motor or
2. Dysphasia. sensory changes.
3. Homonymous 3. Vertigo.
hemianopia. 4. Ataxia.
4. Amaurosis fugax.
 CAUSES
Thrombo-embolic disease involving either the
HEART- AF, Mitral stenosis, Artificial valves, Post-
MI or EXTRACRANIAL VESSELS- Carotid art.
Stenosis.
HTN, Polycythaemia/Anaemia.
Vasculitis.
Sickle Cell disease.
Hypoglycaemia.
Hypoperfusion.
Syphilis.
 ASSESSMENT
The symptoms should resolve in
24hrs to diagnose it as a TIA.
Thorough neurological
examination.
Look for possible sources of emboli-
AF, Heart Murmurs, Carotid
Bruits, MI.
 INVETIGATIONS
Blood glucose levels.
FBC.
ESR.
U&E.
Lipid Profile.
INR, if on any anticoagulants.
ECG.
Imaging.
 ABCD² SCORE
AGE ≥60 1
BP at assessment SBP >140mmHg or
DBP >90mmHg 1
Clinical Features Speech Disturbance 1
Unilateral Weakness 2
Duration of 10-59 min 1
Symptoms ≥60 min 2
Diabetes 1
 >4 Points are at Increased Risk.
IMAGING FOR TIA CASES
Not all require.
If vascular territory or pathology is uncertain, DW-
MRI should be done.
Score >4 or Crescendo TIA, imaging should be
done within 24hrs of onset.
Score <3, should have imaging done within
1week of onset.
Carotid Imaging is for determining the presence &
severity of Carotid Stenosis. Should be done within
1week of symptom onset.
 MANAGEMENT
All suspected TIAs should receive Aspirin 300mg
daily.
Score ≥4, should get assessed by specialist within
24hr.
Crescendo TIA, assessed by specialist within
24hrs.
Score ≤3, assessed by specialist within 1week.
>1 week after the symptoms have resolved should be
assessed by specialist within 1 week of presentation.
Patients being discharged from ER should be
adviced not to drive for atleast 1 month.
 LITERATURE
Stroke Differential Diagnosis - Mimics and
Chameleons- J. Stephen Huff, MD
American Stroke Association.
Uptodate.com
OHEM
Victoria Stacey.
Tintinally.