Slides and explanatory notes available on www.dcn.ed.ac.

uk/studentnotes

Aims of todays symposium

What is stroke? Why is it important? How can be recognise/diagnose it? How do we investigate it? How can we localise the brain lesion? How to distinguish different pathological types? How can we treat it?

Aims of todays symposium

Also: some epidemiological principles
incidence, prevalence, prognosis

simple, clinically relevant neuroanatomy

cerebral localisation

basics of evidence based medicine

randomised trials

Stroke
Cerebrovascular Accident (CVA)

Definition A syndrome characterised by: rapidly developing symptoms and/or signs of focal loss of cerebral function symptoms last more than 24 hours or lead to death no apparent cause other than a vascular origin

Transient Ischaemic Attack (TIA)

A stroke where the symptoms completely resolve within 24 hours An arbitrary concept which has some value in clinical practice and research
may act as a warning different differential diagnosis to stroke more difficult to diagnose with certainty therefore if excluded from stroke makes the latter a more homogenous group.

Dont bother with other terms e.g. RIND

Why is stroke important?

It is common It is often fatal Many survivors remain disabled It has major cognitive and psychological effects It accounts for about 5% of all NHS resources It has a huge impact on families etc

Stroke is common
Incidence (no. new cases/unit pop/yr)
about 200/100,000/yr 120,000/yr in UK

Prevalence (no. cases in population at a single point in time)

about 800/100,000

Stroke is often fatal

Case fatality is
20% by 30 days 30% by 6 months

3rd most common cause of death (after coronary heart disease and cancer) 70,000 deaths per year in UK

The Bath Principle

Incidence

Prevalence

Case fatality

Other consequences
Impairments
weak limbs, absent speech, loss of vision, depression

Disabilities
cannot walk, dress, feed themselves etc

Handicap
cannot fulfil role in society e.g. breadwinner, grand parent

How do we diagnose a stroke?

Listen to the patients story (the history)
where were they? what were they doing? what did they first notice wrong? how did their symptoms progress?

Common symptoms of Stroke

Focal weak/clumsy arm, leg or both
(mono/hemi paresis/plegia)

General Headache Vomiting

loss of feeling or sensation loss of speech

(dysarthria, dysphasia)

loss of balance

The symptoms and signs depend on which part of the brain and which artery is affected

Blocked blood vessels

Remember
In stroke the symptoms come on rapidly the symptoms depend on which part of the brain is affected

The speed of onset influences ones certainty of diagnosis

Why do the symptoms come on rapidly?

the relationship of blood flow and neuronal function

Extension Of Infarction

How do we diagnose a stroke?

If the patients story suggests a stroke Is the patient the sort of person to have had a stroke?
are they elderly? have they got vascular disease elsewhere?
angina, heart attacks, bad circulation in the legs

have they got vascular risk factors?

High blood pressure, smoking, diabetes, high cholesterol

What is a risk factor

Somebody with the characteristic or risk factor has a greater risk of developing the disease The importance of a risk factor is reflected by:
how common it is in the population the strength of its association (relative risk) the absolute risk of the person

It may or may not be on the causal pathway

Causal Pathways
Atrial Fibrillation Clots in the atrium Hypertension

Disease of cerebral vessels

Embolism to the brain

Stroke

A typical story
A 75 year old woman wakes up and tries to get out of bed She falls over and cant get up She tries to speak to her husband but cannot find the words She cannot move her right arm or leg When she arrives at hospital the weakness has improved a bit.

A typical story
Her husband tells us: she has been on treatment for high blood pressure she has angina and diabetes she smoked until recently

How do we diagnose a stroke?

We examine the patient looking for: signs compatible with focal damage to the brain - ones search is guided by the history evidence of underlying vascular problems
irregular pulse, high blood pressure, heart murmurs, bruits over arteries. signs of other diseases which may cause strokes

How do we diagnose a stroke?

Having made a diagnosis of a stroke based on the story and examination we assess our certainty that we are right. We carry out tests to confirm the diagnosis, to identify risk factors and to screen for or diagnose rare causes. The number of tests we do depends on how able we are to answer the following questions.

Important questions to answer when assessing a patient with a probable stroke

How likely is it to be a stroke? Which part of the brain is affected What sort of stroke is it?
Ischaemic (blocked blood vessel) Haemorrhagic (burst blood vessel)

What is the likely cause? What problems has this caused?

There are lots of causes of stroke

Tests (Laboratory Investigations)

Full Blood Count tell us:
how many red cells (erythrocytes)
too many - polycythaemia too few - anaemia

how many white and type of white cells

might indicate infection, leukaemia

how many platelets (sticky bits which form clot)

too many - thrombocythaemia too few - thrombocytopenia

Tests (Laboratory Investigations)

Erythrocyte Sedimentation Rate (ESR) reflects the fibrinogen level in the blood and is a non specific indicator of inflammation Blood glucose will identify
too low (hypoglycaemia) too high (hyperglycaemia) - diabetes

Cholesterol Urea & Electrolytes (renal function and hydration)

Other tests
Electrocardiogram - ECG
Is the heart rhythm normal (e.g. AF)? Has the patient had a heart attack? Is there evidence of prolonged high blood pressure?

Echocardiogram
Is there a structural abnormality in the heart which could be a source of embolism to the brain?

Brain imaging
Computerised Tomography (CT)
Is there another pathology causing the symptoms (e.g. brain tumour)? Are there signs of a stroke? Is the stroke ischaemic or haemorrhagic?

Magnetic resonance imaging

Computerised Tomography (CT)

A cortical infarct

An ischaemic stroke

An haemorrhagic stroke

A cerebellar haemorrhage with hydrocephalus

Haemorrhage into an infarct

Bilateral subdural haematoma

A brain tumour

Imaging the blood vessels

Carotid and Vertebral artery Ultrasound
can show atheroma and occlusions of vessels in neck

Transcranial Doppler (TCD)

can show flow (or lack of flow) in large intracerebral vessels

Magnetic resonance angiography

can show extra and intra cranial blood vessels

Catheter angiography

Carotid Duplex

Carotid Duplex

Carotid Angiography

Stenosis of the origin of the Internal Carotid Artery

Aims of todays symposium

What is stroke? Why is it important? How can be recognise/diagnose it? How do we investigate it? How can we localise the brain lesion? How to distinguish different pathological types? How can we treat it?

Aims of todays symposium

Also: some epidemiological principles
incidence, prevalence, prognosis

simple, clinically relevant neuroanatomy

cerebral localisation

basics of evidence based medicine

randomised trials