Approach To Stroke Patient

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
 neurological
deficit!

Suspected
stroke!

Stroke
VS
Stroke
 mimicker!

Stroke
mimicker
 Tumor
 Infec-on
!

Localiza-on
of
lesion!

Stroke
type! Ischemic
stroke!

Hemorrhagic
stroke!

Stroke
subtype
by
 TOAST
 classifica-on


Primary
VS
 Secondary
 Hemorrhagic
stroke!

Stroke
mimicker! Unrecognized
 seizure!

Confusion
state!

Syncope
!

13%
ini-ally
diagnos-c
 stroke
 
was
stroke
mimicker


Toxic
and
 metabolic
 disorder!

Subdural
 hematoma!

Tumor
!

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.  2.  3.  4.  5. 

Acute onset quadriparesis with urinary incontinence Previous episode of transient right hemiparesis Decreased bilateral carotid pulsations Bilateral frontal lobe signs 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


www.neurologycoffeecup.com