CVA lecture
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Submitted to AskTheNeurologist.Com in 2007 Author Anon.
Slide 2: What is a stroke / CVA ?
• Acute onset of deficit
• Persists > 24 hours ( see TIA definition)
• Result of disturbance of vascular system
Slide 3: TIA’s• Current definition is based on duration less than 24 hours
• Most last minutes
• Always ischaemic….hence “I”
• Warn of impending stroke
Slide 4: CVA Ischaemic HaemorrhagicThrombosis Embolus Epidural Subdural
Carotid / VB Aortic arch
Intracerebral SAH Cardiac
Slide 5: Bleed vs Ischaemia Bleed IschaemiaHyperacute Acute or hyperacuteSevere headache Moderate / no headacheConsciousness usually Consciousness relativelyimpaired if large preserved ( variable)Early signs of herniation Herniation rare / lateNo obvious territory Clear vascular territory
Slide 6: Clinical features of CVA’s
• Depend on part of brain involved
• Very variable
• Common syndromes vs very rare
Slide 7: Common Features of CVA• Hemiparesis• Face asymmetry• Gaze deviation• Dysphasia / aphasia• Dysarthria• Limb incoordination• Ataxia ( +/- vertigo)• One sided sensory symptoms
Slide 8: Features very unlikely to be dueto CVA• General weakness• Isolated headache• Isolated vertigo• General confusion• Memory disturbance• Isolated fall• Bilateral complaints• Gradual deterioration in consciousness
Slide 9: When to think of a CVA in a patient with decreased consciousness • Hyperacute sustained loss of consciousness with no evidence of cardiorespiratory disturbance • Unequal pupils ( if no past surgery!) • Reacts to pain only on one side • Gaze deviationOther causes are more common and usually much more treatable
Slide 10: CVA lecture The old stroke that got worse
• A past stroke is a significant risk factor for a future stroke
• Patients usually improve following stroke
• Deterioration common with fever or other metabolic / haemodynamic disturbance
Slide 11: Common differential diagnoses
• SOL
• Seizure
• Metabolic condition especially hypoglycaemia
Slide 12: Blood pressure following CVA
• Rise in BP following stroke is protective
• Rarely want to decrease BP in acute phase
• Very high BP may be the cause or the effect!
Slide 13: Basic work-up• PMH ( especially risk factors, old strokes)• Drugs ( risk factors, “ blood thinning” )• Vital signs including temperature!• ECG
• Bloods for CBC, Biochemistry ( esp. glucose), ESR ? INR ? X-match
Slide 14: CVA lecture Diagnosis
• Clinical is most important
• CT
• MRI in selected cases
Slide 15: Following diagnosis of ischaemicstroke• Some patients receive immediate treatment with thrombolysis / stenting
• Some with suspected embolus may be started on heparin
• Most started on aspirin alone
Slide 16: Important issues followingstroke• Physiotherapy• Family support• Identify and treat depression• Prevent common complications – DVT – Infections ( aspiration) – Pressure sores
Slide 17: Searching for a treatable cause
• Carotid duplex
• Cardiac echo
• Angiography
Slide 18: Secondary prevention
• Reduce risk factors
• Anticoagulants / antiplatelets
• Neurological follow-up
Slide 19: Case55 year old man with negligible risk factors for cerebrovasculardiseasePresented with acute, progressiveleft-sided weakness and right-sided headache
2 days prior to admission felt sudden onset of sharp, right – sided headacheassociated with left arm numbness and mild articulation difficulty; resolvedspontaneously over minutesOn morning of admission, recurrence of sharp, severe right sided headache(without pulsatile characteristics) associated with left arm numbness andarticulation difficulty
Slide 20: Examination Fully conscious & orientated, no neck stiffness Speech Dysarthric Left central facial weakness - Cranial nerves otherwise intact
Mild right upper limb global weakness (4/5) Power preserved in lower limbs Reflexes symmetrical with no pyramidal signs
Hypoaesthesia left arm Rest of neurological examination unremarkable with noevidence of neglect
Slide 21: Diffusion Perfusion Mismatch OnMRI Diffusion MRI Perfusion MRI
Slide 22: Absent RICA on MRA
Slide 23: Pre-Stent Angiography String Sign Parenchymography phase
Slide 24: Angioplasty and Stenting
CVA lecture Post angioplasty - aneurysm
After 1st stent
After 3rd stent
Slide 25: Comparison of pre andpost –stent Angiogram
Slide 26: Progress in ER
Over period of 2 hours deterioration with markedexacerbation of dysarthria and facial weakness,exacerbation of left arm weakness to 3/5 and appearanceof left leg weakness 4-/5 with a left Babinski sign
Slide 27: Following procedureImmediately following procedure noticeable improvement indysarthria and left sided weaknessTreatment commenced with LMW heparin, aspirin andclopidogrel.On following morning neurological examination had returned tothat noted on arrival to ER: Mild dysarthria with left facial weakness Left arm 4/5 Left leg in tact
Slide 28: Follow – upPatient discharged on Aspirin 325mg, Clopidogrel 75mgTrans-cranial Doppler and follow-up MRA revealed patency andnormal flow in all cervical arteriesFollow-up MRI revealed no progression of infarctPatient responded well to rehabilitation and recovered all functionbeing left with mild dysarthria, left arm sensory complaints andfacial weakness
Slide 29: CVA lecture Submitted toAskTheNeurologist.Com in 2007 Author Anon.