brain attack! is it a stroke? dr richard i lindley consultant geriatrician part-time senior lecturer...

Brain attack! Is it a Stroke?

Dr Richard I Lindley

Consultant Geriatrician

Part-time Senior Lecturer

richard.lindley@ed.ac.uk

How accurate is the diagnosis of stroke typically made by the

doctor in the Emergency Room?

• 50%

• 60%

• 70%

• 80%

• 90%

• 95%

How accurate is the diagnosis of stroke typically made by the

doctor in the Emergency Room?

• 50%

• 60%

• 70%

• 80%

• 90%

• 95%

1991 to 1992 WGH Series

350 patients referred to stroke team

54 did not have stroke

85% accuracy

Mimics

3% Tumour

1% Seizures

1% Previous stroke and new intercurrent illness

Other mimics

• Migraine• TIA• Wernicke’s

encephalopathy• Myelopathy• Hyponatraemia• Labyrinthitis• Septicaemia

• Delirium• Hysteria• Spinal cord stroke• Chest pain!• Lung cancer• Phenytoin toxicity• Spinal cord

compression

Dr Peter Hand 2000-2001

Assessed 350 patients

(92% admitted through ARU)

18.6% were stroke mimics

4% Seizure

3% Tumour

2% Sepsis

2% Toxic/metabolic

Stroke Mimics 2000

• Syncope• Delirium• Vestibular dysfunction• Mononeuropathy• Medically unexplained• Dementia• Migraine

• Parkinson’s Disease• Spinal Cord Lesion• SAH• Transient global

amnesia

What are the key components to identify definite stroke from

stroke mimic?

Need to reflect on the definition of stroke and TIA

Stroke

A clinical syndrome characterized by rapidly developing clinical symptoms and/or signs of focal, and at times global (applied to patients in deep coma and those with subarachnoid haemorrhage), loss of cerebral function, with symptoms lasting more than 24 hours, or leading to death, with no apparent cause other than that of vascular origin.

Hatano 1976

Transient ischaemic attack (TIA)

A clinical syndrome characterized by an acute loss of focal cerebral or monocular function with symptoms lasting less than 24 hours and which is thought to be due to inadequate cerebral or ocular blood supply as a result of low blood flow, arterial thrombosis or embolism associated with diseases of the arteries, heart or blood.

Hankey & Warlow 1994

Advantages of stroke and TIA definitions

•Allows stroke incidence to be compared around the world (epidemiology)

•Ensures a common language (clinicians)

•Helps clinician identify certain non-stroke pathology (guides differential diagnosis)

Disadvantages of definitions of stroke and TIA

•The invention of CT scanning (1970’s) emphasised the heterogeneity of stroke (syndrome can be due to cerebral infarction, cerebral haemorrhage or subarachnoid haemorrhage)

•In the era of “time is brain” what do we call an attack, which has not resolved, assessed within 24 hours of onset?

•They are based on clinical assessment and in the era of modern technology have we not got a better objective method of assessment?

TIA: Ischaemic stroke continuum

Anything which causes a TIA, will, if prolonged cause a stroke.

Quantitatively, not qualitatively, different

Duration of attack and percentage of patients with a

relevant infarct on CT

0

5

10

15

20

25

30

35

40

45

50

% of patients withinfarct on CT scan

1-30

min

31-6

0min

1-4

hou

rs

5-24

hou

rs

1-7

day

s

1-6

wee

ks

Per

sist

ing

Duration of symptoms

Koudstaal et al 1992 JNNP;55:95

The History

Strokes are common in old people with vascular disease

How old are they?

If young (<60 years old) have they premature vascular disease or have they an unusual cause of stroke (e.g. a right to left shunt from patent foramen ovale)

Have they got vascular disease?

Previous heart attacks, diabetes, hypertension, previous stroke or TIA, high cholesterol?

Were they previously well?

The History: exclude mimics

• Transient loss of consciousness suggests seizure or cardiac disease

• Dementia makes all diagnoses difficult

• Have you got a source of history from another person?

The Examination

• Have they got signs of vascular disease (e.g. lost pulses, heart murmurs, carotid bruits, hypertension)?

• Have they got focal neurological deficits?

• Have they got sustained global neurological deficit e.g. coma?

Acute brain attack

Exclude: fits/migraine

Hypo-hyperglycaemia

Other metabolic causes

CT ScanExclude tumour /structural lesion Non-stroke pathology

Confirmed ischaemic brain attack

PICH, SAH, Subdural

Exclude:

intracranial bleed

Stroke IS an Emergency!

Stroke is a “Brain Attack”

Brain Attack is an emergency

“Time is Brain”

The Brain Attack Team: the need for investment• Ambulance Service

• Casualty Dept

• Radiology/Neuroradiology/Physicians/Radiographers

• Acute stroke units

• Pharmacy & Laboratory

• Large RCT’s

• Admissions

• Administration

• Public Relations/CommunityEducation

AMBULANCEAMBULANCE

Confirmed ischaemic brain attack

TIAAre the symptoms/signs resolving rapidly?

Yes

No

Are the symptoms/signs disabling?No

Treat like TIA

Yes

Consider more intensive treatment

Summary

Definitions of TIA and Stroke a bit out of date

The new paradigm of Brain Attack may be useful

There are many non-cerebrovascular causes of brain attack

Question 1

Mrs X 78 years old

Perfectly well until day of presentation

Wife noticed that he was “not himself”

Collapsed and brought into A&E dept

Was noted to be aphasic (language problem) and right sided weakness

Then had an epileptic fit

CT scan

CT scan

Showed a problem in the appropriate hemisphere

Interpreted as being early ischaemia

Admitted to stroke unit

Developed status epilepticus

Is this a stroke?

CT scan reviewed

Odd swollen appearance

Possibly herpes simplex encephalitis

Despite anticonvulsants, and anti-viral therapy, patient died.

Post mortem showed...

Post mortem examination

Gliomatosis cerebri

Brain tumour cells found throughout entire brain

Did eventual tumour mass cause electrical instability?

Lesson

A common mimic of “stroke” in emergency medicine is brain tumour (a cause of about 3-5% of all initial “stroke” diagnoses).

Clues: CT scan appearance very atypical for stroke

Status epilepticus rare after acute stroke

Question 2: Mr Y

A 72 year old lady with known bladder cancer (transitional cell carcinoma) presents with mild left sided weakness.

CT scan

What’s the diagnosis?

What’s the diagnosis?

Right frontal lesion is a primary intracerebral haemorrhage stroke

The left frontal lesion is an incidental meningioma

Lessons

Stroke affects older people and co-morbidity is common

About 10% of all stroke is due to primary intracerebral haemorrhage

Pathology of stroke can now be reliably established by CT scanning done within hours/days of the event

Cerebral infarction 80%

Primary intracerebral haemorrhage 10%

Subarachnoid haemorrhage 5%

Unknown 5%

Sudlow & Warlow 1997

Systematic review of world-wide incidence studies

Question 3

64 year old man was driving his car and he suddenly lost power in his right arm and leg

He had no headache

No loss of consciousness

Called for help and son brought him to casualty

No significant medical history

On examination

Looked well

Blood pressure 200/120 mmHg

Normal language

Slurred speech

Complete weakness affecting his right face, arm and leg

No hemianopia

Is this a stroke?

Yes! Due to a Lacunar Infarction

Question 4: 85 year old lady

Presents with a sudden onset of dizziness and headache

On examination she had nystagmus

Six hours after admission started to complain of worsening headache

24 hours later was unconscious

Is this a stroke?

Yes! A cerebellar

haemorrhage with acute

hydrocephalus

Question 5Mrs X 69 years old

Developed Right hemiparesis and aphasia during breakfast (9am)

Husband called GP and sent immediately to A & E department

Severe (0/5) right face, arm and leg weakness

Dyspraxia (disorganised movement of body)

Aphasic (no understanding or expression of language)

Is this a stroke?

Is this a stroke?

Yes! Dense MCA sign indicating thrombus in the left MCA