8/10/2019 Differential Diagnosis of Stroke

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DIFFERENTIAL DIAGNOSIS OF STROKE

A patient presents with right sided hemiplegia????

Features Cerebral embolus Cerebral Thrombosis Intracerebral hemorrhage Primary subarachnoid

hemorrhage

Time of onset Can occur any time Usually occurs during sleep Usually occurs during activity Usually occurs during activity

(eg: sexual intercourse)

Onset Sudden Gradual (but patient may havehistory of previous TIA)

3

Sudden Sudden

Headache/vomiting - - Yes Yes (thunderstorm headache)

Loss of consciousness - - Yes 50% of cases

Signs of meningeal

irritation

- - Only if hemorrhage becomes

secondary SAH

Yes

Hypertension - Common Most important

predisposing factor

Common in old patients

Risk Factors/ Types Cerebral infarct:

Ophthalmic1, MCA, ACA, PCA,

Vertebrobasilar.

Risk factors:

i) Atrial fibrillation

ii) Recent M.I

iii) Vulvular heart disease (M.S)

iv) Infective endocarditis

v) Prosthetic valves

i) Lacunar Infarct:

Hypertension, diabetes,

hyperlipidemia

ii) Cerebral Infarct: MCA,

ACA, PCA, Vertebrobasilar

artery involvement

R.f: Diabetes, hypercoaguble

states, hyperlipedemia

i) Charchot bouchard

aneurysm (microaneurysms

in perforating vessels in

Hypertensive patients)

ii) Amyloid angiopathy

iii) Bleeding disorders

(Leukemia,

thrombocytopenia,

hemophilia, DIC)

iv) Anticoagulant therapy

v) Liver diseasevi) Substance misuse

(cocaine, alcohol,

amphetamine)

i) Rupture of berry aneurysm

ii) A-V malformation

iii) Trauma

Rupture of berry aneurysm

i) Hypertension

ii) Smoking

iii) Connective tissue disorder

(Marfan, Ehlor danlos)

iv) APKD

v) Neurofibromatosis-Ivi) Coartaction of aorta

Most common site MCA MCA Basal ganglia (putamen)

Other findings i) Atrial fibrillation

ii) Myocardial infarction history

iii) Vulvular heart disease (mitral

stenosis)

iv) Infective endocarditis

v) Carotid bruit

Carotid bruit Hypertensive retinopathy

may be there

May be history of Bleeding

disorders, Anticoagulant

therapy, alcoholism, liver

disease

i) Subhyaloid hemorrhage

ii) Hypertensive retinopathy

in older patients

iii) May have history of

Coartaction of aorta, Marfan

syndrome, Ehlor danlos

syndrome,Neurofibromatosis-I, Adult

polycystic kidney disease

Compiled by: SHAHERYAR ALI JAFRI Ref: D/D by Shabbir nasir, CMDT, Kaplan

8/10/2019 Differential Diagnosis of Stroke

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Features Cerebral embolus Cerebral Thrombosis Intracerebral hemorrhage Primary subarachnoid

hemorrhage

CSF analysis Normal Normal Normal until unless there is

secondary SAH

Hemorrhagic with

xanthocromia

Angiography Shows the site of obstruction i) Site of obstruction

ii) Carotid atheroma may be

seen

i) Aneurysm/ Charcot

bouchard

ii) AV malformation may be

seen

Berry aneurysm may be seen

in young patients and

bleeding point can be

recognized.

Treatment i) Immediate

As needed

ii) Primary

t-PA within 3 hours

iii) Secondary

a) Aspirin or Dipyridamole

b) Anticoagulants esp if embolus

was of cardiac source

Immediate

As needed

i) Primary

t-PA within 3 hours

ii) Secondary

Aspirin (24 hours after t-PA)

If allergic: give Dipyridamole

i) Immediate

ABC/ IV line/ Foley

catheter

Lower blood pressure

(MAP=130), reduce ICP.

ii) Primary

Surgical evacuation of

hematoma

iii) Secondary

Seizure prophylaxis,

steroids for cerebral edema,Treat the underlying

disorder, I/V recombinant

factor VIII.

i) Immediate

ABC/ IV line/ Foley

catheter, lower blood

pressure, reduce ICP

ii) Primary and Adjuvant

Nimodepine,

ii) Secondary

Surgical clipping and coiling

to prevent re-bleeding then

Give i/V fluids to make I/V

volume expansion andprevent vasospasm., VP

shunting for hydrocephalus,

Oral / iv NaCl to compensate

renal salt wasting

Note:

1. Occlusion of ophthalmic artery (Central retinal artery) by thrombus is not clinically significant b/c of collaterals but embolus to ophthalmic

artery can lead to unilateral TIA called Amaurosis fugax.2. Embolus is sudden whereas thrombus is gradual b/c as long as thrombus is enlarging, collaterals are developing.

3. TIA: It is a transient neurological deficit due to vascular insufficiency which completely recovers within 24 hours. 90% cases are due to

embolism. Usual duration is few minutes. Amaurosis fugax is one of its type which causes Transient unilateral painless loss of vision.

TIA may be a warning sign that stroke is gonna happen. Esp a Thrombotic event in future (remember: although 90% TIA is an embolic event)

4. COMA: Infarction in either the carotid or vertebrobasilar territory may lead to loss of consciousness.

5. Most accurate test to detect Cerebral Ischemia is Diffusion weighted MRI.

IMMEDIATE INVESTIGATION: CT-scan without contrast

LABS/Tests for Ischemic stroke: CBC, ESR, BSR, TEST FOR SYPHILIS, LUPUS ANTICOAGULANT, LIPID PROFILE, ECG, BLOOD CULTURE (if I.E),

Echocardiography, Holter monitoring (If arrhythmias ) , Bubble study Echo to detect Patent foramen ovale LABS/Tests for hemorrhagic stroke:

CBC, ESR, BSR, PT, apTT, Bleeding time, LFTs, RFTs.

Compiled by: SHAHERYAR ALI JAFRI Ref: D/D by Shabbir nasir, CMDT, Kaplan