Stroke – acute hemiplegia

History

Sandeep Patel is a 75 year old retired lawyer who has been admitted to MAU following a sudden onset of left sided weakness 2 hours ago.

What differential diagnosis would you consider for this

patient?

What factors in the history would you seek to identify?

What factors in the history would you seek to identify?

1. Timing

2. Anatomy

3. Headache

4. Stroke aetiology

5. Risk factors

What would you seek from the examination?

What would you seek from the examination?

1. General examination

2. Cardiovascular examination

3. Neurological examination

4. Check for complications

How would you investigate?

How would you investigate?

1. Blood tests including clotting profile

2. ECG

3. Neuroimaging

4. Further imaging1. Echo

2. Carotid dopplers

Imaging

Imaging 2

Imaging 2

Call the neurosurgeons!

Pharmacological management (acute)

How might you manage this patient pharmacologically in

the acute phase of their illness?

How might you manage this patient pharmacologically in

the acute phase of their illness?1. Haemorrhagic stroke

2. Thromboembolic ischaemic stroke

Thromboembolic stroke

Are they suitable for thrombolysis?

Thromboembolic stroke

Are they suitable for thrombolysis?

May reduce those dead or with major disability if administered within 3 hours.

Thromboembolic stroke

Decreases mortality at 1 month by 1 %

How would you manage this patient pharmacologically after they have

recovered from the acute illness?

How would you manage this patient pharmacologically after they have

recovered from the acute illness?

Risk reduction!

1. Aspirin

2. Warfarin if AF

3. Statins whatever the cholesterol

4. BP control

Typical drug chart

Typical drug chart

What monitoring will he require?

General Advice

• Stop smoking – 33% reduction in further CVA

• Alcohol – drink a small amount

• Exercise

• Can drive after 1 month if they have made a recovery

TIA risk scoreRisk factor Category Score

A Age Age > 60

Age < 60

1

0

B BP SBP > 140 or DBP > 90

Other

1

0

C Clinical features

Unilateral weakness

Speech disturbance alone

Other

2

0

D Duration > 60 mins

10 – 59 mins

< 10 mins

2

1

0

E Diabetes Yes

No

1

0

Total

Score 4 or over – 30% chance CVA within 7 days

Score 5 or 6 – 50% chance of CVA within 7 days

Any questions?