Brain attack! Is it a Stroke?

1. Brain attack! Is it a Stroke? Dr Richard I Lindley Consultant Geriatrician Part-time Senior Lecturer richard.lindley@ed.ac.uk

2. How accurate is the diagnosis of stroke typically made by the doctor in the Emergency Room? • 50% • 60% • 70% • 80% • 90% • 95%

3. How accurate is the diagnosis of stroke typically made by the doctor in the Emergency Room? • 50% • 60% • 70% • 80% • 90% • 95%

4. 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

5. Migraine TIA Wernicke’s encephalopathy Myelopathy Hyponatraemia Labyrinthitis Septicaemia Delirium Hysteria Spinal cord stroke Chest pain! Lung cancer Phenytoin toxicity Spinal cord compression Other mimics

6. 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

7. Syncope Delirium Vestibular dysfunction Mononeuropathy Medically unexplained Dementia Migraine Parkinson’s Disease Spinal Cord Lesion SAH Transient global amnesia Stroke Mimics 2000

8. What are the key components to identify definite stroke from stroke mimic? Need to reflect on the definition of stroke and TIA

9. 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

10. 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

11. 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)

12. 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?

13. TIA: Ischaemic stroke continuum Anything which causes a TIA, will, if prolonged cause a stroke. Quantitatively, not qualitatively, different

14. Duration of attack and percentage of patients with a relevant infarct on CT Koudstaal et al 1992 JNNP;55:95

15. 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?

16. 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?

17. 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?

18. Acute brain attack Exclude: fits/migraine Hypo-hyperglycaemia Other metabolic causes Exclude tumour /structural lesion CT Scan Non-stroke pathology Exclude: intracranial bleed Confirmed ischaemic brain attack PICH, SAH, Subdural

19. Stroke IS an Emergency! • Stroke is a “Brain Attack” • Brain Attack is an emergency • “Time is Brain”

20. AMBULANCE AMBULANCE 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/Community Education

21. Confirmed ischaemic brain attack Yes Are the symptoms/signs resolving rapidly? TIA No No Are the symptoms/signs disabling? Treat like TIA Yes Consider more intensive treatment

22. 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

23. 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

25. 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?

26. CT scan reviewed Odd swollen appearance Possibly herpes simplex encephalitis Despite anticonvulsants, and anti-viral therapy, patient died. Post mortem showed...

27. 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

28. Question 2: Mr Y A 72 year old lady with known bladder cancer (transitional cell carcinoma) presents with mild left sided weakness. CT scan

30. What’s the diagnosis?

31. 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

32. 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

33. 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

34. On examination Looked well Blood pressure 200/120 mmHg Normal language Slurred speech Complete weakness affecting his right face, arm and leg No hemianopia

35. Is this a stroke?

36. Yes! Due to a Lacunar Infarction

37. 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?

38. Yes! A cerebellar haemorrhage with acute hydrocephalus

39. Question 5 Mrs X 69 years old Developed Right hemiparesis and aphasia during breakfast (9am) Husband called GP and sent immediately to A & E department

40. Severe (0/5) right face, arm and leg weakness Dyspraxia (disorganised movement of body) Aphasic (no understanding or expression of language)

41. Is this a stroke?

42. Is this a stroke? Dense MCA sign indicating thrombus in the left MCA Yes!