Clinical presentation and diagnosis Stroke and TIA

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Clinical presentation and diagnosis
Stroke and TIA

• Diane Ames
• Cons Stroke Physician
• Imperial College

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Format

• Definitions
• TIA clinical features and mimics
• Differential diagnoses
• Stroke clinical features and mimics
• Differential diagnoses

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Classic TIA definition

• A clinical syndrome
• Acute loss of focal cerebral or monocular
  function
• Symptoms last lt 24 hours
• Due to inadequate cerebral or ocular blood supply

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Aetiology of TIA

• Results from
• Low blood flow from
• Arterial thrombosis or embolism assoc with
• disease of arteries, heart or blood
• Note
• Stroke risk following a TIA is maximal at 7-14
  days

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Controversies

• 24 hour time cut-off is arbitory
• Majority of TIAs last much lt 60 minutes
• Some/not all TIAs show radiological evidence of
  cerebral infarction
• Proposals for imaging-based diagnosis but

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Common clinical features of TIA

• Unilateral weakness, clumsiness, heaviness of
• One, both limbs or just hand
  50
• Unilateral sensory loss
• numbness, tingling, dead
  35
• Speech loss - dysarthria
  23
• - dysphasia
  18
  
  
• Transient monocular blindness, blurring
  18

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Less common clinical symptoms

• Unsteadiness 12
• Vertigo
  5
• Homonymous hemianopia 5
• Diplopia
  5
• Bilateral Limb weakness 4
• But NOT in isolation..

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May see emboli in absence of clinical signs
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Symptoms in isolation

• Imbalance
• Simultaneous bilateral weakness
• Slurred speech
• Rotational vertigo
• Double vision
• A sensation of movement
• Do not necessarily indicate focal ischaemia
  (without a relevant CI or PICH or additional
  focal symptoms.)

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Non- focal symptoms

• Faintness
• Dizziness
• Very rarely due to focal cerebral ischaemia
• More likely due to
• Syncope
• Non-vascular causes eg drugs

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Symptom duration

• If symptoms last gtone hour , complete recovery
  likely to take gt 24 hours
• Recurrent stroke more likely
• Sensory symptoms lasting lt 1 minute unlikely to
  support diagnosis of TIA
• ?minimum duration for TIA 10 mins? but
• Symptoms of retinal ischaemia may be very
  short-lived

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Risk stratification- in the 7 days after TIA

• High risk ABCD2 score of 4 or
• Crescendo TIAs (2 or more TIAs in a week)
• Treat with aspirin and investigate within 24
  hours
• Low risk score of 3 or less
• Treat with aspirin and investigate within 7 days
• NICE, RCP and
  HfL performance Indicator

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ABCD2 score
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Reconstructed CTA showing Carotid stenosis at
bifurcation
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Differential Diagnoses of TIAs

• Other causes of sudden and focal ischaemia
• Migraine with aura
• Metabolic- especially hypoglycaemia
• Partial seizures
• Structural intra-cranial abnormality
• Labyrinthine disorders (Menieres or BPV)
• Peripheral nerve /c.spine lesions
• Demyelinating disease
• Psychological

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Non-vascular diagnoses OXVASC
2002-2004

• Migraine 25
• Anxiety 14
• Seizure 9
• Periph Neuropathy 8
• Arrhythmia 6
• Labyrinthine 6

• Postural hypotension 6
• TGA 6
• Syncope 5
• Tumour or mets 4
  
• C Spine disease 3

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Cervical arterial dissection

• Not uncommon
• Carotid or vertebral
• After neck injury, extension, manipulation,
  hairdressers
• P/w pain neck, side of head
• Horners?

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Headaches TIAs ?

• Mild headache is common 1/6 TIAs
• Usually ipsilateral to affected carotid territory
• Most common in posterior territory TIAs
• Note haemorhagic TIAs are rare but do exist

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Headache bilateral - TIA unlikely
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Epidemiology

• 20 strokes preceded by TIA Rothwell Warlow
  2007
• OXVASC 2005, n 91,000
• Stroke incidence 2.3/1000
• Definite TIAs, incidence 0.5/1000
• But TIA referral rates 3.0/1000 (mimics)
• Incidence of cerebro-vascular events similar to
• acute vascular coronary events Rothwell et
  al 2005

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Risk Factors for ischaemic stroke or TIA

• Non- modifiable
• Age
• Sex
• Race
• Previous stroke or TIA
• Modifiable
• Life style factors
• Social deprivation
• Obesity, diet, exercise, alcohol, smoking

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Risk Factors for ischaemic stroke or TIA

• Hypertension
• Diabetes
• Atrial Fibrillation
• IHD and LV dysfunction
• Valvular HD,PAD
• Invasive procedures/post surgery
• Embolic sources- carotid stenoses, PFO
• Dyslipidaemia

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Other vascular risk factors

• Thrombophilias
• Chronic infections retroviral disease
• Hyper viscosity malignancies
• Vasculitidies
• Sickle cell
• Recreational drugs
• Genetic

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Localisation
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Vascular territory

• 80 carotid 20 vertebro-basilar
• Implications for Ix and secondary prevention
• Often difficult to differentiate as motor
  sensory symptoms supplied by both systems
• DW MRI very helpful when positive

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From a PFO
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Causes of transient monocular loss

• Include
• TIA
• Glaucoma
• Raised ICP
• Retinal haemorrhage/detachment/venous thrombosis
• Intra-orbital tumour
• We have all ours seen at Western Eye Hospital

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Posterior circulation symptoms

• Vertigo
• Diplopia
• Dysphagia
• Unsteadiness
• Tinnitus,
• Dysarthria
• Drop attacks

• Usually need 2 symptoms
• to localise to POC
• Mimics common here
• MRI very helpful to aid differentiation

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Clinical signs of TIA

• Often non-existent when examined
• History important
• More commonly seen earlier with FAST/999 calls
• Retinal emboli, cardiac dysrhythmias, PVD may
  help elucidate the cause

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Gold standard

• No confirmatory test for TIA
• Neither on imaging or blood tests
• Gold standard is a thorough assessment by
  experienced physician asap after event

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Diagnostic Clues for TIA?
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Some diagnostic clues

• TIAs largely negative symptoms
• Good careful history essential
• Seizures positive motor symptoms
• Migraines positive visual spectra
• Tumours stuttering onset
• Syncope non-focal (LoC)
• Course fluctuating with tumour

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Summary - TIA

• Negative symptoms
• Abrupt onset, maximal in few seconds
• Antecedent headache, nausea unusual (unless neck
  pain)
• Few signs
• Frequent stereotyped attacks more likely to be
  seizures

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RCP guidelines 2008

• Consider any patient p/w transient neurological
  symptoms of CV nature to have had a TIA
• All suspected TIAs require (ABCD 2) within 24
  hours
• All high risk (ABCD 2 risk4 or gt )should receive
  aspirin 300mg immediately and specialist
  assessment and investigation in 24 hours
• 24/7 pathways available pan London

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Clinical features and diagnosis of acute stroke
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Blurred vision

• 57 year civil servant
• Unable to see PC
• Went to WEH. Eyes fine . Referred SMH
• CT scan occipital stroke ( FAST Negative!)
• Ventricular standstill.
• PPM inserted

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Stroke diagnostic criteria

• A clinical syndrome
• Rapidly developing clinical symptoms
• Focal or sometimes global loss(e.g. deep coma)
  of brain function
• Loss of cerebral function
• Symptoms last gt 24 hours or leading to death
• Of apparent vascular origin

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General comments

• Often fairly straight foward diagnosis
• BEWARE mimics errors have consequences
• Localisation of site helps with targeting
  investigation
• Clues from accurate history and examination
• Care to identify potential non-vascular cause

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Stroke onset/progress

• If focal neurological deficit of sudden onset or
  on waking stroke diagnosis likely
• If time of onset unknown cannot thrombolyse
• May progress over minutes or hours especially
  POCS
• Deficit usually stabilises over 12-24 hours, if
  patient survives
• Recovery starts usually in a few days

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Diagnosis uncertain
Beware

• Fever
• Headaches, seizures, deficit worsening over days
• Head injury, falls
• On warfarin, especially with alcohol history
• Known primary tumour elsewhere
• Peripheral nerve lesion and pain
• Neck injury neck pain

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Misses occipital strokes and those with leg
weakness
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Recognition of stroke Rosier
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Differential diagnosis of acute stroke

• HT encephalopathy
• Head Neck injury
• Peripheral Nerve lesion
• MS
• Psychogenic
• abscess, viral encephalitis

• Subdural haematoma
• Epileptic seizure
• Metabolic
• Syncope
• Systemic Sepsis
• Structural intracranial lesion

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Top 5 differential diagnoses of
Stroke TIA

• The 5 Ss
• Seizure
• Syncope
• Sepsis
• SDH
• Somatization

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Mimics.. In an alcoholic
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After a fall , patient on warfarin but had been
to pub!
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The ideal rapid stroke pathway

• Detection -recognition of stroke
• Dispatch -call 999 priority LAS
• Delivery -prompt transport pre-hospital
  notification
• Door - Immediate triage
• Data - Assessment, bloods, imaging
• Decision - Diagnosis decision re therapy
• Drug - Appropriate drug/other
  intervention
• Adams et al. AHA Guidelines Stroke
  2007381655-1711

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Why the rush?- ischaemic penumbra
Core of dead tissue
Poorly perfused penumbra
Ischaemic /poorly perfused brain cells may be
saved from
infarction by prompt treatment
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Favourable outcome at 3/12(i.e. Modified
Rankin 0 or 1, pooled ATLANTIS, ECASS
NINDS
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Thrombolysis

• Alteplase via i/v route
• On-licence
• Patients who meet inclusion criteria and are able
  to receive treatment lt 3 hours on licence
• In trial
• lt 6 hours IST-3
• Highly effective (only 10 people need to be
  treated to prevent 1 becoming dead or disabled)

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Stroke clinical classification

• Total anterior circulation syndrome TACS
• Partial anterior circulation PACS
• Lacunar Syndrome LACS
• Posterior circulation syndrome POCS
• Gives some prognostic information based on
  territory

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TACs

• Usually caused by large infarct (or haemorrhage)
  affecting large proportion of MCA territory
• Findings
• Contralateral hemiparesis
• An homonymous visual field defect
• Cortical deficits (dysphasia, neglect or
  visuo-spatial problems)

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Massive TACS 47 year male RF
Hypertension Developed Malignant
MCA Hemicraniectomy
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Post surgery Malignant MCA syndrome
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PACS

• More restricted than TACS
• Clinically any two of TACs features or
• Isolated cortical deficits eg dysphasia
• Cause is often cardioembolic and thus risk of
  recurrence
• Investigate quickly

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Haemorrhage in (L) MCA territory
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Lacunar syndromes LACS

• Usually small, deep lesions secondary to
  hypertension
• Clinical features include deficits of
• Pure motor deficit - 2 or 3 of face, arm, leg
• Pure sensory deficit -
  
• Sensorimotor deficit -
  
• Ataxic hemiparesis- clumsy hand syndrome

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(L) hemispheric lacune
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POCS

• Brainstem,cerebellar,occipital lobe thalamic
  signs
• Motor/or sensory cranial nerve palsies
• Bilateral motor/or sensory deficits
• Loss of conjugate gaze
• Isolated hemianopia or cortical blindness

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Large occipital infarction
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Cerebellar syndromes

• Mild sudden vertigo, nausea, imbalance and
  horizontal nystagmus
• More extensive ipsilateral weakness truncal
  ataxia
• Very Severe headache, vomiting, reduced
  conscious level
• Urgent imaging is mandatory
• Risk of hydrocephalus
• Can miss if you dont check gait!

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Cerebellar Infarct 50 year female RF
Hypertension
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Thalamic strokes

• Variety of syndromes according to nuclei affected
  and vascular territory.
• Sensory/sensori-motor /-ataxia
• Paralysis of upward gaze, small pupils, reduced
  consciousness,hypersomnolence
• Often p/w acute onset behavioural disturbances

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(L) Thalamic stroke Light-bulb sign on DW MRI
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Haemorrhagic strokes

• Clinically indistinguishable from infarcts
• Always consider when on warfarin
• When p/w acute headache esp with nausea/vomiting
  posterior symptoms
• Cerebellar haemorrhages maydevelop hydrocephalus

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These scans were 3
hours apart
What drug was he taking?
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52 year lady Old (L) haemorrhage MCA aneurysm
on
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Diagnostic considerations

• Gradual onset unusual
• Head neck trauma?
• Headache 25, mild, localised to lesion site
• Early seizures are unusual
• If impaired consciousness but only mild focal
  loss- stroke less likely
• Chest pain/ECG changes and focal loss -
• 5-10 strokes/concurrent MI
• Care when on warfarin

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Thank you
Primary prevention remains best strategy