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Approachtostrokepa-ent!
SuratTanprawate,MD,FRCPT(T)NorthernNeuroscienceCenter
ChiangmaiUniversity!
www.neurologycoffeecup.com
Outlineapproachtopa-ent !Suddenonsetofneurologicaldeficit!
StrokeVSStrokemimicker!
Suspectedstroke!
StrokemimickerTumorInfec-on!
Stroketype!
Ischemicstroke! Hemorrhagicstroke!
PrimaryVSSecondary
Hemorrhagicstroke!
StrokesubtypebyTOAST
classifica-on
Localiza-onoflesion !
Strokemimicker!
13%ini-allydiagnos-cstroke
wasstrokemimicker
Misdiagnosisofstroke:Lancet,1982;1:328‐331!
Unrecognizedseizure!
Syncope!
Toxicandmetabolicdisorder!
Subduralhematoma! Tumor!
Confusionstate!
“strokelocaliza.on:vasculardistribu.onoftheischemiclesion”!
AnteriorVSposteriorcircula-ostroke!
Anteriorcircula-onstroke!
Posteriorcircula-onstroke!
Infarc-onVSHemorrhage!
• SomecluesfromHx.AndPE• ICH
– Comaonarrival
– Vomi-ng– Severeheadache– Currentwarfarintherapy– SBP>220mmHg– Glucoselevel>170mg/dLinnon‐diabe-cpa-ent
Stroke1981;12:288‐293ArchInternMed1985;145:1800‐1803!
Classifica-onofischemicstroke“TOASTclassifica-on”!
1. Largearteryatherosclerosis2. Cardioembolism
3. Smallvesselocclusion
4. Strokeofotherdeterminede-ology
5. Strokeofundeterminede-ology!
Problem list
1. Acute onset quadriparesis with urinary incontinence 2. Previous episode of transient right hemiparesis 3. Decreased bilateral carotid pulsations 4. Bilateral frontal lobe signs 5. Left parietal cortical impairement
(astereognosis, agraphia) 6. Right UMN VII 7. Bilateral pyramidal weakness 8. Bilateral babinski response
Old R frontal lobe infarction Anterior watershed infarction at left frontal and parietal lobes
Normal
Border-zone ischemia
Ischemia at center of bl supply
Anterior watershed
Posterior watershed
Subcortical watershed
Anterior Watershed Infarction
Moyamoya-“like” disease = “Puff-Of-Smoke”!
Bilateral occlusion of internal carotid arteries
⇒ Fine collateral arteries
Children ⇒ Alternating hemiplegia
Adults ⇒ Subarachnod haemorrhage !
Thankyouforyouraden-on
www.neurologycoffeecup.com