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8/2/2019 Stroke & Limb Weakness
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Stroke
Stroke occurs suddenly. If there is a second stroke, always worry about
haemorrhage. If there is dizziness, the brain stem/cerebellar may be
affected. Most of blood supply goes to the middle cerebral artery.
Stroke + Nausea + Vomiting usually come together.
Normally, if the stroke affects the frontal lobe, it will cause personality
changes.
If the patient complains of palpitation, think about Atrial Fibrillation. Why?
Without proper contraction, blood pools in the heart and thrombus forms.
The thrombus from the heart could travel to the brain and cause a blockage
leading to ischemic stroke. Hence, Atrial Fibrillation is a risk factor.
Depression may occur in these patients too.
In a stroke patient, always ask Does he have Atrial Fibrillation? Then,
investigate for:
1. FBC: RBS (Polycythemia), Platelet (Thrombocytopenia causes
bleeding tendencies/haemorrhage)
2. Lipid profile (Hyperlipidimia is a risk factor)
3. Glucose
4. ECG
5. Chest X-Ray (Cardiomegaly in long standing Hypertension)
6. CT Scan (Differentiates between an ischemic and haemorrhagic
stroke)
7. Echocardiography (Infective Endocarditis will show mural thrombus)
8. ESR
In a young stroke patient, investigate for:
1. FBC: RBC (Anemia, morphology)
2. Anti-phospholipid Antibody syndrome (in recurrent spontaneous
abortion)
3. Autoimmune diseases (Takayashu, SLE, Vasculitis)
4. Echocardiography: Transthoracic or Transoesophageal (Infective
Endocarditis, Paradoxical Embolism, Patent Foramen Ovale which hasa Right-to-Left Shunt)
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5. Thrombophilia
20%: Hemorrhagic Stroke
80%: Ischemic Stroke
1. Large Vessel Disease
2. Small Vessel Disease (Lacunar infarcts)
3. Cardioembolic
4. Others
For physical examination:
Also, look for signs of Infective Endocarditis such as splinter
haemorrhages, Oslers nodes, Janeways lesion; and signs of
Hyperlipidemia such as Tendon Xanthomata and Xanthelesma.
If there is a stroke patient, ALWAYS LISTEN FOR BRUIT!!! A carotid
bruit is suggestive of cardiac emboli.
If there is Right-sided weakness of upper and lower limbs, then there is
Right-sided weakness of the face and Right Hemianopia.
Asses Cranial Nerve
- 2: Visual field
- 7: Bells palsy
- 9 + 10: Swallowing and speech
It is difficult to diagnose whether it is a hemorrhagic or ischemic stroke
from the history. Although, it is more common that patients with
hemorrhagic stroke would complaint of a sudden onset of severe headachewith very high blood pressure.
Stroke should be differentiated from Stokes-Adam Attack which is syncope
due to cardiac arrhythmia, most commonly transient complete heart block,
and resulting in severe bradycardia or asystole with hypotension due to
decreased cardiac output. It is otherwise known as drop attacks.
Stroke affects both motor and sensory systems.
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Limb Weakness
53 y.o. man presents with progressive weakness x 3 weeks. Associated
symptoms are cramps and swallowing difficulty.
P.E. shows:
- Muscle wasting
- Fasciculations
- Tone: Normal
- Power: 4/5
- Reflexes: Hyperreflexia
- Plantar extension: Positive
- Sensory: Normal
Differential Diagnosis: Myasthenia Gravis
- It is also a cause of ptosis (do H-Test, opposite direction from lid lag)
- The patient cannot sustain and upward gaze.
ALS (Amyotrophic Lateral Sclerosis)
Motor Neuron Disease characterized by generalised weakness instead
of proximal muscle weakness. ALS has a poor prognosis as there is no
treatment. Most patients die due to respiratory failure. They also
have the inability to swallow.
Mixture of UMNL and LMNL
presentation
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Lesion PresentationSpinal cord lesion Sensory lossMultiple sclerosis UMNL/ Cerebellar may have
sensoryALS Both UMNL and LMNL
These presentations can be mimicked by:
1. Cervical Myelopathy
2. Malignancy
Proximal Weakness (Can be detected by asking patient to squat and stand
multiple times)
1. Myasthenia Gravis (Differential: Eaton-Lambert)
2. Hereditary (Rare)
3. Endocrine: Hypothyroid, Cushings Disease
4. Autoimmune: Polymyositis (Especially in young females, investigate
Creatine Kinase), Dermatomyositis (Rash together with weakness)
5. Malignancy: Paraneoplastic
6. Hypokalemia
Parkinsons Disease
Motor Signs
1. Resting tremor
2. Mask-like facies - No expression and face does not move
3. Speech Soft, monotonous
4. Gait Shuffling gait with stooping posture, difficulty in stopping and
turning, there is a freeze before the turn and there is no arm
swinging.
5. Decreased tone cogwheel / lead pipe rigidity
6. Glabela test multiple blinks with each tap on the forhead
7. Micrographia
8. Postural instability
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Non-motor Signs
1. Neuropsychiatric : Dementia, Depression, Anxiety
2. Autonomic disturbances: Constipation, Postural hypotension,
sweating,
decreased urination