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