Describe the methods and findings for techniques used to investigate arterial disease,
to include Doppler pressure measurements, Arteriograms and Duplex
scanning. Describe the methods and findings for investigations used to investigate venous disease and lymphatic disease.
Doppler Pressure Measurements Finds blood pressure by using a Doppler probe The blood pressure cuff is inflated proximal to the artery in question and the Doppler is used on a distal artery Same as normal blood pressure but a Doppler probe instead of stethoscope Systolic blood pressure on lower limb of <50mmHg indicates critical ischaemia
Arterial/Brachial Pressure Index (ABPI) It is a measurement of the cuff pressure at which blood flow is detectable by a hand held Doppler in the posterior tibial or anterior tibial arteries compared to the brachial artery. Blood pressure cuff is applied to the calf and the pressure where you hear the Doppler as you release the cuff is the value Normally the ABPI should be more than 1.0 and systolic pressure in the ankle being equal or greater than the pressure in the arm The ratio decreases if severity is worse
No peripheral arterial disease >1.0 Mild to moderate (intermittent claudication) 0.5-0.9 Severe (critical limb ischemia) <0.5
The sensitivity of the test may be improved with a fall in ABPI after exercise. If the arteries are heavily calcified and incompressible i.e. in renal or diabetic disease the ABPI may be falsely elevated. In these patients, a toe pressure value is more sensitive.
Duplex ultrasound Uses B-mode ultrasound and colour Doppler Useful for mapping out both arterial and venous flow Provides an accurate anatomical map of the lower limbs with sensitivity of 87% and specificity of 94% compared to angiography but this is operator dependent
Arteriography (Angiography) X-ray Digital Subtraction Angiography (DSA) MRI Magnetic Resonance Angiography (MRA) CT Computed Tomographic Angiography (CTA)
Digital subtraction angiography (DSA) Provides an arterial map But requires peripheral arterial cannulation and exposes the patient to iodinated contrast This should be reserved for patients immediately prior to intervention 3-D contrast enhanced MR angiography (MRA) Provides excellent imaging of both legs with a single contrast injection without exposure to ionizing radiation Sensitivity of 97% and specificity of 96% CT angiography (CTA) Effective alternative to MRA although extensive calcification may obscure stenosis CTA requires ionizing radiation and iodinated contrast media
What are the main stroke mimics and how do you differentiate them from true cerebrovascular disease
Ischaemic Stroke Symptoms occur suddenly Patients would not exhibit GI symptoms or headache typically CT or MRI for an ischaemic infarct would appear as a hypoattenuation (darkness) many do not appear for many hours after stroke onset
Intracerebral Haemorrhage No symptoms or signs reliably distinguish haemorrhagic stroke from ischaemic stroke Haemorrhagic stroke is more often associated with reduced level of consciousness and signs of increased intracranial pressure than ischaemic stroke CT or MRI demonstrates haemorrhage with hyperattenuation (brightness)
Transient Ischaemic Attack Neurological symptoms last less than 24 hours with no evidence of acute infarct CT or MRI may be normal or may reveal evidence of older infarcts
Complicated Migraine Repetitive history of similar events preceding aura, headache in a marching pattern differentiates complicated migraine Stroke often presents with negative symptoms (e.g. visual loss, numbness or weakness) Positive symptoms (e.g. marching paraesthesias, visual hallucinations and abnormal motor manifestations) are more likely with complicated migraine MRI shows no evidence of infarction
Conversion and Somatisation Disorders Mental factors that cause physical or neurological symptoms Neurological signs and symptoms do not fit a vascular territory No cranial nerve deficits Conversion disorder usually displays multiple signs that are neurologically inconsistent CT or MRI shows no evidence of infarction or haemorrhage
Seizure (Todds Palsy) and Postictal Defects Postictal defect An altered state of consciousness after an epileptic seizure Todds Palsy Weakness and paralysis (commonly of face and arms) following a seizure and can last up to 48 hours. History of seizures or a witnessed seizure followed by postictal deficits (e.g. drowsiness, tongue biting) Wrong way eye deviation (i.e. gaze deviates away form the side of the brain lesion, towards the hemiparetic side) should consider seizure but can also occur with stroke affecting the pons or thalamus EEG results may identify seizure activity MRI shows no evidence of infarction
Hypertensive Encephalopathy A neurological dysfunction induced by malignant hypertension caused by sudden and sustained severe elevation of arterial blood pressure Combination of headache, cognitive abnormalities or decreased level of consciousness and HTN significantly above patients baseline BP Other signs/symptoms include visual changes or loss, or signs of increased intracranial pressure Less frequently these patients present with focal abnormalities in neurological examination CT or MRI shows cerebral oedema
Multiple Sclerosis Chronic disease that affects the CNS (it is thought to be autoimmune). The immune system produces antibodies that attack myelin. Sudden onset of generalised or focal neurological deficit resembling a TIA is often the first presentation of multiple sclerosis Symptoms are short in duration and occur progressively frequently
Trauma Can present with neurological deficit No vascular pattern Inconsistencies No findings of investigations
Structural Lesions
Subdural Haematoma Collection of clothing blood that forms in the subdural space o Acute SDH o Subacute SDH (begins 3-7 days after initial injury) o Chronic SDH (begins 2-3 weeks after initial injury)
Brain Tumour Symptoms and signs are more likely to have been on-going May be history of cancer if it is due to metastatic lesion CT head demonstrates lesion or lesions
Metabolic/toxic Syndromes
Sepsis General symptoms of nausea, vomiting, lethargy Symptoms of infection: fever, tachycardia, tachypnoea etc. Neurological deficit Important especially in the elderly to take a good history and blood tests can rule this out
Hypoglycaemia Low blood sugar There may be a history of diabetes with use of insulin or insulin secretagogues Sweating tremor, hunger, confusion and decreased level of consciousness Low serum glucose at time of symptoms
Hyponatraemia Sodium deficiency If a drop in sodium levels is sudden it can cause significant symptoms o Mild: Anorexia, headache, nausea, vomiting, lethargy o Moderate: Personality change, muscle cramps and weakness, confusing, ataxia o Severe: Drowsiness Neurological signs include cognitive impairment, focal or generalised seizures, decreased lelve of consciousness Serum sodium can rule this out
Hypocalcaemia Low calcium levels A rapid fall in levels can cause severe form of symptoms o Paraesthesia (usually fingers, toes and around mouth) o Tetany (seizure) o Dementia and confusing with prolonged hypocalcaemia Take fasting blood specimens to determine if patient is truly hypocalcaemic
Wernickes Encephalopathy Neurological symptoms caused by biochemical lesions of the CNS, after exhaustion of B-vitamin reserves particularly thiamine History of alcohol abuse Irritability, confusion and delirium are common presenting features Decreased blood thiamine level and successful therapeutic trial of thiamine