DIFFERENTIAL DIAGNOSIS OF STROKE

A patient presents with right sided hemiplegia????

Features Cerebral embolus Cerebral Thrombosis Intracerebral hemorrhage Primary subarachnoid

hemorrhage
Time of onset Can occur any time Usually occurs during sleep Usually occurs during activity Usually occurs during activity
(eg: sexual intercourse)
Onset Sudden Gradual (but patient may have Sudden Sudden
3
history of previous TIA)
Headache/vomiting - - Yes Yes (thunderstorm headache)
Loss of consciousness - - Yes 50% of cases
Signs of meningeal - - Only if hemorrhage becomes Yes
irritation secondary SAH
Hypertension - Common Most important Common in old patients
predisposing factor
Risk Factors/ Types Cerebral infarct: i) Lacunar Infarct: i) Charchot bouchard i) Rupture of berry aneurysm
1
Ophthalmic , MCA, ACA, PCA, Hypertension, diabetes, aneurysm (microaneurysms ii) A-V malformation
Vertebrobasilar. hyperlipidemia in perforating vessels in iii) Trauma
Hypertensive patients)
Risk factors: ii) Cerebral Infarct: MCA, ii) Amyloid angiopathy Rupture of berry aneurysm
i) Atrial fibrillation ACA, PCA, Vertebrobasilar iii) Bleeding disorders i) Hypertension
ii) Recent M.I artery involvement (Leukemia, ii) Smoking
iii) Vulvular heart disease (M.S) R.f: Diabetes, hypercoaguble thrombocytopenia, iii) Connective tissue disorder
iv) Infective endocarditis states, hyperlipedemia hemophilia, DIC) (Marfan, Ehlor danlos)
v) Prosthetic valves iv) Anticoagulant therapy iv) APKD
v) Liver disease v) Neurofibromatosis-I
vi) Substance misuse vi) Coartaction of aorta
(cocaine, alcohol,
amphetamine)
Most common site MCA MCA Basal ganglia (putamen)
Other findings i) Atrial fibrillation Carotid bruit Hypertensive retinopathy i) Subhyaloid hemorrhage
ii) Myocardial infarction history may be there ii) Hypertensive retinopathy
iii) Vulvular heart disease (mitral May be history of Bleeding in older patients
stenosis) disorders, Anticoagulant iii) May have history of
iv) Infective endocarditis therapy, alcoholism, liver Coartaction of aorta, Marfan
v) Carotid bruit disease syndrome, Ehlor danlos
syndrome,
Neurofibromatosis-I, Adult
polycystic kidney disease
Compiled by: SHAHERYAR ALI JAFRI Ref: D/D by Shabbir nasir, CMDT, Kaplan
 Features Cerebral embolus Cerebral Thrombosis Intracerebral hemorrhage Primary subarachnoid
hemorrhage
CSF analysis Normal Normal Normal until unless there is Hemorrhagic with
secondary SAH xanthocromia
Angiography Shows the site of obstruction i) Site of obstruction i) Aneurysm/ Charcot Berry aneurysm may be seen
ii) Carotid atheroma may be bouchard in young patients and
seen ii) AV malformation may be bleeding point can be
seen recognized.
Treatment i) Immediate Immediate i) Immediate i) Immediate
As needed As needed ABC/ IV line/ Foley ABC/ IV line/ Foley
ii) Primary i) Primary catheter catheter, lower blood
t-PA within 3 hours t-PA within 3 hours Lower blood pressure pressure, reduce ICP
iii) Secondary ii) Secondary (MAP=130), reduce ICP. ii) Primary and Adjuvant
a) Aspirin or Dipyridamole Aspirin (24 hours after t-PA) ii) Primary Nimodepine,
b) Anticoagulants esp if embolus If allergic: give Dipyridamole Surgical evacuation of ii) Secondary
was of cardiac source hematoma Surgical clipping and coiling
iii) Secondary to prevent re-bleeding then
Seizure prophylaxis, Give i/V fluids to make I/V
steroids for cerebral edema, volume expansion and
Treat the underlying prevent vasospasm., VP
disorder, I/V recombinant shunting for hydrocephalus,
factor VIII. Oral / iv NaCl to compensate
renal salt wasting

Note:

1. Occlusion of ophthalmic artery (Central retinal artery) by thrombus is not clinically significant b/c of collaterals but embolus to ophthalmic
artery can lead to unilateral TIA called Amaurosis fugax.
2. Embolus is sudden whereas thrombus is gradual b/c as long as thrombus is enlarging, collaterals are developing.
3. TIA: It is a transient neurological deficit due to vascular insufficiency which completely recovers within 24 hours. 90% cases are due to
embolism. Usual duration is few minutes. Amaurosis fugax is one of its type which causes Transient unilateral painless loss of vision.
TIA may be a warning sign that stroke is gonna happen. Esp a Thrombotic event in future (remember: although 90% TIA is an embolic event)
4. COMA: Infarction in either the carotid or vertebrobasilar territory may lead to loss of consciousness.
5. Most accurate test to detect Cerebral Ischemia is Diffusion weighted MRI.
IMMEDIATE INVESTIGATION: CT-scan without contrast
LABS/Tests for Ischemic stroke: CBC, ESR, BSR, TEST FOR SYPHILIS, LUPUS ANTICOAGULANT, LIPID PROFILE, ECG, BLOOD CULTURE (if I.E),
Echocardiography, Holter monitoring (If arrhythmias ) , Bubble study Echo to detect Patent foramen ovale LABS/Tests for hemorrhagic stroke:
CBC, ESR, BSR, PT, apTT, Bleeding time, LFTs, RFTs.
Compiled by: SHAHERYAR ALI JAFRI Ref: D/D by Shabbir nasir, CMDT, Kaplan