2. My patient named Gopal, 59 years old, hailing
from Kavoor carpenter by occupation came to
GWH hospital with chief complaint of weakness
of the right side of the body since 20 days.
3. History of presenting illness
Patient was apparently normal 20 days back when he developed
weakness over right side of the body, when he was about to go
to bathroom at 7 30 am, where he suddenly felt weak and could
not move his right side. It was sudden in onset and evolution of
paralysis was complete within 6 hours. Patient complained of
deviation of angle of the mouth to left side during eating or
speaking and slurring of speech.
No history of loss of consciousness,
No history of seizures, headache or vomiting.
No history of previous neurodeficit which recover completely.
No history of loss of bowel and bladder control.
No history difficulty in swallowing and nasal regurgitation.
No history of vertigo or diplopia
No history of fever, breathlessness, chest pain and palpitation.
4. Past history
No history of DM, hypertension or seizures.
No history contact with tuberculosis.
Family history
No significant family history.
Personal history
Patient consume mixed diet.
Sleep and Appetite normal.
Normal bowel and bladder habits.
History of intake of 180 ml of alcohol per for 25 years.
No history of any other addictions
5. General physical examination
Patient is conscious , cooperative, oriented with time, place and
person.
Afebrile at time of examination.
No pallor, icterus, cyanosis, clubbing, lymphadenopathy and
pedal edema.
Vitals
PR: 70/min, normal rhythm, good volume, normal character, no
vessel wall thickening, no radio-radial or radio-femoral delay. All
peripheral pulses felt.
RR: 17/min abdomino-thoracic.
BP:130/84 mmHg, right arm supine position.
JVP is not raised.
6. Central Nervous System Examination:
Higher mental function test
1-Education: Patient is right handed, uneducated.
2-Language: Good comprehension but slurring of
speech is present.
Able to name, repeat, read and write.
3-Speech: Slurred speech
4-Memory: All remote, intermediate and recent memory
are intact.
5-No delusion, hallucination and illusion.
7. Cranial nerve examination Right Left
Olfactory nerve normal normal
Optic nerve
•Visual acuity Finger counting at 6m. Finger counting at 6m.
•Visual field Normal Normal
•Colour vision normal Normal
Occulomotor, trochlear and
abducens nerve
•Movement of eyeball Normal Normal
•Pupil
-shape Normal Normal
-position Central Central
•Light reflex
-direct Normal Normal
-consensual Normal Normal
•Accommodation reflex Normal Normal
Trigeminal nerve
•Sensory Normal Normal
•Motor Normal Normal
-clenching of teeth
-jaw against resistance Normal Normal
•Reflex-corneal reflex
-jaw jerk
8. Cranial nerve examination Right Left
Facial nerve
•No loss of nasolabial fold
• Deviation angle of mouth to
left side
•Orbicularis oculi
•Buccinator
•Frontalis Normal Normal
•Taste sensation of ant. 2/3 of
tongue –
Vestibulocochlear nerve
•Rinne’s test AC > BC AC > BC
•Weber’s test Lateralized equally both sides
Glossopharyngeal and vagus
nerve
•Movement of uvula Central
•Palatal movement Normal
•Gag reflex Normal
Spinal accesory nerve
•shrugging of shoulder Normal Normal
•Movement of neck Normal Normal
9. Cranial nerve examination Right Left
Hypoglossal nerve
•No wasting and fasciculation
of tongue
•No deviation of tongue
10. Motor system Right Left
Nutrition (bulk) No wasting No wasting
Tone
•Upper limb Hypertonic Normal
•Lower limb Hypertonic Normal
Power
•Upper limb 2/5 5/5
•Lower limb 2/5 5/5
•Grip test Weak Normal
Coordination Could not be tested Normal
11. Reflexes Right Left
• Superficial
- Corneal Present Present
- Abdominal Present Present
- Plantar Extensor Flexor
• Deep
- Biceps Exaggerated Normal
- Triceps Exaggerated Normal
- Supinator Exaggerated Normal
- Knee Exaggerated Normal
- Ankle Exaggerated Normal
• Clonus
- patella Absent Absent
- ankle Present Absent
12. Sensory system Right • Left
• Superficial
-pain
-touch Normal Normal
-temperature
• Deep
-crude touch
-fine touch Normal Normal
-vibration
-joint sense
-tactile localisation
-tactile discrimination Normal Normal
-position sense
13. Gait : Not assessed
Involuntary movement :Absent
Skull and spine :Normal
Meningeal sign :No neck stiffness, Kernig’s and Brudzinki’s sign negative.
Cerebellar function :Within normal limit
Other system:
•Respiratory system: normal vesicular breath sound, no added sound
•Cardiovascular system: S1 S2 heard, no murmur
•Abdominal: soft, non-tender, no organomegaly
Provisional Diagnosis: Right sided hemiplegia due to
cerebrovasular accident most likely of the thrombotic
type, with the lesion in the left internal capsule involving
the left middle cerebral artery.
33. IMAGING STUDIES
• CT SCANS
– identify or exclude hemorrage
– Imaging modality of choice in acute stroke-
because of its speed and wide availability
– Identify other conditions:
• Extraparenchymal hemorrages
• Neoplasm
• abscesses
34. – Ct scans obtained in the first several hours after an
infarction generally shows no abnormality
– Contrast enhanced CT scans :
• showing contrast enhancement of subacute infarct
• Allow visualisation of venous structures
– CT angiography (CTA) may visualised :
• Cervical and intracranial arteries
• Intracranial veins
• Aortic arch
• Coronary arteries
• Intracranial aneurysm
35.
36. • MRI
– Documents the extent and location of infarction
– Less sensitive than CT for detecting acute blood
– MR perfusion studies (gadolinium contrast iv)
– MR angiography is sensitive for stenosis of
extracranial internal carotid arteries and of large
intracranial vessels
37.
38.
39. • Cerebral angiography
– X ray cerebral angiography is the gold standard for
• identifying and quantifying artherosclerotic stenoses of the
cerebral arteries
• Characterising aneurysm,vasospasm,intraluminal thrombi,
fibromuscular dysplasia,arteriovenous fistula, vasculitis
– Endovascular technique
• To deploy stents within delicate intracranial vessels
• To perform balloon angioplasty of stenotic lesions
• To treat intracranial aneurysm by embolisation
• To open occluded vessels in acute stroke with mechanical
thrombotic devices
40. • Ultrasound
– Duplex ultrasound (combination of B-mode
ultrasound image with a doppler ultrasound
assestment of flow velocity)
• Can identified stenosis at the origin of internal carotid
artery
– Transcranial doppler (TCD)
• Can detect stenotic lesion in the large intracranial
arteries
• Assist thrombolysis
• Improve large artery recanalisation following rtPA
administration
41. • Perfusion techniques
– Both xenon techniques (principally xenon CT) and
PET can quantify cerebral blood flow.
– CT perfusion
• Increase sensitivity for detecting ischemia
• Can measure the ischemic penumbra
– MR diffusion & MR perfusion combination
• Identify the ischemic penumbra
45. Intravenous Recombinant Tissue
Plasminogen Activator (rtPA)
Indications: Contraindications
- Clinical diagnosis of stroke. - Sustained BP >185/110 mmHg
- Onset of symptoms to time of despite treatment.
administration ≤ 3 hours. - Platelets <100,000 ; HCT <25% ;
- CT scan showing no h’hage or glucose <50 or > 400 mg/dl.
edema of >1/3 of the MCA - Used of heparin within 48 hrs
territory. and prolonged PTT or elevated
- Age ≥ 18 years. INR.
- Consent by patient or surrogate. - Rapidly improving symptoms.
- Prior stroke or head injury
within 3 mnths ; prior
intracranial h’hage.
- Major Sx in preceding 14days.
- Minor stroke symptoms.
- GI bleeding in preceding 21
days.
- Recent MI
- Coma or stupor.
ACUTE LEFT MIDDLE CEREBRAL ARTERY (MCA) STROKE WITH RIGHT HEMIPLEGIA BUT PRESERVED LANGUAGE. CT perfusion mean-transit time map showing delayed perfusion of the left MCA distribution (blue) Predicted region of infarct (red) and penumbra (green) based on CT perfusion data Conventional angiogram showing occlusion of the left internal carotid- MCA bifurcation (left panel), and revascularisation of the vessels following succesful thrombectomy 8 hours after stroke symptom onset(right panel) The clot removed with a thrombectomy device CT scan of the brain 2 days later,note the infarction in the region predicted in B but presevation of the penumbral region by successfl revascularization.
