Geriatric OSCE: Stroke Assessment

General assessment:
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Assess the patient, their state, any aids / equipment etc.

Motor function, standing / sitting / lying
Facial appearance, speech

Examination:
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Facial movements:
o Raise eyebrows
o Scrunch eyes
o Puff out cheeks and hold them out
o Open mouth, and against resistance
o Tongue in / out / left / right
Facial sensation:
o Ocular / maxillary / mandibular branches
o Tongue
Ocular:
o PLRs
o Movements: Double-H
o Visual fields: seeing, and when movement stops
Upper limbs:
o Tone
o Gross motor
o Sensation
o Reflexes: including grasping
Lower limbs:
o Tone
o Gross motor
o Sensation
o Reflexes: including Babinski
Speech:
o Orientation in time / place / person
o General use of words:
o Stating names and purposes of finger / pen / watch, name things starting with F
Nominal aphasia if cant name it
Agnosia if cant identify purpose
o Identify their ownership of left / right hands
Hemi-neglect
Actions:
o Act as if youre brushing your teeth
Dyspraxia if cant carry out actions
o Draw a clock
May detect hemi-neglect, impaired executive function,
o Simple maths: 2+6 = 8
May detect acalculia
o Write their name
May detect agraphia or dyspraxia

Interpretation:
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Dominant (Left) MCA lesion:

o Right weakness / impaired sensation
o Aphasia Wernickes or Brocas
o Dysarthria distinguish from cerebellar speech
o Right visual field deficit
o Impaired reading / writing / calculating (acalculia, agraphia)
Non-dominant (Right) MCA lesion:
o Left weakness / impaired sensation
o Spatial disorientation
o Left visual field deficit
o Dysarthria (distinguish from cerebellar speech)

Brainstem lesion:
o 4-limb weakness and sensory impairment
o Ataxia
o Nystagmus
o Bilateral visual field deficits
Anterior Cerebral Artery lesion
o Slowed mentation, decreased executive function
o Incontinence
o Frontal release of primitive reflexes
Lateral Medullary Syndrome:
o Ipsilateral numbness, limb ataxia, Horners Syndrome, pain over eye
o Contralateral loss of sensation (pin prick and hot-cold)
o Vertigo, nausea, hoarseness, hiccups, dysphagia

Questions:
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Treatment for acute stroke:

o Rule out intracranial haemorrhage first
o Thrombolysis if less than 4hrs (exact timeframe of who benefits at what time is
still unclear)
o Rehabilitation: rehabilitation physician, physiotherapy, speech and occupational
therapy
Outcomes of stroke:
o Majority of recovery occurs within first 3 months, minimal neuro improvement
past 6 months
o At 1 yr: 1/3 die, 1/3 permanently impaired, 1/3 minimally or no residual
impairment
o High rate of post-stroke depression
Secondary prevention:
o Anticoagulation (aspirin / clopidogrel / other antiplatelets, NOACs, warfarin)
o Lipid, diabetes, HTN control
o Carotid endarterectomy
CT findings:
o Haemorrhagic stroke:
Hyperdense diffuse region of haemorrhage
Mass effect, increased intracranial pressure, herniation / displacement
o Ischaemic stroke:
Loss of grey-white distinction
Loss of clarity of basal ganglia
MRI findings:
o Haemorrhagic stroke:

Poor for detection of subarachnoid haemorrhage

o Ischaemic stroke:
Loss of grey-white distinction
Loss of clarity of basal ganglia
Differentials:
o Thromboembolic stroke
o Haemorrhagic stroke
o Mass lesion (+/- acute necrosis / haemorrhage within mass)
o Hypoglycaemia
o Electrolyte abnormalities, esp hyponatraemia +/- overly rapid correction
o Delirium