Limb Weakness

STROKE: APROACH AND MANAGEMENT

BY DR. MUSTAFA F. AL BAGHDADI

Approach

Approach

Assess power, ask

about pre-existing
weakness &
measure glucose.

Immobilize the cervical

spine

Disk prolapse, pathological

fracture & Spinal stroke
(severe back pain)
Increase tone, Brisk
reflexes, extensor
planter response

Suggest
myelopathy Do
MRI

Suggest
myelopathy Do
MRI

syringomyelia,
glioma, abscess

Signs of raised ICP, LP

for CSF, brain MRI,
serum B12, autoimmune
& infective screen

Sensory loss pattern, Nerve

conduction studies, LP, vital
capacity,

GuillainBarr, diabetic neuropathy,

acute intermittent porphyria, chronic
inflammatory demyelinating
polyneuropathy, & hereditary
sensorimotor neuropathy.

post-radiation
myelopathy, subacute combined
degeneration of
the cord,
transverse
myelitis, & ALS.

Ocular and bulbar involvement

(ptosis, diplopia, voice
weakening), +ve tendon reflex,
AChRAb,& chest CT.
myopathie
s

UMN or LMN

Stop statins, exclude other

drugs,& antibody
patchy screen(anti-jo1).
pattern of
weaknessa

lumbosacral plexopathy,
malignant, vasculitic or
infiltrative disorder

Compare pulses, color,

temperature,& capillary
refill. Limb x-ray, CK, ask
about seizure,&
previous stroke.

Assess the
risk of
impending
stroke

Assessing the risk of impending

stroke
Admit if ABCDD
score 4 Or >1 TIA

Otherwise

consider discharge with

appropriate secondary
prevention and specialist
follow-up within a week.

Arrange neuroimaging prior to

discharge in any patient
taking warfarin.

carotid Doppler USS

Compare pulses, color,

temperature,& capillary
refill. Limb x-ray, CK, ask
about seizure,&
previous stroke.

Assess the
risk of
impending
stroke

Further
assessment of
Step 1 stroke
Assess eligibility
for thrombolysis

Potentially disabling
stroke.

Less than 3 hours

immediate CT brain to
exclude hemorrhagic
stroke.

Step 2 Classify stroke

according to clinical
and radiological findings
Perform a CT brain urgently if:
the patient is eligible for
thrombolysis
coagulation is impaired
GCS
symptoms include a severe
headache
there is a rapidly progressive
neurological deficit
cerebellar hemorrhage is
suspected (to
Otherwise, perform CT within 24
exclude
obstructive
hours

hydrocephalus).

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Acute treatment & Prevention

Acute Supportive treatment (airway protection,

oxygen, IV fluids) is initiated.

Aspirin is best if given within 24 hours of

symptom onset.

Assess the patients ability to protect his or her

airway, keep NPO, and elevate the head of the
bed 30.

Do not give antihypertensive agents unless one

of the following three:

Prevention according to the cause:

atherosclerosis of the carotid arteries
(Aspirin, Control HTN, DM, smoking,
hypercholesterolemia, obesity, Surgery carotid
endarterectomy in Symptomatic patients)
embolic disease anticoagulation (aspirin),
reduction of atherosclerotic risk factors

So if patient presents
within 3 hours of
stroke onset,
thrombolytics are
indicated.
If after 3 hours, give
aspirin. If patient
cannot take aspirin,
give
clopidogrel.
1- BP is very high
>220/>120.
2- medical indication for
antihypertensive(MI, HF)
3- receiving thrombolytic
therapy

Step 3 Evaluate for risk factors/

underlying cause
Suspect a cardiac source
if :
evidence of AF or MI
features suggesting
endocarditis ,e.g. fever &
new murmur
2 cerebral infarcts
systemic emboli e.g.
lower limb
Investigate for an unusual
cause of stroke in younger
patients without vascular
risk factors:
thrombophilia screen.
echocardiography

Complications of Stroke
1.

Progression of neurologic insult

2.

Cerebral edema occurs within 1 to 2 days and

can cause mass effects for up to10 days.
Hyperventilation and mannitol may be needed
to lower intracranial pressure.

3.

Hemorrhage into the infarctionrare

4.

Seizuresfewer than 5% of patients

Compare pulses, color,

temperature,& capillary
refill. Limb x-ray, CK, ask
about seizure,&
previous stroke.

Assess the
risk of
impending
stroke

If no
result do
LP MRI

fever, meningism,
purpuric rash, or features
of shock blood cultures,
give empirical IV
treatment
If you cant do brain CT or MRI
Or sensory
if cranial nerve or cerebellar
level
signs +ve

Exclude
spinal cord

Slowly
progressive

MRI
spine
Still possible so we should
do CT

sudde
n

Single peripheral
n.

References
DAVISONS PRINCIPLES
MACLEODS CLINICAL DIAGNOSIS
STEP UP TO MEDICINE

Thank you
FOR YOUR ATTENTION