History Taking In Stroke And Transient Ischemic Attack Excluding Stroke Mimics
History Taking In Stroke And Transient Ischemic Attack Excluding Stroke Mimics
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Content
0 ->
1.04 -> My name is Il Fan,
2.75 -> an advanced practice nurse,
4.49 -> and I'm happy to present
5.96 -> this topic together with Doctor
8.06 -> Tu Tian Ming, a stroke
9.86 -> neurologist.
10.94 -> And both of us are from National
13.73 -> Neuroscience Institute.
15.89 -> Over the course
16.88 -> of this presentation,
19.08 -> we will be focusing on how
21.08 -> to take a history in stroke
23.78 -> and transient ischemic attack,
26.1 -> with a focus on excluding stroke
28.575 -> mimics.
29.075 ->
32.36 -> At the end of this presentation
34.82 -> you have learned how to take
36.64 -> a focused history to identify
39.44 -> stroke.
40.42 -> Able to differentiate what
42.11 -> is stroke
42.96 -> and transient ischemic attack.
45.14 -> How to identify stroke mimics.
47.34 ->
50.66 -> Acute stroke is an emergency.
53.89 -> Treatments is an emergency
56.27 -> and has to be treated early
58.13 -> for outcomes.
59.67 -> There are two major stopgaps
61.34 -> of strokes, with ischemic stroke
63.89 -> as the most common.
65.75 -> Where approximately 80% of all
68.21 -> strokes are ischemic in nature.
71.15 -> Time is brain: every minute
73.64 -> of transient ischemic stroke
75.44 -> results in the death of 2
77.392 -> million brain cells.
79.52 -> Treatment options,
80.94 -> such as intravenous thrombolysis
83.81 -> and endovascular therapy
85.54 -> are
86.04 -> available for ischemic stroke.
88.55 -> However, these treatments
90.47 -> are only beneficial if patients
92.85 -> presents
93.56 -> a lethal ischemic stroke.
95.4 ->
98.81 -> More over, these treatments
100.94 -> carry certain degree of risk,
103.47 -> such as intra cerebral
105.44 -> hemorrhage.
107.03 -> Stroke remains
108.23 -> a clinical diagnoses,
110.24 -> hence taking a history
112.49 -> and performing a focus
113.91 -> clinical examination to confirm
116.09 -> stroke is crucial.
118.34 -> Additionally, exclusion
120.23 -> of stroke mimic
121.3 -> is essential to avoid
123.08 -> unnecessary treatment.
125.198 ->
127.95 -> Stroke can present
129.419 -> with a variety of symptoms.
131.52 -> Many diseases can also mimic
133.74 -> symptoms.
134.88 -> Taking a focused history
136.68 -> helps to reasonably arrive
138.48 -> at a diagnosis of stroke.
139.77 ->
144.91 -> Arriving
145.41 -> at the correct diagnosis
146.82 -> with certainty and speed
148.56 -> are important.
150.09 -> The acronym of OLD CART
152.49 -> helps one to take
153.54 -> a focused yet comprehensive
155.55 -> history to confirm the presence
157.41 -> of stroke.
157.965 -> In particular, the onset
160.2 -> of stroke, or the timing when
162.22 -> the patient was last seen well,
164.28 -> helps the clinician to decide
166.14 -> on the most suitable treatments.
168.57 -> In addition,
169.44 -> the present symptoms
171.21 -> such as weakness,
172.78 -> numbness, giddiness, helps
174.93 -> to confirm the type of stroke
176.88 -> syndrome
177.63 -> that the patient is
178.47 -> experiencing.
180.12 -> In addition,
181.12 -> other pertinent information
182.55 -> include alleviating
184.08 -> and relieving factors
185.19 -> for the neurological symptoms
186.75 -> may point to stroke mimics
188.67 -> such as migraine
190.17 -> or hypoglycemia.
192.39 -> The patient's
192.96 -> past medical and surgical
194.7 -> history, such as recent surgery,
197.34 -> or even a recent stroke,
198.93 -> may contraindicate some
200.37 -> of the patients
201.3 -> to available stroke treatments.
203.76 -> Patients current medication
205.14 -> list,
205.86 -> such as anti-coagulation
207.63 -> medications,
208.71 -> also helps the clinician
209.91 -> to decide on the suitability
212.01 -> of treatment.
213.078 ->
215.77 -> In addition to the history
217.09 -> taking, one will also perform
218.92 -> a clinical examination
220.36 -> to identify the features are
222.22 -> consistent with the suspected
223.84 -> stroke syndrome.
225.26 -> These include left or right
227.2 -> hemisphere syndromes, lacunar
229.36 -> syndromes such as pure motor,
232 -> pure sensory, sensory motor,
234.49 -> a toxic hemiacetal pareisis.
235.72 ->
238.24 -> All posterior circulation
239.71 -> syndromes such as syndrome.
243.35 -> As part of the examination
244.64 -> it is also important to assess
246.5 -> the severity of stroke
248.24 -> with a validated standardized
250.97 -> scale.
251.93 -> This scale has to be understood
253.73 -> by all clinicians caring
255.29 -> for patients.
256.92 -> The strict scale that we use
259.01 -> is the National Institutes
260.39 -> of Health stroke scale which
262.19 -> comprises of 11
263.72 -> different examination findings.
266.21 -> With this scale,
267.71 -> we can communicate the severity
269.39 -> among clinicians.
270.8 -> This helps with the management
272.06 -> of patient subsequently.
276.32 -> Nevertheless, even
277.31 -> with a comprehensive history
279.17 -> and clinical examination,
280.79 -> how sure are we that patient
282.41 -> in front of us
283.19 -> is indeed suffering
284.33 -> from a stroke?
284.94 ->
287.96 -> Stroke is defined
289.46 -> as a neurological deficit that
291.83 -> causes an acute focal injury
294.65 -> of the central nervous system
296.63 -> by vascular cause.
299.12 -> There must be cell death
300.92 -> due to ischemia based
302.48 -> on pathological imaging
304.97 -> or other objective evidence.
307.97 -> Transient ischemic attack
309.35 -> is defined a transient episode
312.23 -> of neurological dysfunction
314.521 -> caused
315.02 -> by a focal central nervous
316.85 -> system ischemia
318.35 -> without acute infarction or cell
321.321 -> death.
321.821 ->
324.41 -> The following flow sheet
325.93 -> optically the dynasty algorithm
328.85 -> of ischemic stroke
330.35 -> and transient ischemic attack.
332.9 -> Ischemic stroke is diagnosed
335.21 -> in the presence
336.41 -> of neurological symptoms
338.66 -> resulting from focal occlusion
342.11 -> and the presence
343.28 -> of radiological imaging evidence
346.01 -> of cell death.
348.05 -> This radiological evidence
350 -> include a positive CT or MRI
353.915 -> scan of the brain.
356.06 -> The diagnoses
357.03 -> of transient ischemic attack
359.64 -> will only be for few.
361.87 -> If there's
362.37 -> no radiological evidence of cell
365.04 -> death
365.73 -> and resolutions
366.87 -> of neurological symptoms
368.67 -> within 24 hours.
371.53 -> In the absence of all validity
373.94 -> of radiological investigation,
376.7 -> the clinical diagnosis
378.23 -> of transient ischemic attack
380.12 -> will solely be based
381.89 -> on clinical symptoms lasting
384.08 -> less than 24 hours.
387.11 -> As part
387.83 -> of the clinical spectrum,
391.22 -> in an event when a patient does
393.83 -> not present with any kind
395.53 -> of stroke symptoms the incident
398.36 -> of infarction
399.53 -> is far
400.15 -> overhead neurological
401.39 -> investigations.
403.01 -> This kind of scenario
405.02 -> can be conceived
406.34 -> as a silent stroke.
408.05 ->
411.2 -> Now we're move on to stroke
412.47 -> mimics.
413.81 -> Stroke mimics presents
415.21 -> like stroke, but not due
416.5 -> to vascular causes.
418.66 -> Patients with acute stroke,
420.25 -> rapid intervention
421.45 -> is crucial to maximize
423.28 -> early treatment benefits,
425.14 -> and to correctly identify stroke
427 -> and exclude stroke mimics are
428.65 -> crucial.
429.82 -> According to the evidence stroke
431.23 -> mimics can account for up to 21
433.36 -> percent of all stroke
434.71 -> presentations.
436.029 -> Hence, having
436.57 -> a reliable clinical to exclude
439 -> stroke mimics may be helpful.
441.08 -> Even in the best scientists,
443.23 -> it's inevitable that sometimes
445.42 -> even stroke mimics are treated
447.1 -> with stroke treatment
448.06 -> such a thrombolytics.
449.92 -> Nevertheless,
450.58 -> the acceptable international
451.93 -> rate of error and treatment
453.61 -> should be below 3%.
454.54 ->
458.09 -> There are many causes of stroke
459.89 -> mimics.
461.03 -> One of the most common
462.23 -> medical cause is hypoglycemia.
465.2 -> Due to the high prevalence
466.7 -> of diabetic patients
468.11 -> on oral hypoglycemia agents
470 -> in the community,
471.41 -> screening for hypoglycemia
473.21 -> is critical with patients
475.07 -> presenting
475.7 -> with acute neurological
477.18 -> deficits.
478.65 -> In patients with seziures
480.86 -> with postnatal paralysis,
482.93 -> may also present with weakness
485.01 -> that looks like a stroke.
486.77 -> In patients with migraine
488 -> with aura, they can present
489.68 -> with sudden onset of weakness
491.51 -> during or even
492.89 -> after the onset
494.12 -> of their migraine.
495.59 -> Other rarer causes,
496.86 -> such as
497.36 -> hypertensive encephalopathy,
499.37 -> central nervous system abscesses
501.13 -> or tumors, may cause stroke
503.09 -> like symptoms.
504.92 -> Drugs is always a consideration,
507.02 -> as many drugs can cause weakness
509.33 -> or numbness that presents
511.07 -> acutely with toxicity.
513.32 -> In a subgroup of patients
515.049 -> that can present with stroke
516.44 -> like symptoms.
517.32 -> But are psychogenic in origin
519.2 -> and not due to any vascular
520.82 -> congenital.
521.51 ->
524.5 -> There are many clinical skills
525.88 -> to have been developed
526.99 -> to identify stroke or exclude
529 -> stroke mimics in the emergency
530.56 -> department.
531.85 -> One of the most validated skills
534.19 -> to help to identify stroke
536.29 -> is the recognition of stroke
538.33 -> in the emergency room school.
540.61 -> Also known as the ROSIER scale.
543.18 -> The ROSIER scale comprises
544.87 -> of critical variables
546.67 -> such as symmetrical facial, leg
549.88 -> and weakness speech
551.98 -> disturbances,
553.21 -> and visual disturbances.
555.6 -> While the ROSIER score is
556.97 -> good at screening for stroke
559.01 -> patients, it is not
561.02 -> good excluding stroke mimics
562.82 -> with certainty.
564.14 -> Other scores have been developed
565.64 -> for the purpose of identifying
567.68 -> stroke mimics in patients are
569.66 -> really considered for stroke
571.73 -> treatments.
573.03 -> These include the FABS score.
575.214 -> No facial droop,
575.88 -> no atrial fibrillation,
578.42 -> normal blood pressure, presence
580.46 -> of seizures,
581.9 -> isolated sensory finding.
584.3 -> Other scores include
585.95 -> the Guangzhou strokes scale,
587.52 -> which was a score developed
589.1 -> from Chinese patients
591.29 -> for the purpose of excluding
593.24 -> stroke mimics.
594.32 -> However, applying all
595.64 -> these scores may be difficult
597.56 -> as many clinical parameters are
599.54 -> required.
600.33 -> It may not be utilized
601.75 -> in a real world setting.
603.56 -> Additionally, the skills have
605.27 -> not been reliably validated
607.1 -> across different communities.
608.69 ->
611.76 -> So which scale should be used?
613.8 -> Unfortunately, none
614.91 -> of the scores
615.9 -> are highly reliable.
617.31 -> Available guidelines do not
618.87 -> recommend use of any
620.55 -> of these scales
621.39 -> to exclude mimics.
623.24 -> What does this leave us?
624.96 -> This means that a diagnosis
626.76 -> of stroke
627.43 -> is based on in-focus history
629.58 -> and critical examination.
631.26 -> And clinical diagnosis
632.54 -> is key to guide on treatments
635.754 -> in our patients.
636.42 ->
639.79 -> In summary, acute stroke is life
642.79 -> threatening and time
644.11 -> sensitive diagnoses.
646 -> It remains a clinical diagnosis.
648.91 -> Transient ischemic attack
650.65 -> is similar to a stroke
651.98 -> but without evidence of cell
654.07 -> death on the imaging.
656.47 -> Consider causes of stroke
658.04 -> mimic systematically when you
660.16 -> approach patients with stroke
661.475 -> symptoms.
661.975 ->
665.28 -> We hope that you have learned
666.94 -> the basic importance
668.38 -> of identify stroke and stroke
670.33 -> mimic from these presentations.
672.71 -> Thank you.
674.56 ->
Source: https://www.youtube.com/watch?v=dIAPuER7s-4