history taking in stroke patient
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History Takingin Stroke Patient
Pagan Pambudi
from.Handbook of Stroke
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4 Fundamentals Question
1. Is this Vascular or Non vascular2. If vascular, ischaemic or
haemorrhagics3. if hemorrhagic where is the
lession, if ischaemic what is the artery involved
4. What is the underlying mechanism
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Vascular vs Non vascular
• Acute and rapid onset
• Distinguish:– TIA < 24 h– RIND 24 h – 3
weeks– Complete Stroke
> 24 h– Progresive >
worsening
• Chronic• If acut consider
Todd paralysis an hemiparesis after seizure
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Ischaemic or hemorrhagic
Ischaemic• Gradual onset• no in activity• headache,
vomiting, decrease of conciousness, seizure (uncommon)
Haemorrhagic• Abrupt, complete
deficit at onset• in activity• Headache,
vomiting, decrease of conciousness, seizure common
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If haemorrhagic , Where is the lession
• Epidural– history of trauma
• Subdural– history of trauma– old people– lucid interval, mental status
detoriation
• Subarachnoid– severe headache
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If haemorrhagic , Where is the lession
• ICH– Supratentorial lobar– supratentorial deep
• basal ganglia. capsula interna• thalamus
– Brainstem– Cerebellar
• IVH
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If Ischaemic, what is the artery involved
• Anterior Circulation– hemiparesis– defect of high cortical
function: aphasia, apraxia, anosognosia, agnosia
– Seizure– hemianopsia– vertigo is uncomon– cranial nerve
involvement supranuclear
• Posterior Circulation– hemiparesis– vertigo, ataxia,
dizzines is common– bulbar palsy– diplopia– decrease of
conciousness– tend to progresive
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What is Underlying Mechanism
• Ischaemics– Heart
• aritmia, valve disease, ischaemic disease, etc
– Large vessel• ateroschlerotics disease, Takayasu disease
– Small vessel• infection, imunological
– Hematologic• hypercoagulation state, polisitemia vera
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What is Underlying Mechanism
• Hemorrhagic– EDH
• trauma
– SDH• trauma, tear in bridging vein (old people)
– SAH• AVM, aneurism, trauma, ICH, IVH
– ICH• Hipertension, AVM, Aneurism, Amyloid
angiopathy, Charcot Boucard microaneurism, Neoplam, Drugs, hematologic disease
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What is Underlying Mechanism
• IVH– Hipertension, ICH extension,
neoplasm, drugs, hematologic diorder
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Neurological Common Complaint
• Decrease of conciousness• Headache• Vertigo and Dizzines• Visual disturbance• Motor paralyze• Sensory distrubance• Seizure• Movement and gait disturbance• Cognitif impairment
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Decrease of conciousness
• akut atau pelan• Bedakan dengan sinkop• Penurunan kesadaran pada stroke
bisa– Stroke Perdarahan– Stroke infark yang:
• luas (misal emboli 1 hemisfer dengan edema serebri berat)
• infark brainstem
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Nyeri kepala
• Bedakan akut atau kronik progresif• Lokasi nyeri kepala• SAH sering keluhan hanya nyeri
kepala yang hebat, Sentinel headache (Px bisa tahu persis saat serangan nyeri)
• Hilang-timbul AVM, aneurisma
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Vertigo
• Central– not severe– autonomic
symptoms rare– nystagmus
vertical and rotatory
– continous– tinitus uncomon
• Perifer– severe– autonomic
symptoms prominent
– nystagmus horizontal or rotatory
– paroxysmal– tinitus common
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Visual disturbance
• Visual Loss– unilateral:
• acut: vascular eg Amaurosis Fugax• subacut: inflamation• chronic: compresion e.g optic nerve
meningioma
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Visual Disturbance
• Bilateral Visual Loss– complete:
• large chiasmal lession, bilateral optic pathway and cortices disturbance
– Episodic• posterior circulation disorder
– Intermittent• demyelinating
– Gradual• neoplasm, aneurism
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Diplopia
• Binokular diplopia– kelemahan otot ekstraokular– neurological
• Monokular diplopia– ocular problems
• untuk mengetahui bila ada diplopia, tutup satu mata membaik berarti misalignment misal parese n III, tetap diplopia problem ocular
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Motor paralyze
• Can be– hemiparese/plegia– paraparese (lesi parasagital)– double hemiparese/plegia bedakan
dengan tetraparese pada double hemiparese ada keterlibatan saraf kranial
– Pure motor paralyze dapat terjadi pada infark lakunar
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Sensory
• Hipesthesia• Rasa nyeri, panas thalamic
lesion• Sensory seizure: tingling,
parestesia sensory hallucination lesi parietal
• sensory disturbance of the face onion distribution lesi di tractus spinalis n V
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Speech
• disartria– cortical– subcortical– cerebellar– brainstem
• dysfonia– parese plica voklais
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Seizure vs Sinkop
Seizure• Aura +• Gerakan-gerakan
saat serangan• Post ictal lama• ngompol, BAB,
ejakulasi +
Sinkop• Aura –• Saat serangan
lunglia tidak ada aktivitas
• Cepat bangun• tidak ada
ngompol, BAB, ejakulasi
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Seizure
• First time seizure in adult– usually organic
• structural– CVA: hemoragic, emboli– infection: meningensefalitis, cerebral abscess– neoplasm
• Metabolic– non ketotic hiperglicemia– hiponatremia, hipocalcemia– alcohol, benzodiazepine and opiates
withdrawal. neuroleptic overdosage, teofilin, antidepresan trisiklik
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Cognitif impairment
dominant hemisphere
• aphasia• Gertzman
syndrome• alexia• Speech apraxia
Non dominat• Constructional
aphasia• Anosonogsia• Prosopagnosia