Tis “stroke nowhere” business also applies to


strokes in the thalamus where the only symptom might be loss of memory, perhaps along with some sleepiness – but the clue as ever is the sudden onset, “out of the blue”. Sometimes stroke in the right parieto-occipital region can be very difficult if all the patient complains of is vague difficulty with their vision, maybe not recognising places and people. It is all too easy to brush off the symptoms as psychological, but again the clue is that they came on all of a sudden – one day they were there, the day before they were not.


Early diagnosis: delays can matter Not so long ago it really didn’t matter too much if the diagnosis of stroke was delayed for hours or even a day or two. It didn’t even matter if the diagnosis was completely missed, provided the patient recovered, because until the 1980s there was no intervention that would reduce the risk of another


stroke. Now it does matter


because intravenous


thrombolysis is, or at least should be, available. Although this treatment is no panacea (anymore than thrombolysis for acute myocardial infarction), it does on average across a population of


stroke patients reduce somewhat the risk of dying or being leſt dependent, and it may even reduce the level of dependency of patients not all that affected in the first place. Trombolysis does not work for everyone, but is


most likely to be helpful if the patient is treated within six hours, better in under three hours, and in someone whose stroke is not already getting better.


WINTER 2014


Of course thrombolysis is contraindicated if the


stroke is due to haemorrhage, so everyone needs a CT brain scan first. Upsetting as it may be for the neurologists who prefer the comfort of their outpatient clinic to the hurly burly of an acute ward, stroke patients are now blue light medical emergencies. Recently qualified doctors know this; older ones may not be so aware. In their day stroke was ‘untreatable’.


“No history available” What nonsense – there is always some history from someone if one bothers to look for it. But how oſten does one see these three weasel words written in medical notes! Apart from the patient, has anyone else been asked what happened – paramedics, friends, relatives, bystanders, police? Tis issue is important for inebriated patients who are found unconscious where a cut on the head might be due to falling as a result of a stroke rather than alcohol. Te presence of focal neurological signs should be one clue to do a scan, but of course rather than a stroke one might find a subdural haematoma which is certainly useful to know about. A sound history is also important for anyone who is


otherwise unable to give their own history, particularly if they are dysphasic. Dysphasia can be misinterpreted for psychosis if you are not careful to listen to how the patient is speaking. Are their words wrong, jumbled up, rather than just slurred?


Conclusions n Take a decent history and not just from the patient. Was the onset sudden? Exactly when did it all start? What exactly seems to be wrong?


n Make an attempt at the neurological examination. It does sometimes matter a lot, e.g. radial nerve palsy vs stroke.


n If in doubt ask for help, and fast if there has been an apparently sudden onset of focal neurological symptoms in the previous few hours.


n And again ask for help if the patient keeps coming back with the same problem and you have not got a sensible diagnosis, even if the brain scan is normal.


n Charles Warlow is Emeritus Professor of Medical Neurology at the University of Edinburgh


17


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24