DIFFERENTIAL DIAGNOSIS OF STROKE

A patient presents with right sided hemiplegia????

Features

Cerebral embolus

Cerebral Thrombosis

Intracerebral hemorrhage

Time of onset

Can occur any time

Usually occurs during sleep

Usually occurs during activity

Onset

Sudden

Gradual (but patient may have

3
history of previous TIA)

Sudden

Headache/vomiting
Loss of consciousness
Signs of meningeal
irritation
Hypertension

Common

Risk Factors/ Types

Cerebral infarct:
1
Ophthalmic , MCA, ACA, PCA,
Vertebrobasilar.

i) Lacunar Infarct:
Hypertension, diabetes,
hyperlipidemia

Risk factors:
i) Atrial fibrillation
ii) Recent M.I
iii) Vulvular heart disease (M.S)
iv) Infective endocarditis
v) Prosthetic valves

ii) Cerebral Infarct: MCA,

ACA, PCA, Vertebrobasilar
artery involvement
R.f: Diabetes, hypercoaguble
states, hyperlipedemia

MCA
i) Atrial fibrillation
ii) Myocardial infarction history
iii) Vulvular heart disease (mitral
stenosis)
iv) Infective endocarditis
v) Carotid bruit

MCA
Carotid bruit

Yes
Yes
Only if hemorrhage becomes
secondary SAH
Most important
predisposing factor
i) Charchot bouchard
aneurysm (microaneurysms
in perforating vessels in
Hypertensive patients)
ii) Amyloid angiopathy
iii) Bleeding disorders
(Leukemia,
thrombocytopenia,
hemophilia, DIC)
iv) Anticoagulant therapy
v) Liver disease
vi) Substance misuse
(cocaine, alcohol,
amphetamine)
Basal ganglia (putamen)
Hypertensive retinopathy
may be there
May be history of Bleeding
disorders, Anticoagulant
therapy, alcoholism, liver
disease

Most common site

Other findings

Compiled by: SHAHERYAR ALI JAFRI

Primary subarachnoid
hemorrhage
Usually occurs during activity
(eg: sexual intercourse)
Sudden
Yes (thunderstorm headache)
50% of cases
Yes
Common in old patients
i) Rupture of berry aneurysm
ii) A-V malformation
iii) Trauma
Rupture of berry aneurysm
i) Hypertension
ii) Smoking
iii) Connective tissue disorder
(Marfan, Ehlor danlos)
iv) APKD
v) Neurofibromatosis-I
vi) Coartaction of aorta

i) Subhyaloid hemorrhage
ii) Hypertensive retinopathy
in older patients
iii) May have history of
Coartaction of aorta, Marfan
syndrome, Ehlor danlos
syndrome,
Neurofibromatosis-I, Adult
polycystic kidney disease

Ref: D/D by Shabbir nasir, CMDT, Kaplan

Features

Cerebral embolus

Cerebral Thrombosis

CSF analysis

Normal

Normal

Angiography

Shows the site of obstruction

i) Site of obstruction
ii) Carotid atheroma may be
seen

Treatment

i) Immediate
As needed
ii) Primary
t-PA within 3 hours
iii) Secondary
a) Aspirin or Dipyridamole
b) Anticoagulants esp if embolus
was of cardiac source

Immediate
As needed
i) Primary
t-PA within 3 hours
ii) Secondary
Aspirin (24 hours after t-PA)
If allergic: give Dipyridamole

Intracerebral hemorrhage
Normal until unless there is
secondary SAH
i) Aneurysm/ Charcot
bouchard
ii) AV malformation may be
seen
i) Immediate
ABC/ IV line/ Foley
catheter
Lower blood pressure
(MAP=130), reduce ICP.
ii) Primary
Surgical evacuation of
hematoma
iii) Secondary
Seizure prophylaxis,
steroids for cerebral edema,
Treat the underlying
disorder, I/V recombinant
factor VIII.

Primary subarachnoid
hemorrhage
Hemorrhagic with
xanthocromia
Berry aneurysm may be seen
in young patients and
bleeding point can be
recognized.
i) Immediate
ABC/ IV line/ Foley
catheter, lower blood
pressure, reduce ICP
ii) Primary and Adjuvant
Nimodepine,
ii) Secondary
Surgical clipping and coiling
to prevent re-bleeding then
Give i/V fluids to make I/V
volume expansion and
prevent vasospasm., VP
shunting for hydrocephalus,
Oral / iv NaCl to compensate
renal salt wasting

Note:
1. Occlusion of ophthalmic artery (Central retinal artery) by thrombus is not clinically significant b/c of collaterals but embolus to ophthalmic
artery can lead to unilateral TIA called Amaurosis fugax.
2. Embolus is sudden whereas thrombus is gradual b/c as long as thrombus is enlarging, collaterals are developing.
3. TIA: It is a transient neurological deficit due to vascular insufficiency which completely recovers within 24 hours. 90% cases are due to
embolism. Usual duration is few minutes. Amaurosis fugax is one of its type which causes Transient unilateral painless loss of vision.
TIA may be a warning sign that stroke is gonna happen. Esp a Thrombotic event in future (remember: although 90% TIA is an embolic event)
4. COMA: Infarction in either the carotid or vertebrobasilar territory may lead to loss of consciousness.
5. Most accurate test to detect Cerebral Ischemia is Diffusion weighted MRI.
IMMEDIATE INVESTIGATION: CT-scan without contrast
LABS/Tests for Ischemic stroke: CBC, ESR, BSR, TEST FOR SYPHILIS, LUPUS ANTICOAGULANT, LIPID PROFILE, ECG, BLOOD CULTURE (if I.E),
Echocardiography, Holter monitoring (If arrhythmias ) , Bubble study Echo to detect Patent foramen ovale LABS/Tests for hemorrhagic stroke:
CBC, ESR, BSR, PT, apTT, Bleeding time, LFTs, RFTs.
Compiled by: SHAHERYAR ALI JAFRI
Ref: D/D by Shabbir nasir, CMDT, Kaplan