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History Taking in Stroke Patient

Pagan Pambudi
from. Handbook of Stroke

4 Fundamentals Question
1. Is this Vascular or Non vascular 2. If vascular, ischaemic or haemorrhagics 3. if hemorrhagic where is the lession, if ischaemic what is the artery involved 4. What is the underlying mechanism

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

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

If haemorrhagic , Where is the lession


Epidural
history of trauma

Subdural
history of trauma old people lucid interval, mental status detoriation

Subarachnoid
severe headache

If haemorrhagic , Where is the lession


ICH
Supratentorial lobar supratentorial deep
basal ganglia. capsula interna thalamus

Brainstem Cerebellar

IVH

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

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

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

What is Underlying Mechanism


IVH
Hipertension, ICH extension, neoplasm, drugs, hematologic diorder

Neurological Common Complaint


Decrease of conciousness Headache Vertigo and Dizzines Visual disturbance Motor paralyze Sensory distrubance Seizure Movement and gait disturbance Cognitif impairment

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

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

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

Visual disturbance
Visual Loss
unilateral:
acut: vascular eg Amaurosis Fugax subacut: inflamation chronic: compresion e.g optic nerve meningioma

Visual Disturbance
Bilateral Visual Loss
complete:
large chiasmal lession, bilateral optic pathway and cortices disturbance

Episodic
posterior circulation disorder

Intermittent
demyelinating

Gradual
neoplasm, aneurism

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

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

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

Speech
disartria
cortical subcortical cerebellar brainstem

dysfonia
parese plica voklais

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

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

Cognitif impairment
dominant hemisphere aphasia Gertzman syndrome alexia Speech apraxia Non dominat Constructional aphasia Anosonogsia Prosopagnosia