Diagnosis of Stroke

Diagnostic Test list for Stroke:

The list of medical tests mentioned in various sources as used in the diagnosis of Stroke includes:

• Neurological exam
• Blood tests
• Brain CT scan
• Brain MRI scan
• Blood flow tests
• Doppler ultrasound - a blood flow study
• Arteriography
• EEG (electroencephalogram)
• Evoked response test
• Electrocardiogram

Stroke Diagnosis: Book Excerpts

• Ask the following questions - DYSARTHRIA
• Differential Diagnosis - Dysarthria
• Differential Diagnosis - Flank Pain/CVA Tenderness
• Approach to the Diagnosis - DYSARTHRIA AND SPEECH DISORDERS
• History and physical examination - Dysarthria
• History and physical examination - Dysarthria
• History - Stroke
• Differential Overview
  - Stroke Syndromes
• Differential Overview - Aphasia/Dysarthria
• Diagnosis - Stroke
• History - Dysarthria
• History - Dysarthria
• History and physical examination - Dysarthria
• Approach to the Diagnosis - DYSARTHRIA AND SPEECH DISORDERS

Tests and diagnosis discussion for Stroke:

NINDS Stroke Information Page: NINDS (Excerpt)

Stroke is diagnosed through several techniques: a short neurological examination, blood tests, CT scans, MRI scans, Doppler ultrasound, and arteriography. (Source: excerpt from NINDS Stroke Information Page: NINDS)

Stroke: NWHIC (Excerpt)

Before a stroke can be treated, diagnostic tests must be performed. Health care providers must find out what kind of stroke it is to treat it correctly. A person thought to be having a stroke may have a neurological exam, blood tests and an electrocardiogram.

Other kinds of tests used in diagnosing stroke include:

· Imaging tests that give a picture of the brain. These include CT (computed tomography) scanning, sometimes called CAT scans, and MRI (magnetic resonance imaging) scanning. CT scans are particularly useful for determining if a stroke is caused by a blockage or by bleeding in the brain.

· Electrical tests such as EEG (electroencephalogram) and an evoked response test to record the electrical impulses and sensory processes of the brain.

· Blood flow tests, such as Doppler ultrasound tests, to show any changes in the blood flow to the brain. (Source: excerpt from Stroke: NWHIC)

Stroke Prevention and Treatment - Age Page - Health Information: NIA (Excerpt)

Doctors make an early diagnosis by studying symptoms, reviewing the patient's medical history, and performing tests such as a computerized tomography (CT) scan-a 3-dimensional x-ray of the brain. (Source: excerpt from Stroke Prevention and Treatment - Age Page - Health Information: NIA)

Diagnosis of Stroke: medical news summaries:

The following medical news items are relevant to diagnosis and misdiagnosis issues for Stroke:

• Aneurysms are often asymptomatic and can rupture unexpectedly
• Co-morbidities override high blood pressure
• Dentists role in diagnosing stroke risk
• Eye doctors can pick up a variety of diseases from an eye examination
• Familial hypercholesterolemia
• Folic acid prevents neural tube defects
• Hypertension needs rapid attention
• Metabolic syndrome and heart disease risk
• Native Americans at significant risk for heart problems
• People need to be aware of stroke symptoms and prevention
• Pregnancy-induced hypertension predicts metabolic syndrome in later life.
• Small strokes cause of dementia
• Smoking addiction
• Stroke risk detected with blood tests
• Symptoms of old age may be similar to many other treatable conditions
• Targeting high blood pressure in young men
• The 'know how' to cholesterol
• More news »

Diagnostic Tests for Stroke: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about diagnostis of Stroke.

DYSARTHRIA: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is it intermittent? Intermittent dysarthria should make one think of myasthenia gravis, epilepsy, and transient ischemic attacks.
2. Is there associated ataxia or nystagmus? The findings of nystagmus or ataxia should make one think of a cerebellar disorder such as multiple sclerosis, drug intoxication, or cerebellar ataxia.
3. Is there a history of drug or alcohol ingestion? Alcohol and phenytoin (Dilantin®) are just two of the toxic substances that may affect speech.
4. Is there tremor or rigidity? If there is tremor or rigidity, one should suspect Parkinson's disease, hepatolenticular degeneration, and phenothiazine toxicity.

DIAGNOSTIC WORKUP

The yield for diagnoses of dysarthria is high for a blood alcohol level and urine drug screen. If the dysarthria is intermittent, an EEG and Tensilon test or acetylcholine receptor antibody titer should be done. If transient ischemic attacks are suspected, a carotid scan should be done, but the only way to completely exclude this possibility is by doing four-vessel cerebral angiography. A CT scan or MRI should be done in all cases of persistent dysarthria. A neurologist can help decide which study would be most appropriate. If Wilson's disease is suspected, a test for serum copper and ceruloplasmin should be done. A spinal tap may help diagnose multiple sclerosis and intracranial hemorrhage.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Dysarthria: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Neurological causes
  –Lesions of upper motor neurons: Stroke, tumor, abscess, degeneration (e.g., Parkinson's disease); voluntary motor pathways to cranial nerve nuclei 9, 10, and 12 are affected
  –Lesions of lower motor neuron: Brainstem stroke, amyotrophic lateral sclerosis, hypothyroidism, diabetic nerve infarction
  –Lesions of the neuromuscular junction: Myasthenia gravis, prolonged effects of anesthesia, botulism, nerve gas/ organophosphate poisoning; all cause oropharyngeal or glossal weakness
  –Lesions of muscle: Polymyositis, dermatomyositis, inherited muscle diseases such as myotonic muscular dystrophy, mitochondrial diseases
• Structural causes
  –Tumors of the lips, tongue, squamous cell epithelium of the vocal cords and oropharynx
  –Polyps or salivary gland dysfunction resulting in xerostomia (dry mouth)
  –Hypoglossal nerve damage due to surgical traction from carotid endarterectomy
• Less common etiologies include glossitis (amyloidosis, hypothyroidism, anaerobic infection), acute dystonic reaction, unrecognized foreign accent, mild cerebral palsy, sedative/anticonvulsant intoxication, poor dentition or ill-fitting dentures, cleft palate

Workup and Diagnosis

• History and physical examination, with focus on past medical history and a comprehensive ENT and neurologic exam
• Upper motor neuron lesions: Cerebral imaging (especially MRI) is indicated to distinguish ischemic from hemorrhagic infarction, and an abscess from a tumor
• Lower motor neuron lesions: MRI is vastly superior to CT; labs may include TSH, glucose tolerance testing, and toxicology screen in patients with suspected metabolic causes or sedative drug intoxication
• EMG with nerve conduction tests is indicated in suspected cases of ALS
• Neuromuscular junction lesions often present with fluctuations of dysarthria; myasthenia gravis antibody testing may be indicated; ECG and telemetry are indicated in various poisonings
• Muscle lesions: Genetic testing for heritable causes; creatine phosphokinase level and EMG testing for acquired causes
• Structural causes: Proper ENT examination with indirect laryngoscopy and MRI of the oropharynx if masses are suspected or palpated

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Flank Pain/CVA Tenderness: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Degenerative disk disease and/or disk herniation is the most frequent cause of pain
• Muscle spasm or cramping
• Trauma
• Nephrolithiasis/urolithiasis (renal or ureteral calculi or stones) is the most common urinary tract etiology
• Pyelonephritis (acute or chronic)
  –E. coli is the most common cause of upper and lower urinary infections, followed by Staphylococcus saprophyticus
  –Acute pyelonephritis is usually a complication of a lower UTI
  –Chronic pyelonephritis is usually associated with obstruction
  • Perirenal (kidney) abscess
  • Acute pancreatitis
  • Glomerulonephritis
  • Herpes zoster
  • Bacterial cystitis
  • Polycystic kidney disease
  • Renal infarction or trauma
  • Papillary necrosis
  • Duodenal ulcer
  • Cholecystitis or biliary colic
  • Pneumonia
  • Appendicitis
  • Obstructive uropathy
  • Ectopic pregnancy
  • Cervicitis
  • Renal or bladder cancer
  • Leaking or ruptured abdominal aortic aneurysm

  Workup and Diagnosis

  • History should include onset, duration, quality, intensity, and location of pain; radiation; associated symptoms (e.g., nausea/vomiting, fever, dysuria, hematuria, rash); history of recent trauma or illness; and family history of renal disease or cancer
  • Exam should include complete cardiovascular, pulmonary, abdominal, and genitourinary exam, and pelvic exam if suspect cervicitis or ectopic pregnancy
    –Turner's sign (bluish discoloration at flank) and/or Cullen's sign (bluish discoloration at the umbilicus) indicate retroperitoneal hemorrhage and may be present in cases of pancreatitis or ruptured AAA
    –Initial labs may include CBC, ESR, electrolytes, BUN/creatinine, calcium, amylase/lipase, liver function tests, pregnancy test, blood cultures, urinalysis, and urine culture
  • Urine cytology, cystoscopy, and biopsy may be indicated if renal or bladder cancer is suspected
  • Renal or abdominal ultrasound or abdominal CT scan
  • Spiral CT scan without contrast is the gold standard to diagnose stones and urinary tract obstruction
  • Intravenous pyelography has high sensitivity/specificity for stones, urinary tract obstruction, and renal cysts
  • Voiding cystourethrography
  • Lumbosacral X-ray may be indicated to evaluate for degenerative joint disease
  • Lumbosacral MRI may be indicated to evaluate for disk disease

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

DYSARTHRIA AND SPEECH DISORDERS: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Dysarthria without other symptoms or signs requires that myasthenia gravis be ruled out with a Tensilon test and psychometrics be done to rule out hysteria. In the presence of other neurologic signs, speech disorders require a thorough neurologic workup with an EEG, skull x-ray, and CT scan or MRI of the brain; a spinal tap or arteriogram may be indicated. The clinician should remember that dysarthria may be only the first sign of a serious neurologic disease such as multiple sclerosis, Wilson disease, lupus erythematosus, or chronic alcoholism; therefore, close follow-up is important.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

Dysarthria: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Explore dysarthria completely. When did it begin? Has it gotten better? Speech improves with resolution of a transient ischemic attack, but not in a completed stroke. Ask if dysarthria worsens during the day. Then obtain a drug and alcohol history. Also, ask about a history of seizures. Check dentures for a proper fit.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Dysarthria: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Explore dysarthria completely. When did it begin? Has it gotten better? Speech improves with resolution of a transient ischemic attack, but not in a completed stroke. Ask if dysarthria worsens during the day. Then obtain a drug and alcohol history. Also, ask about a history of seizures. Observe dentures for a proper fit.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Stroke: History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

 A. Characteristics of the stroke. What is the duration of the deficit? Is the problem acute and lasting several hours? Impaired consciousness can occur in all types of stroke. More specific symptom may help localize the area of stroke:

 1. Carotid circulation: symptoms of hemiplegia, hemianesthesia, aphasia, visual field defects, and loss of spatial function; occasionally, seizures, headache, amnesia, and confusion.

2. Vertebrobasilar circulation: symptoms of diplopia, vertigo, ataxia, facial paresis, Horner’s syndrome, dysphagia, dysarthria, quadraparesis
(a component of bilateral arms or legs), and crossed sensory symptoms (ipsilateral face and contralateral body). Cerebellar lesions often display headache, nausea or vomiting, and ataxia.

B. Past history. A history of trauma, migraine, vasculitis, seizure, and hypoglycemia could produce a condition that can mimic stroke. Fever or infection may suggest abscess. A prior history of stroke or TIA often precedes the presentation of a new stroke. A history of valvular heart disease, atrial fibrillation, or MI is relevant.

 C. Risk factors. Patients need to be assessed for hypertension, cardiac disease (specifically atrial fibrillation), smoking, diabetes mellitus, hypercoagulable states, and hormonal therapy.

 D. Hospitalization. This may be necessary for patients with transient or ongoing ischemic deficits. TIAs can herald a high-grade carotid stenosis or occult left atrial thrombus.

Physical examination (PE)

 A. General examination. This should include vital signs (notably blood pressure), Mini-Mental Status Examination, and an examination of the eyes, including funduscopic. A screening neurologic examination of cranial nerves, coordination, muscle strength, sensation, deep tendon, reflexes, and gait is recommended.

 B. Additional PE. Evaluate the heart (arrhythmia, mitral stenosis) and vascular system (carotid bruits), and palpate the scalp and neck (trauma and migraine) and superficial temporal arteries (arteritis).

» READ BOOK EXCERPT ONLINE »

Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Stroke Syndromes: Differential Overview

(Field Guide to Bedside Diagnosis)

TIA/Stroke

❑ Middle cerebral artery stroke

❑ Anterior cerebral artery stroke

❑ Posterior cerebral artery stroke

❑ Watershed stroke

❑ Thalamic lacune

❑ Vertebrobasilar ischemia

❑ Pontine lacune

❑ Pontine stroke

❑ Midbrain stroke

❑ Pure motor hemiplegia

❑ Ataxic hemiparesis

❑ Lateral medullary stroke

❑ Temporal lobe stroke

Hemorrhage

❑ Subarachnoid hemorrhage

❑ Cerebellar hemorrhage

❑ Thalamic hemorrhage

❑ Pontine hemorrhage

❑ Putaminal hemorrhage

Diagnostic Approach

Brain ischemia leading to stroke may be due to embolism from carotid or cardiac sources, systemic hypoperfusion, or in situ thrombosis. Embolic strokes occur suddenly with maximal focal deficits at the onset. Rapid improvement favors an embolic TIA. Thrombosis symptoms fluctuate in a stepwise pattern. Intracerebral hemorrhage progresses gradually over minutes to hours. Aneurysmal subarachnoid hemorrhage occurs in an instant, and focal brain dysfunction is usually absent. Strokelike symptoms due to migraine are recognized by a headache, epiphenomena such as anorexia/nausea and photophobia, and occurrence in younger patients.

A TIA proceeds to stroke in 10% to 40%. Risk is especially high in “crescendo TIA,” which is usually caused by an ulcerated carotid plaque. Amaurosis fugax (“a shade coming down” or transient monocular loss of vision) is a classic presentation. Amaurosis fugax, an anterior circulation event, should be distinguished from transient hemianopsia, a posterior circulation event. An asymptomatic carotid bruit is an imperfect indicator of carotid stenosis and subsequent stroke risk, with an annual risk of an ipsilateral stroke not preceded by a TIA of 1% to 3% per year.

Examination of the optic fundus may reveal a cholesterol crystal, white platelet-fibrin or red clot emboli. Subhyaloid hemorrhage often accompanies a subarachnoid or intracerebral hemorrhage. A red patch with a white center (Roth spot) may be seen in bacterial endocarditis. With occlusion of the carotid artery, the iris may appear speckled and the ipsilateral pupil dilated and poorly-reactive.

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Aphasia/Dysarthria: Differential Overview
(Field Guide to Bedside Diagnosis)

Aphasia (Central)

❑ Broca

❑ Wernicke

❑ Conduction

❑ Anomic

❑ Global

❑ Motor aphasia

❑ Pure word deafness

❑ Alexia without agraphia

❑ Alexia with agraphia

Dysarthria (Peripheral)

❑ Bulbar

❑ Parkinson

❑ Multiple sclerosis

❑ Tongue infiltration

Diagnostic Approach

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Stroke: Diagnosis
(Handbook of Diseases)

Confirmation of stroke is based on symptoms, a history of risk factors, and the results of diagnostic tests.

❑ Computed tomography scan shows evidence of hemorrhagic stroke immediately but may not show evidence of thrombotic infarction for 48 to 72 hours.

❑ Magnetic resonance imaging may help identify ischemic or infarcted areas and cerebral swelling.

UNDER STUDY: Positron emission tomography can quantify cerebral blood flow. Single-photon emission tomography, computed tomography perfusion, and magnetic resonance perfusion techniques report relative blood flow and are research tools.

❑ Ophthalmoscopy may show signs of hypertension and atherosclerotic changes in retinal arteries.

❑ Angiography outlines blood vessels and pinpoints atherosclerotic plaques, vessel occlusion, or the rupture site.

❑ EEG helps to localize the damaged area.

Other baseline laboratory studies include urinalysis, coagulation studies, complete blood cell count, serum osmolality, and electrolyte, glucose, triglyceride, creatinine, and blood urea nitrogen levels.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Diseases, 2003

Dysarthria: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Obtain a history of the condition. When did it begin? Has it gotten better? Ask if dysarthria worsens during the day. Then obtain a drug and alcohol history. Also, ask about a history of seizures.

Physical examination

Explore dysarthria completely. Speech improves with resolution of a transient ischemic attack, but not in a completed stroke. Observe dentures for a proper fit. Ask the patient to produce a few simple sounds and words. Compare muscle strength and tone in the limbs on one side of the body with the other. Assess the patient’s tactile sense, DTRs, and note gait ataxia. Assess cerebellar function, test visual fields, and ask about the presence of double vision. Check for signs of facial weakness. Evaluate LOC and mental status.

» READ BOOK EXCERPT ONLINE »

Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

Dysarthria: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Explore dysarthria completely. When did it begin? Has it gotten better? Speech improves with resolution of a transient ischemic attack, but not in a completed stroke. Ask if dysarthria worsens during the day. Then obtain a drug and alcohol history. Also, ask about a history of seizures. While taking the patient’s history, pay attention to his speech. Dysarthria is usually evident in ordinary conversation. Observe dentures for a proper fit.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Dysarthria: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

If dysarthria isn't accompanied by respiratory muscle weakness and dysphagia, assess for other neurologic deficits. Compare muscle strength and tone in the limbs. Then evaluate tactile sensation. Ask the patient about numbness or tingling. Test deep tendon reflexes (DTRs), and note gait ataxia. Assess cerebellar function by observing rapid alternating movement, which should be smooth and coordinated. Next, test visual fields and ask about double vision. Check for signs of facial weakness such as ptosis. Next, determine the patient's level of consciousness (LOC) and mental status.

Obtain a patient history. Explore dysarthria completely. When did it begin? Has it gotten better? Speech improves with resolution of a transient ischemic attack, but not in a completed stroke. Ask if dysarthria worsens during the day. Then obtain a drug and alcohol history. Also ask about a history of seizures. Check dentures for a proper fit.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

DYSARTHRIA AND SPEECH DISORDERS: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Dysarthria without other symptoms or signs requires that myasthenia gravis be ruled out with a Tensilon test and psychometrics be done to rule out hysteria. In the presence of other neurologic signs, speech disorders require a thorough neurologic workup with an EEG, skull x-ray, and CT scan or MRI of the brain; a spinal tap or arteriogram may be indicated. The clinician should remember that dysarthria may be only the first sign of a serious neurologic disease such as multiple sclerosis, Wilson disease, lupus erythematosus, or chronic alcoholism; therefore, close follow-up is important.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

 » Next page: Signs of Stroke

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