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CNS CASE PRESENTATION - STROKE (CEREBROVASCULAR ACCIDENT)

MBBS Medicine Practical Examination - Complete Guide

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PART 1: CASE PRESENTATION

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PRESENTING THE CASE TO THE EXAMINER

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BIODATA

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CHIEF COMPLAINTS

1. Sudden onset weakness of right side of the body - 3 days
2. Inability to speak properly - 3 days
3. Deviation of angle of mouth to the left - 3 days

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HISTORY OF PRESENT ILLNESS

• No seizures at onset or afterwards
• No preceding TIA episodes (no prior transient weakness/vision loss/speech disturbance)
• No trauma
• No fever or neck stiffness

• No recent myocardial infarction
• No palpitations (no obvious AF)
• No visual complaints at onset
• No bladder/bowel involvement initially

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PAST HISTORY

• Hypertension - known for 8 years, on Tab. Amlodipine 5 mg OD, poorly controlled
• Type 2 Diabetes Mellitus - 5 years, on Tab. Metformin 500 mg BD
• No prior strokes or TIAs
• No history of cardiac disease, rheumatic fever, valvular heart disease
• No history of anticoagulant use

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PERSONAL HISTORY

• Diet: Mixed
• Appetite: Decreased since illness
• Sleep: Disturbed
• Bowel: Constipated since illness
• Bladder: No incontinence
• Smoking: 20 pack-year history, stopped 5 years ago
• Alcohol: Occasional, social
• No illicit drug use

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FAMILY HISTORY

• Father died of a "brain attack" (stroke) at 70 years
• Mother: Hypertension
• No family history of bleeding disorders

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SOCIOECONOMIC HISTORY

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SUMMARY OF HISTORY

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PHYSICAL EXAMINATION

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GENERAL EXAMINATION

• Patient conscious, alert, but anxious
• Lying in bed with right arm and leg in characteristic posture
• Oriented to person and place (difficulty in verbal response due to aphasia)
• Built: Average, mildly obese
• Nourishment: Adequate

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NEUROLOGICAL EXAMINATION

HIGHER MENTAL FUNCTIONS

• Consciousness: Alert, GCS = 14/15 (E4 V4 M6) - verbal score reduced due to aphasia
• Orientation: Oriented to person and place, partially to time
• Speech: Expressive aphasia (Broca's aphasia) - non-fluent speech, difficulty in naming and repetition, comprehension relatively preserved
• Memory: Difficult to fully assess due to aphasia
• Attention: Maintained

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CRANIAL NERVE EXAMINATION

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MOTOR SYSTEM EXAMINATION

• Wasting: None (acute presentation)
• Fasciculations: Absent
• Posture: Right arm flexed (flexion synergy), right leg extended
• Involuntary movements: None

• Right upper limb: Increased (spasticity/clasp-knife rigidity)
• Right lower limb: Increased (spasticity)
• Left limbs: Normal

• Finger-nose test: Unable to perform on right. Normal on left.

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REFLEXES

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SENSORY SYSTEM

• All modalities (pain, temperature, light touch, vibration, proprioception) reduced over right side
• Cortical sensations (two-point discrimination, stereognosis): Impaired on right
• No sensory level

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CEREBELLAR EXAMINATION

• Gait: Unable to assess (patient bedridden)
• No nystagmus, dysarthria (masked by aphasia), dysdiadochokinesia not testable on right

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MENINGEAL SIGNS

• Neck stiffness: ABSENT
• Kernig's sign: ABSENT
• Brudzinski's sign: ABSENT

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PART 2: DISCUSSION

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SUMMARY OF EXAMINATION FINDINGS

1. Expressive (Broca's) aphasia
2. Right homonymous hemianopia
3. Right-sided UMN facial palsy
4. Right-sided spastic hemiplegia (UMN pattern - tone increased, power reduced, reflexes exaggerated, Babinski positive)
5. Right-sided hemisensory loss
6. Gaze deviation to the left

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DIAGNOSIS

• Sudden onset
• Right hemiplegia (contralateral to lesion) - UMN pattern
• Expressive aphasia (left hemisphere dominant for language in right-handed individuals)
• Right homonymous hemianopia
• Right hemisensory loss
• Hypertensive, diabetic, smoker - multiple vascular risk factors
• Gaze deviation towards lesion side
• Absence of meningeal signs (against hemorrhage/meningitis)
• Absence of fever (against meningitis/cerebral abscess)

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CLASSIFICATION OF STROKE

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INVESTIGATIONS

Immediate (Emergency)

1. Non-contrast CT Brain - FIRST investigation; to exclude hemorrhage (appears as hyperdense area within 6 hours; ischemic infarct appears hypodense after 24-48 hours)
2. MRI Brain (DWI - Diffusion Weighted Imaging) - Most sensitive for early ischemic stroke (shows restricted diffusion within minutes to hours)
3. 12-lead ECG - Atrial fibrillation? Evidence of MI?
4. Blood glucose (exclude hypoglycemia mimicking stroke)
5. Complete blood count (CBC)
6. Coagulation profile: PT, aPTT, INR
7. Renal function tests (BUN, creatinine)
8. Electrolytes (Na, K)
9. Cardiac enzymes (Troponin I/T)
10. Serum lipid profile

To Determine Etiology

1. 2D Echocardiogram - Valvular disease, thrombus, patent foramen ovale
2. Carotid Doppler ultrasound - Carotid stenosis/plaques
3. MR Angiography (MRA) or CT Angiography (CTA) - Vascular occlusion site
4. Holter monitoring (24-48 hours) - Paroxysmal AF
5. HbA1c - Glycemic control assessment
6. Fasting lipid profile

Expected Results in This Patient

• CT brain: Normal in first 6-24 hours OR may show early MCA sign (hyperdense MCA)
• MRI DWI: Bright signal in left MCA territory (restricted diffusion)
• ECG: May show left ventricular hypertrophy (due to hypertension)
• Blood glucose: Elevated (uncontrolled DM)

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MANAGEMENT

A. ACUTE MANAGEMENT (First 24-72 hours)

• Ensure airway (position patient, suction if needed)
• O2 supplementation only if SpO2 <94%
• IV access - two large bore peripheral lines
• Cardiac monitoring and continuous pulse oximetry
• Nil by mouth initially (dysphagia risk - NGT if needed)
• Foley catheter for urinary output monitoring

• In ischemic stroke patients NOT receiving thrombolysis: Allow permissive hypertension (do NOT lower BP unless >220/120 mmHg) - brain needs collateral perfusion
• If eligible for tPA: Lower BP to <185/110 mmHg before administration
• Avoid abrupt BP lowering - can worsen ischemia

• Target: 140-180 mg/dL
• Treat hypoglycemia (<60 mg/dL) immediately - it mimics stroke
• Avoid hyperglycemia (worsens infarct)

• Indication: Ischemic stroke within 4.5 hours of symptom onset
• Dose: 0.9 mg/kg IV (max 90 mg); 10% as bolus, 90% over 60 min
• NIHSS should be documented before administration

• Hemorrhage on CT
• BP >185/110 mmHg (refractory)
• Platelet count <100,000/mm³
• INR >1.7 or on anticoagulants
• Recent surgery (<14 days)
• Prior stroke or head trauma within 3 months
• Blood glucose <50 or >400 mg/dL
• Known intracranial hemorrhage, AVM, or tumor

• Indication: Large vessel occlusion (LVO), within 6-24 hours if mismatch criteria met
• Highly effective for proximal MCA/ICA/basilar artery occlusion

• Aspirin 300 mg stat (if no hemorrhage on CT and thrombolysis not given/completed >24 hrs)
• Do NOT give aspirin within 24 hours of tPA

B. SECONDARY PREVENTION

C. REHABILITATION

• Physiotherapy (early mobilization - Day 1-2 if stable)
• Occupational therapy (ADL retraining)
• Speech therapy (for aphasia and swallowing)
• Psychological support
• Prevention of complications: DVT prophylaxis, pressure sores, aspiration pneumonia

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COMPLICATIONS

• Cerebral edema (peak at 3-5 days) - malignant MCA infarction
• Hemorrhagic transformation
• Aspiration pneumonia (most common cause of early death)
• DVT and pulmonary embolism
• Urinary tract infection
• Pressure sores

• Post-stroke depression (very common, ~30%)
• Spasticity and contractures
• Epilepsy (post-stroke seizures)
• Vascular dementia
• Recurrent stroke (risk ~10% in first year)

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PART 3: COMPLETE VIVA QUESTIONS AND ANSWERS

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SECTION A - DEFINITION AND CLASSIFICATION

• Ischemic stroke (80%): Thrombotic (large vessel, small vessel/lacunar), Embolic (cardiogenic, artery-to-artery)
• Hemorrhagic stroke (20%):
  • Intracerebral hemorrhage (ICH) - 15%
  • Subarachnoid hemorrhage (SAH) - 5%

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SECTION B - ETIOLOGY AND RISK FACTORS

• Non-modifiable: Age (>55 years, risk doubles each decade), sex (males > females), race, family history, prior stroke/TIA
• Modifiable:
  • Hypertension (most important, accounts for ~50% attributable risk)
  • Atrial fibrillation (5-fold increased risk)
  • Diabetes mellitus
  • Hyperlipidemia
  • Smoking
  • Obesity
  • Physical inactivity
  • Excessive alcohol use
  • Oral contraceptive pills (especially + smoking + migraine with aura)
  • Carotid artery stenosis
  • Cardiac disease (heart failure, valvular disease, PFO)

• Most common: Atrial fibrillation (AF) - 50% of cardioembolic strokes
• Rheumatic heart disease with mitral stenosis
• Infective endocarditis
• Prosthetic heart valves
• Acute MI with mural thrombus
• Left ventricular aneurysm
• Cardiomyopathy with reduced EF
• Patent foramen ovale (PFO) - paradoxical embolism
• Left atrial myxoma (rare but important)

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SECTION C - PATHOPHYSIOLOGY

• Core: CBF <10-12 mL/100g/min - irreversibly infarcted tissue within minutes
• Penumbra: CBF 12-23 mL/100g/min - ischemic but potentially salvageable tissue if reperfusion occurs in time

• The left FEF is damaged
• The right FEF is unopposed
• Eyes are driven to the LEFT (towards the side of the lesion)
• The patient "looks towards the lesion" This is contrasted with pontine lesions where the eyes deviate AWAY from the lesion (towards the hemiplegia side).

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SECTION D - CLINICAL FEATURES AND SYNDROMES

• Contralateral hemiplegia (face and upper limb > lower limb)
• Contralateral hemisensory loss
• Contralateral homonymous hemianopia
• Conjugate gaze deviation towards lesion side
• Left MCA (dominant hemisphere): Aphasia (Broca's or Wernicke's depending on division)
• Right MCA (non-dominant hemisphere): Contralateral neglect, anosognosia, constructional apraxia
• Severe malignant MCA infarction can cause life-threatening cerebral edema

• Ipsilateral: Facial pain and temperature loss (V), Horner's syndrome (ptosis, miosis, anhidrosis), cerebellar signs, dysphagia, dysarthria
• Contralateral: Pain and temperature loss in the limbs and trunk (spinothalamic)
• Dissociated sensory loss (crossed pattern - hallmark)
• Vertigo, nystagmus, hiccup
• Motor power is PRESERVED (pyramidal tracts spared)

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SECTION E - DIAGNOSIS AND INVESTIGATIONS

1. Exclude intracerebral hemorrhage (appears as hyperdense/bright white area)
2. Exclude other structural causes (tumor, subdural hematoma)
3. Determine eligibility for thrombolysis (must exclude hemorrhage first) Note: CT is normal in the first 6-24 hours in ischemic stroke.

• 0-6 hours: Often normal; may show early signs:
  • Hyperdense MCA sign (thrombus in MCA)
  • Loss of gray-white matter differentiation
  • Sulcal effacement
  • Insular ribbon sign (loss of insular cortex demarcation)
• 12-24 hours: Hypodensity in infarcted area
• 24-48 hours: Well-defined hypodense area corresponding to vascular territory
• 1-2 weeks: Fogging effect (isodense)
• Weeks-months: Encephalomalacia (cavitation/cystic area)

• Guide thrombolysis eligibility (score 4-22 typically eligible)
• Monitor progression
• Predict outcome
• Research standardization

• ECG and Holter: AF detection
• 2D Echo: Cardiac source of embolism
• Carotid Doppler: Atherosclerotic stenosis
• CT/MR Angiography: Large vessel disease, dissection
• Lipid profile: Hyperlipidemia
• HbA1c: Glycemic control
• Thrombophilia screen (young stroke): Protein C, S deficiency; Antiphospholipid antibody syndrome; Factor V Leiden; Homocysteine
• Vasculitis screen: ANA, ANCA, anti-dsDNA, VDRL (syphilis)
• TTE/TEE: Paradoxical embolism (PFO)

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SECTION F - TREATMENT

• Inclusion: Ischemic stroke with measurable neurological deficit (NIHSS 4-22 typically); onset within 4.5 hours; age >18 years; NCCT showing no hemorrhage
• Key Contraindications:
  • Hemorrhage on CT
  • BP >185/110 mmHg (refractory to treatment)
  • Recent surgery within 14 days (major); within 3 months (head/spine)
  • Active bleeding or coagulopathy (INR >1.7, platelets <100,000)
  • Recent MI or stroke within 3 months
  • Blood glucose <50 or >400 mg/dL
  • Seizure at onset with postictal deficit
  • Prior intracranial hemorrhage

• 10% (0.09 mg/kg) given as IV bolus over 1 minute
• Remaining 90% infused over 60 minutes
• Monitor closely for bleeding complications; ICH can occur in 6%

• Normal autoregulation is lost in the ischemic penumbra
• CBF becomes PRESSURE-DEPENDENT (pressure-passive)
• Lowering BP reduces perfusion pressure and extends infarction into penumbra
• Therefore, permissive hypertension is allowed: do NOT treat unless BP >220/120 mmHg (if no thrombolysis)
• If giving tPA: Lower BP to <185/110 mmHg first, then maintain <180/105 during infusion
• After 24-48 hours: Gradually normalize BP

• Large vessel occlusion confirmed on CTA/MRA
• Within 6 hours of onset (up to 24 hours if DWI-perfusion mismatch criteria met - DAWN/DEFUSE 3 trials)
• NIHSS >6 (significant deficit)
• Premorbid mRS 0-1 (good functional status)
• It significantly reduces disability (NNT ~2.6 for good outcome)

• Acute phase (within 24-48 hrs of non-thrombolyzed stroke): Aspirin 300 mg stat, then 75-100 mg/day
• Long-term: Aspirin 75 mg OD OR Clopidogrel 75 mg OD
• For high-risk TIA/minor stroke (ABCD2 score ≥4): Dual antiplatelet (Aspirin + Clopidogrel) for 21 days, then monotherapy
• Cardioembolic stroke (AF): Anticoagulation preferred - Warfarin (INR 2-3) or NOAC (Apixaban, Rivaroxaban, Dabigatran)
• Statins are given regardless of cholesterol level in ischemic stroke

• TIA/minor stroke: Anticoagulate early (within 48-72 hours)
• Moderate stroke: Delay 5-7 days
• Large stroke: Delay 14 days
• Use NOAC (preferred over warfarin) unless valvular AF (mechanical valve/rheumatic MS) where warfarin is indicated

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SECTION G - DIFFERENTIALS AND COMPLICATIONS

1. Hypoglycemia (most important mimic - always check blood glucose urgently)
2. Todd's paralysis (post-ictal paresis after seizure)
3. Hemiplegic migraine
4. Brain tumor with sudden decompensation
5. Subdural/epidural hematoma
6. Hypertensive encephalopathy
7. Encephalitis/meningitis
8. Multiple sclerosis (acute demyelination)
9. Complex partial seizure
10. Conversion disorder (functional neurological disorder)

• HI1/HI2: Petechial hemorrhage (Hemorrhagic Infarct) - usually asymptomatic
• PH1/PH2: Parenchymal Hematoma - PH2 (>30% of infarct volume) is clinically significant, worsens outcomes Risk factors for hemorrhagic transformation: Large infarct, cardioembolic cause, thrombolysis, anticoagulation, hyperglycemia.

• Progressive decrease in consciousness
• Herniation (uncal, transtentorial)
• Mortality up to 80% with medical treatment alone
• Treatment: Decompressive hemicraniectomy (removal of skull flap to allow brain expansion) - significantly reduces mortality and disability, especially in patients <60 years performed within 48 hours (DESTINY, HAMLET, DECIMAL trials).

• Decreasing level of consciousness (most important early sign)
• Headache (worsening, positional)
• Vomiting (projectile)
• Bradycardia + hypertension + irregular respiration = Cushing's triad (late, ominous sign)
• Papilledema (fundus)
• Third nerve palsy (uncal herniation - fixed dilated pupil)
• False localizing sixth nerve palsy

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SECTION H - IMPORTANT CLINICAL QUESTIONS

• F - Face drooping (ask patient to smile - uneven?)
• A - Arm weakness (ask patient to raise both arms - one drifts?)
• S - Speech difficulty (slurred or strange speech?)
• T - Time to call emergency services

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SECTION I - DRUGS USED IN STROKE

• Antiplatelets: Aspirin, Clopidogrel, Dipyridamole
• Anticoagulants (AF): Warfarin, Apixaban, Rivaroxaban, Dabigatran, Edoxaban
• Statins: Atorvastatin 40-80 mg (LDL target <70 mg/dL or <1.8 mmol/L)
• Antihypertensives: ACE inhibitors (Ramipril/Perindopril + Indapamide most studied - PROGRESS trial)
• Diabetes management: Metformin, newer agents (GLP-1 agonists may have cardiovascular benefits)

• Reduce recurrent stroke risk by ~20%
• Pleiotropic effects: anti-inflammatory, plaque stabilization, endothelial protection
• Target LDL <70 mg/dL (1.8 mmol/L) or ≥50% reduction from baseline
• Caution: Statins should NOT be started acutely for hemorrhagic stroke (theoretical risk of worsening bleeding)

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SECTION J - IMPORTANT EXAM POINTS TO REMEMBER

• "Time is brain" - approximately 1.9 million neurons die every minute of stroke
• IV tPA window: Within 4.5 hours of symptom onset
• Mechanical thrombectomy: Within 6-24 hours (LVO with salvageable tissue)
• Door-to-needle time (for tPA): Target <60 minutes
• Door-to-groin puncture time (for thrombectomy): Target <90 minutes

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TIPS FOR THE VIVA

1. Always start with: "This is a case of left/right-sided MCA territory ischemic stroke" - be definitive
2. When asked about facial palsy - always immediately say "forehead spared - UMN"
3. Babinski sign = extensor plantar = UMN lesion - say this clearly
4. CT before tPA - never give tPA without excluding hemorrhage
5. "Time is brain" - mention it, it impresses examiners
6. If asked about young stroke (<45 years) - think: dissection, APS, PFO, vasculitis, CADASIL, cocaine use
7. Always discuss rehabilitation as part of management
8. Know the difference between stroke syndromes (MCA vs ACA vs PCA vs posterior fossa)
9. Mention NIHSS - shows you know current clinical practice
10. FAST acronym - important for the community medicine aspect

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What This Contains

• Realistic case: 62-year-old hypertensive diabetic male with left MCA stroke
• Complete history (presenting complaints, HPI, past history, social/family)
• Full neurological examination with expected findings, organized in standard examination order (Higher functions → Cranial nerves → Motor → Sensory → Reflexes → Cerebellum → Meningeal)
• Summary statement in examiner-ready format

• Diagnosis with clinical basis
• Stroke classification table
• Investigations (acute + etiological) with expected results
• Complete management (ABC, BP management, tPA criteria/dose, thrombectomy, secondary prevention, rehabilitation)
• Complications

• Definitions and classification
• Etiology and risk factors (including CHA2DS2-VASc, ABCD2 scores)
• Pathophysiology (penumbra, UMN vs LMN facial palsy, gaze deviation, tongue deviation)
• Vascular syndromes (MCA, ACA, PCA, Wallenberg)
• Aphasia types (Broca's vs Wernicke's)
• CT scan findings at each time point
• tPA eligibility, dose, and contraindications
• BP management rationale in acute stroke
• Mechanical thrombectomy, antiplatelets, anticoagulation
• Differentials (including hypoglycemia - most important mimic)
• Hemorrhagic transformation, malignant MCA, raised ICP
• Drugs in secondary prevention
• 10 practical exam tips