Everyday First Aid: Stroke
Mrs D?
Oh, man.
Mrs D?
F.A.S.T.
F- face. It looks a bit droopy.
Can you give us a smile, Mrs D?
(The woman mumbles)
A - arms.
Mrs D, can you raise your arms for me? Mrs D?
That's it. And the other one?
S - speech.
Mrs D, speak to me.
Tell me how you're feeling.
(The woman mumbles, frustrated)
T - time. Time to call an ambulance.
Don't worry, Mrs D, I’m not going anywhere.
I’m just getting us some help.
Hello?
Can I have an ambulance, please?
I’ve done the F. A. S.T. test and I think it’s a stroke…
Mrs D, don't worry. I’m not going anywhere, Mrs D.
It’s okay. Help’s on the way, it’s going to be fine.
Carry out the FAST test
Face: is there a weakness on one side of the face?
Arms: can they raise both arms?
Speech: are they easily understood?
Time: to call 999.
Remember:
Carry out the FAST test
https://www.youtube.com/watch?v=PCNTMIcOMpE
Diagnosing strokes with imaging CT, MRI, and Angiography
- [Voiceover] So, we know that
once a stroke is suspected
immediate diagnosis and treatment
is really really important,
so that if a stroke has actually occurred
than treatment can get underway
to save as much brain tissue as possible.
So, what are the parts of diagnosis?
Well, the health care team will
sort of interview the
patient about their symptoms
and do some physical exams.
And that's to test the
patient's neurological system
to look for any compromise
due to the stroke.
But an extremely important
part of diagnosing stroke
is doing imaging tests to
actually look at the brain
and actually see what's going on in there.
So, what sorts of imaging,
what sorts of scans
can be done to look at the brain?
Well, let's go through a few
of the more common and important ones.
So, first up, you'd likely
get an immediate CT scan
or Computerized Tomography Scan
which is basically a special type of x-ray
that takes lots of images
from lots of different levels and angles.
And the end result is that you get to look
at the brain in lots of different views.
So, this is a view of the brain here
that was generated with a CT scan
and we're looking at this brain
as if it's been cut from front to back,
what's known as an axial view.
So this is a normal brain, right?
No stroke or anything has
happened to this brain,
and I just want to point out a few things.
And actually, let me also
say that we're looking
at this brain from the bottom up,
so that makes this the left side
and this the right side.
And that'll be the case
for all the images we see,
so keep that in mind.
So, what are some of the
features of normal brain on CT?
Well you can see the nice,
fairly well delineated
curves of the brain tissue here,
and you can also see
that the edges, right,
the surface of the brain
look a little different
from just below the surface,
and that's a reflection of the gray matter
on the outside of the brain
and the white matter on the
inner parts of the brain.
And one more thing I might mention
is that you can see this normal brain
looks nice and symmetrical, right?
Everything is pretty even
about the left and the right sides.
But, what about a brain
that's had a stroke?
Well that's where things get
a little bit more interesting
because you actually
can't immediately tell,
like even if you took a CT
scan of a person's brain
a few minutes or even like an hour
after they've had a stroke,
it would look pretty much
like this normal CT scan here,
and that's because the changes
that happen in the brain
during and after a stroke,
they take time to develop
and sometimes you can't
see any brain changes
on CT until about half a day
after the stroke has occurred.
Usually about 12 to 18 hours after
is when you can start
seeing some changes on CT.
Having said all of that,
even though you might not be able to see
any brain tissue changes
right after a stroke,
at least not on a CT scan,
as I keep mentioning,
you might be able to see
a clot that caused it.
So, here's a CT scan taken
pretty quickly after a stroke,
like within a few hours,
and what you might
notice is this thing here
which is actually the Left
Middle Cerebral Artery.
It certainly stands out doesn't it?
One might even say it looks "hyper dense",
and in fact, this is called
the MCA Hyperdense Sign.
And that signifies that
there's possibly a clot there.
So, in some cases, that
may be one of the things
that you can see early on a CT,
but let me bring up another CT.
So, this scan here is from
48 hours after a stroke.
So, let's see how things have evolved.
You can see some swelling developing here,
and remember neurons have been swelling up
and dying off and inflammation
in this brain region
result in all this swelling
that you see here, right?
And notice where it is.
It's on the outside, sort of the side bit
of the brain here on the left.
And remember the outer sides of the brain
are primarily supplied with blood
by the Middle Cerebral Artery.
So, just to jump back a bit
in the diagnosis timeline,
by this point, you'd have already done
your physical exam on this person,
and you probably discovered some problems
on the right side of their body,
maybe some weakness of
their right-sided limbs
or something like that.
So, you'd already be suspecting
that there's a problem on
the left side of their brain,
and this CT scan certainly adds
some evidence to your diagnosis now.
So, a few other things to notice.
In our stroke brain,
our nice well-delineated curves
of the surface of the brain
are not really so present
anymore because of the swelling.
And notice that the surface of the brain
is starting to look pretty similar
to what's underneath
in contrast to the normal side over here
where there's good differentiation
between gray matter on
the outside of the brain
and white matter underneath.
So, in the brain with
the stroke developing,
you actually start to lose
this gray-white differentiation
and things start to look a little bit more
the same as each other,
and that's another sign
of stroke on a CT scan.
And maybe the last thing I'll mention
is the disruption of the
left and right sided symmetry
that we talked about earlier.
So in this stroke brain,
you can pretty quickly see
that there's some bulging of this
left side over to the right.
And again that's caused by
swelling over on this side,
and it's referred to as a Mass Effect.
And this is an extra bad sign
because it can cause compression
of other parts of the brain
from them being pushed on,
and that can be fatal.
And you can actually
already see an example
of this Mass Effect by the
swollen area here pushing on
and reducing the volume
of these brain ventricles.
These ventricles, by the way,
they produce your Cerebral Spinal Fluid,
your CSF that bathes and
nourishes your brain.
And actually just one more thing.
These images are of the most common
type of stroke, Ischemic Stroke.
But here's a CT image of the less common
type of stroke: Hemorrhagic Stroke.
And CTs are really good for diagnosing
these hemorrhagic strokes
because blood leaking out of your
cerebral circulation and
into your head space,
they show up really well on CT
as an abnormal, bright area.
So, that's blood there.
So, maybe we'll leave this
normal type of CT scanning now
and just take a brief look at another
kind of CT imaging you can do.
So, I just wanted to spend a bit of time
on this basic CT technique though
because they're pretty much
the first scan you order,
and they can give you a lot
of information about what's going on.
So this sub-type of CT scanning,
this one that we'll talk about now,
is called CT Angiography,
and it can give you a lot of
useful information as well,
and it's actually pretty cool.
So, a special dye gets
injected into your bloodstream,
and it makes your blood vessels
sort of light up on a CT scan.
So then it's really easy to see
where in your cerebral blood vessels
the problem is that caused the stroke
cause everything's all lit up.
So, look here.
Here's our blood vessels, right?
Nicely lighting up, and
we're following along,
and we're following along,
and everything looks good, it's good.
Whoa. Houston we have a problem.
This bit looks abnormal.
This is where our blockage is
which likely caused our stroke,
and this scan made it a lot
easier to pinpoint that.
And in another type of angiography,
you can use computer software to hide
the image of the actual brain tissue
and surrounding structures in your head,
like your skull and your meninges, etc.
So, what you're left with is
just these cerebral blood vessels.
And it's pretty cool, right?
You can actually see that everything
that is not a blood vessel has
been hidden using a computer
and now this image here can give us
a pretty clear idea of
what caused the stroke.
Everything looks good,
looks good, good, good...
Whoa. Blockage. Sudden stop here, right?
So, blood's not going through here,
and that's a problem for the
tissue on the other side.
So the last type of scan we'll look at
is probably something
you've already heard of
called MRI scanning or
Magnetic Resonance Imaging.
This is the one that Dr. House
probably has right in his office
because for some reason
all of his patients
seem to get one right away
which is kind of interesting.
Anyway, these use magnetic
fields and radio-waves
to provide some really high
resolution images of the body.
In our case, they let us
see the tissues of the brain
and the surrounding
structures pretty well.
And they're actually more sensitive
in detecting brain
ischemia than CT scans are,
but they're less available and
they take a lot longer to do
than a quick, sort of
readily available CT scan
which is still really, really good.
But let's actually look
at these MRI images.
So, remember how I said that it can take
up to a day almost for brain
changes to appear on a CT scan?
Yeah, that's not the case with MRI.
These images were taken a mere half hour
after the patient started
having their stroke symptoms,
just incredible.
So, you can see that there's already
ischemic brain changes happening
in the right MCA territory here.
And these next set of images,
these look pretty fun and colorful.
These are special MRI images
that measure how much blood flow
is running through your brain.
So, this right half of the brain
in this patient is normal, right?
This is how normal blood flow looks,
but on the left here, you can see that
there's a lack of blood flow going on.
That's what a lack of
blood flow looks like.
So, it would make you think of a clot
in the left Middle Cerebral Artery
because the MCA is what serves
this area here on the left.
And these were only taken actually an hour
after symptom onset in this patient.
So, you can see how quickly
MRI can detect stroke.
And the last image we'll look at is
another type of MRI called the Flair MRI
in which pictures of the brain are taken
but then computer software removes any
fluid in the brain from
showing up in the final image.
So, what you end up with is just
a super clear image of
just the brain tissue.
So you can see in this
high resolution, crisp
Flair image that there's a lesion.
There's some damage happening
in the left half of the brain here.
So, those are some of the more important
imaging tests that happen
as part of a stroke work-up.
CT, Angiography, and MRI.
https://www.youtube.com/watch?v=xC55TgPmfZ0
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