Stroke Localisation
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This study aimed to compare clinical diagnoses of stroke localization to CT scan findings in 110 patients. Clinically, 80.9% were diagnosed with cerebral infarction and 19.1% with cerebral hemorrhage. CT scans confirmed infarction in 83% and hemorrhage in 47.6%. Left parietal/temporo parietal infarction was the most common clinical diagnosis (43 patients) and CT scans confirmed this in 41 patients. Middle cerebral artery territory involvement was most frequent. The study concluded that clinical localization of stroke is not always accurate but CT scans help provide confident diagnoses and inform prognosis and treatment.
Stroke Localisation
- 1. Original Article Stroke Localization: Clinical Correlation versus Findings of CT Scan Brain in Patients Admitted at Liaquat University Hospital Hyderabad/Jamshoro Ghulam Hussain Baloch, Samiullah Shaikh, Mukhtiar Hussain Jaffery, Suhail Ahmed Almani, Noor Muhmmad Memon and Muhammad Qasim ABSTRACT OBJECTIVE: To study clinical localization of stroke and correlate with findings on C-T Scan of brain. DESIGN: Observational study. PLACE AND DURATION OF STUDY: The study was conducted at the Medical Department of Liaquat University Hospital Hyderabad/Jamshoro from January 2006 to December 2006. MATERIAL AND METHODS: Total 110 patients with features of stroke were included in this study. These patients were further evaluated for clinical correlation with findings on CT scan brain, done within 24 hours after the development of focal neurological deficit. Brain tumor, meningitis, viral or bacterial encephalitis, multiple sclerosis and metabolic derangements that could explain focal neurological deficit e.g hypoglycemia were` the exclusion parameters. RESULTS: Total of 110 patients, 60 (54.5%) were males and 50 (45.5%) were females. Age of pa- tients ranged 22-84 years with mean±SD age of 53±5 years. On clinical ground cerebral infarc- tion was suspected in 89 (80.9%) and cerebral hemorrhage in 21 (19.1%) patients. In 74 (83%) patients infarction was confirmed by CT scan brain, whereas cerebral hemorrhage was proved in 10 (47.6%) out of a total of 21 patients. These patients were further evaluated for clinical local- ization of area of stroke. Clinically left parietal / temporo parietal lobe infarction was suspected in 43 patients and right parietal / temporo parietal lobe in 25 patients. Left frontal lobe infarction in 7 patients right frontal lobe infarction in 8 patients, left internal capsule infarction in 2 pa- tients and right internal capsule infarction in 4 patients. Comparing with the CT scan brain find- ings: left parietal / temporo parietal lobe infarction was confirmed in 41 (95.34%) patients, right parietal / temporo parietal lobe in 19 (76%), left frontal lobe in 5 (71.4%), right frontal lobe in 4 (50%), left internal capsule in 2 (100%) and right internal capsule in 3 (75%) patients. Left middle cerebral artery territory involvement was observed in 43 (58%) patients and right middle cerebral artery territory in 22(30%) patients. No Significant difference was observed in other cerebral artery territories. CONCLUSION: It was concluded from the study that cerebral infarction was more common than hemorrhage and middle cerebral artery territory infarction of both sides was more common than other cerebral artery territories. Localization of stroke on clinical basis is not always easy. Con- fident diagnosis requires careful case history taking, extensive neurological assessment and with the help of focal neurological deficit of a particular area. CATEGORY: Internal Medicine KEYWORDS: Stroke - Ischemic strokes - Intra cerebral hemorrhage - localization. INTRODUCTION Ethnic, socio-economic and dietary factors may be responsible for this variance. Retrospective analysis Stroke is defined as ‘the rapidly developing clinical of patients admitted with stroke in two hospitals of the symptoms and sign of focal (or global) disturbance of same locality some 8 years ago in Karachi, Pakistan cerebral function with symptoms lasting for more than showed that out of the 12,454 cases 796(6.4%) had 24 hours or longer or leading to death with no appar- stroke. 3 According to WHO report 2002, total mortality ent cause other than vascular origin1. Stroke ranks due to stroke in Pakistan was 78512.4 The incidence second after ischemic heart disease as a cause of of stroke varies among countries and increases expo- DALY (Disability Adjusted Life in Years) in high- nentially with age.5 It is also the leading cause of dis- income countries and as a cause of death worldwide.2 JLUMHS JANUARY - APRIL 2009; Vol: 08 No. 01 03
- 2. Stroke Localization: ability in adults. Among the 350,000 survivors each RESULTS year, 31% require assistance in activities of daily liv- Total 110 patients were evaluated, 60 (54.5%) were ing, 20% require assistance in walking and 16% re- males & 50 (45.5%) were females. Age of patients quire institutional care.6 Stroke not only increases range 22-84 years with mean age of 53 ± 5 years. mortality but also put a great economic burden on the Stroke was found more commonly in age group of 51- society.7 In western societies, about 80% of strokes 70 years in 54 (49%). Patients of more than 70 years are caused by focal cerebral ischemia and the remain- of age were 22 (20%), between 30-50 year 20 ing 20% are caused by hemorrhages.5 It is difficult to (18.2%) & under 30 year 14 (12.8%) (Figure I). Of asses clinically about the type of stroke in the majority these 110 patients 89 (80.9%) were diagnosed cere- of patients as there is no specific differentiating fea- bral infarction on clinical ground and 21 (19.1%) pa- ture. Computed tomography scan brain (plain) is an tients were diagnosed cerebral hemorrhage. Area of accurate, safe and noninvasive procedure for differen- stroke was localized clinically by presence of focal tiating between cerebral infarction and hemorrhage. It also shows site of lesion. Though the mortality for neurological signs of particular area of brain (Table I) stroke has been on the decline still it represents and confirmed by CT scan brain done within 24 hours the most common cause of chronic disability. Lo- of development of focal neurological deficit as shown calization of stroke on clinical basis is not always in Table II. Distribution of cerebral arterial territories easy. With the help of focal neurological deficit for par- involvement is described in Table III. Out of these 89 ticular area we would be able to make confident diag- (clinically diagnosed cerebral infarctions), in 74 (83%) nosis. Localization area of stroke helps in prognosis patients infarction was confirmed by CT scan brain, outcome, occupational and therapeutic strategies. whereas in remaining 15 (17%) patients CT scan brain This localization of stroke is easily done by careful was normal or inconclusive. Out of 21 clinically sus- history taking and extensive neurological examination. pected hemorrhagic stroke patients, only 10 (47.6%) The purpose of this study was to determine clinical were confirmed by CT scan. We further correlate the stroke localization in admitted patients and correlation clinically diagnosed area of brain involvement with CT with findings on CT scan of brain in patients hospital- scan brain findings. In 43 patients left parietal lobe ized at Liaquat University Hospital Hyderabad / infarction was suspected clinically and confirmed by Jamshoro. CT scan in 41 (95.4%) patients. Whereas in right tem- poro parietal lobe infarction was suspected in 25 pa- METHOD AND MATERIAL tients, infarction was confirmed in 19 (76%) patients. Patients admitted to medical ward of Liaquat Univer- Left frontal lobe infarction was suspected clinically in sity Hospital Hyderabad / Jamshoro during the period 07 patients and confirmed by CT scan in 05 (71.4%) of January 2006 to December 2006. This was an ob- patients. Right frontal lobe infarction was suspected in servational study in patients above the age of 18 08 patients confirmed by CT scan in 04 (50%) pa- years with stroke, verified by CT scan brain done tients. In 02 patients infarction was suspected at left within 24 hours after the development of focal neuro- internal capsule and CT scan confirm area of involve- logical deficit. The area of brain involvement was as- ment in both (100%). Whereas in 04 patients right in- sessed by clinical determination of focal neurological ternal capsule infarction was suspected and infarction deficits. All these patients were further evaluated to was confirmed in 03 (75%) patient. Of 21 clinically clinically distinguish between ischemic or hemorrhagic diagnosed cerebral hemorrhages 12 were diagnosed stroke by history of unconsciousness, headache, vom- intra lobar cerebral hemorrhage and 09 were sub ara- iting, elevated blood pressure and other clinical neuro- chonoid (ventricular) hemorrhage. On CT scan brain logical findings. Patients with meningitis, brain tumor, intra lobar cerebral hemorrhage in was found in 03 encephalitis, epilepsy, hepatic coma, history of head (30%) patients and sub arachonoid (ventricular) hem- injury, TIA, multiple sclerosis & metabolic degenera- tive disorders that could explain focal neurological orrhage in 05 (50%) patients, in 1 (10%) case basal defect e.g, hypoglycemia were exclusion parameters. ganglia hemorrhage and in 1 (10%) case multiple Data were analysed by SPSS V. 13. cerebral hemorrhage (Figure II). JLUMHS JANUARY - APRIL 2009; Vol: 08 No. 01 04
- 3. Ghulam Hussain Baloch, Samiullah Shaikh, Mukhtiar Hussain Jaffery, Suhail Ahmed Almani, Noor M. Memon and M. Qasim FIGURE I: with stroke was 53 ± 5 year. That is compatible with Age Distribution (n=110) study done by Jahangir et al8, and also study done by Zahir Shah at Peshawar. 9 He noticed in his study that mean presenting age of stroke patients was 55 years. 60 Localization of area of infarction on the basis of clini- cal focal neurological deficit is not always accurate. 50 With the help of focal neurological deficit for particular 24 area, we were able to make confident diagnosis. This 40 No. of Patients Clinical localization of stroke is best done by careful history taking and extensive neurological assessment. 30 Localizing area of stroke helps in prognosis and out- 20 come of stroke patients and therapeutic or occupa- 6 30 12 tional strategies. In our study parietal / temporo parie- 10 8 tal lobe infarction (middle cerebral artery territory) of 14 6 10 both side is more significant than other lobar infarction 0 (anterior cerebral and posterior cerebral artery territo- > 30 31-50 51-70 > 70 ries). Zahir Shah in his study observed that middle Age (in years) cerebral artery territory was most commonly involved 9 . About 80% of the patients had infarction of carotid Male Female TABLE I: FOCAL NEUROLOGICAL DEFECIT / CLINICAL DIAGNOSIS Focal Neurological No. of Clinical Diagnosis Focal Neurological No. of Clinical Diagnosis Deficit Patients Deficit Patients Right arm and face Right-Parietal/ Left arm and face weakness > leg 30 Left parietal Lobe 25 Temporo-parietal weakness > leg Lobe Right arm and face Left Temporo- weakness > leg with 13 - - - parietal dysphasia Right leg weakness > Left leg weakness > 7 Left Frontal Lobe 08 Right frontal Lobe arm and face arm and face Right complete Left Internal Left complete Right Internal 2 04 hemiplegia Capsule hemiplegia Capsule UMN* hemiplegia and H/O sever head- Cerebral 12 ache, vomiting and hemorrhage unconciousness UMN hemiplegia, Sub archnoid- Neck rigidity and 9 hemorrhage Kerining sign * Upper Motor Neuron territory and 20% of vertebro basilar artery was also observed by Razzak A. in his study10. Comparing the DISCUSSION both sides of parietal/temporo parietal cerebral infarc- Despite new post-stroke management strategies tions. Left parietal/temporo parietal cerebral infarction stroke remains a serious disease affecting not only the is more frequent than right side (41:19). This observa- patient but his family as well.8 Attack of stroke occur in tion is quite comparable with study done by Ali Nawaz older age group due to enhancement of atherosclero- Khan.11 In his study he found most common area of sis. In this study mean age of the patients admitted the brain involved was cortical infarction (32.3%) fol- JLUMHS JANUARY - APRIL 2009; Vol: 08 No. 01 05
- 4. Stroke Localization: TABLE II: LOCALIZATION OF THE CEREBRAL INFARCTION CLINICAL/VERSUS CT SCAN BRAIN FINDINGS Left Side Infarction Right Side Infarction Site Clinical CT scan brain Clinical CT scan brain Parietal/ 43 41 (P=0.83) Parietal/Temporo 25 19 (P=0.37) Temporo parietal lobe parietal lobe Frontal lobe 7 5 (P=0.56) Frontal lobe 8 4 (P=0.25) Internal capsule 2 2 (P=1.0) Internal capsule 4 3 (P=0.71) TABLE III: CEREBRAL ARTERY INVOLVEMENT Left middle cerebral artery 43 58% Right middle cerebral artery 22 30% Left anterior cerebral artery 5 6.7% Right anterior cerebral artery 4 5.3% FIGURE II: ized cerebrovascular lesions in 40 patients out of 386 Localization of Site of Hemorrhage on CT Scan Brain in whom stroke was clinically diagnosed12. Out of 21 clinically diagnosed cerebral hemorrhagic stroke, in 3 Multiple 1 (14%) patients intra cerebral lobar hemorrhage and in intracerebral hemorrhage 0 5 (23%) patients ventricular hemorrhage confirmed on CT scan brain. Khan J in his study found 13 (52%) patients in whom CT scan brain confirmed the hemor- Basal ganglia 1 rhage, out of 25 patients in whom cerebral hemor- 0 rhage was diagnosed clinically8. These observations also comparable with study done by Ali Nawaz Khan. 1 He found 5 (15%) patients of sub arachnoids hemor- Intracerebral (lobar) 2 rhage out of 33 patients with hemorrhagic stroke 11. In our study most common site of intra cerebral hemor- rhage was cerebral lobe then basal ganglia. Whereas 2 Ali Nawaz Khan found basal ganglia hemorrhage in SAH (ventricle) 3 39% patients. Cerebral hemorrhage in our study is over diagnosed clinically (21/10) then cerebral infarc- 0 0.5 1 1.5 2 2.5 3 3.5 tion (89/74). This defers the study done by Zahir Male Female Shah. He found that cerebral infarction tends to be over diagnosed clinically as compared to cerebral lowed by internal capsule (25.7%)11. He also found in hemorrhage which tends to be under diagnosed clini- his study that most commonly affected artery was left cally as compared with CT scan findings 11. middle cerebral artery and its perforate branches, fol- CONCLUSION lowed by right middle cerebral artery and its perforat- ing branches (32.9%) and anterior cerebral artery and It was concluded from the study that cerebral infarc- its branches in (3.59%) 11. In this study CT scan was tion was more common than hemorrhage and middle inconsequential or normal in 26 patients who were cerebral artery territory infarction of both sides was clinically diagnosed as infarction or hemorrhagic more common than other cerebral artery territories. stroke. Possibility of lacunar infarction could not be Localization of stroke on clinical basis is not always ruled out in those patients. This observation indicated easy. Confident diagnosis requires careful case his- that MRA (MR angiography) is needed in such pa- tory taking, extensive neurological assessment and tients for proper localization. K.S Sotaniemi et al found with the help of focal neurological deficit of a particular in his study that computed tomography failed to visual- area. JLUMHS JANUARY - APRIL 2009; Vol: 08 No. 01 06
- 5. Ghulam Hussain Baloch, Samiullah Shaikh, Mukhtiar Hussain Jaffery, Suhail Ahmed Almani, Noor M. Memon and M. Qasim REFERENCES of diagnosis and management. Philadephia, 1. Hantano S. Experience multi-centre stroke regis- Bullerworth-Heinemann, 2000: 1125-66. ter. A preliminary report bulletin. WHO 1976; 54: 7. American Heart Association. Heart and stroke 541-53. statistics-2004 update. Dallas, Am Heart Assoc 2. Lopez AD, Mathers CD, Ezzati M, Janison DT, 2004. Murray CJ. Global and regional burden of disease 8. Khan J, Atique-ur- Rehman. Comparison of clini- and risk factors. 2001: systemic analysis of popu- cal diagnosis with computed tomography in ascer- lation health data. Lancet 2006;367:1747-57. taining types of strokes. J Ayub Med Coll Abbotta- 3. Vohra EA, Ahmed WO, Ali M. Etiology and prog- bad 2005;17(3):145-8. nostic factors of patients admitted for stroke. J 9. Shah Z, Hinagul M. Risk factors and comparion of Pak Med Assoc 2000;50(7):234-6. CT versus clinical findings in stroke. J Med Sci- 4. Judith M, George AM (ed). The Atlas of Heart dis- 2003; 11(1):53-8 eases and Stroke. 1st ed. World Health Organiza- 10. Razzak A, Khan B, Baig S. CT and MRI in young tion and CDC. London, The Han way press, 2004. stroke patients. J Pak Med Assoc 1999;49(3):66- 5. Feigin VL, Lawes CM, Bennett DA, Anderson CS. 8. Stroke epidemiology: a review of population- 11. Khan AN, Hashmi A. To correlate the clinical pic- based studies of incidence, prevalence, and case- ture with computed tomography scan finding in fatality in the late 20th century. Lancet Neurol 200 cases of stroke. Pak Armed Forces Med J 2003;2:43-53. 2006;2:68-9. 6. Biller J, Love BB. Ischemic cerebrovascular dis- 12. Sotaniemi KA, Pyhtinen J, Myllyla VV. Correlation ease. In: Bradely WG, Daroff, Fenichel GM, of clinical and computed tomography findings in Marsden DC (eds). Neurology in clinical practice stroke patients. Stroke 1990;21(11): 243-5. AUTHOR AFFILIATION: Dr. Ghulam Hussain Baloch (Corresponding Author) Assistant Professor, Department of Medicine Liaquat University of Medical & Health Sciences (LUMHS), Jamshoro, Sindh-Pakistan. Dr. Samiullah Shaikh Assistant Professor, Department of Medicine LUMHS, Jamshoro, Sindh-Pakistan. Dr. Mukhtiar Hussain Jaffery Senior Lecturer, Department of Medicine LUMHS, Jamshoro, Sindh-Pakistan. Dr. Suhail Ahmed Almani Professor, Department of Medicine LUMHS, Jamshoro, Sindh-Pakistan. Prof. Noor Muhammad Memon Dean Faculty of Medicine & Allied Sciences LUMHS, Jamshoro, Sindh-Pakistan. Dr. Muhammad Qasim Assistant Professor, Department of Medicine LUMHS, Jamshoro, Sindh-Pakistan. JLUMHS JANUARY - APRIL 2009; Vol: 08 No. 01 07