stroke or cerebrovascular accident
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STROKESQN LDR DR AAMIR HUSSAIN
ASSTT PROF AND MEDICAL SPECIALIST
INTRODUCTIONSUDDEN
WEAKNESS OF ARM,LEG OR FACENUMBNESSCONFUSIONDIFFICULTY IN SPEAKING OR UNDERSTANDINGVISUAL PROBLEMDIZZINESSVOMITINGHEADACHE
DEFINITIONSTROKE
SUDDEN ONSET OF FOCAL NEUROLOGICAL DEFICIT THAT PERSISTS FOR MORE THAN 24 HOURS
TRANSIENT ISCHEMIC STROKESUDDEN ONSET OF FOCAL NEUROLOGICAL DEFICIT
THAT RESOLVES WITHIN 24 HOURS
DEFINITION STROKE IN EVOLUTION
FOCAL NEUROLOGICAL DEFICIT WORSENS WITH TIME
COMPLETED STROKE FOCAL NEUROLOGICAL DEFICIT PERSISTS AND DO NOT
WORSEN WITH TIME
REVERSIBLE ISCHEMIC NEUROLOGICAL DEFICIT FOCAL NEUROLOGICAL DEFICIT FROM WHICH THE PATIENT
RECOVERS WITHIN A FEW DAYS TO A WEEK
EPIDEMIOLOGY THIRD MOST COMMON CAUSE OF DEATH MOST COMMON CAUSE OF DISABILITY IN ADULTS NINETY-FIVE 95 % OF ALL STROKES OCCUR IN
PEOPLE AGED OVER 65 YEARS MALES ARE MORE AT RISK OF STROKE THAN
FEMALES ACCORDING TO WHO,
15 MILLION PEOPLE WORLDWIDE SUFFER A STROKE EACH YEAR
5 MILLION ARE LEFT PERMANENTLY DISABLED AND NEARLY 5 MILLION DIE
TYPES ISCHEMIC STROKE 80%
THROMBUSEMBOLUS
HAEMORRHAGIC STROKE 20%ANEURYSMSAV MALFORMATIONINTRACEREBRAL OR SUBARACHNOID
RISK FACTORS INCREASING AGESMOKINGHYPERTENSIONDIABETES MELLITUSHYPERLIPIDEMIAALCOHOLATRIAL FIBRILLATIONHYPERCOAGULABLE STATES
ANATOMY ANTERIOR CIRCULATION STROKE(80%)
OPHTHALMIC ARTERY ANTERIOR CEREBRAL ARTERY MIDDLE CEREBRAL ARTERY POSTERIOR COMMUNICATING ARTERY
POSTERIOR CIRCULATION STROKE(20%) VERTEBRAL ARTERY FROM SUBCLAVIAN ARTERY PICA BASILAR ARTERY POSTERIOR CEREBRAL ARTERY
HISTORY ONSET
PROGRESSION
RECOVERY
TIA AND RISK FACTORS
LEVEL OF CONSCIOUSNESS
PARALYSIS
SPEECH
BOWEL CONTROL
BLADDER CONTROL
FITS
ASPIRATION
MEDICATIONS
EXAMINATION NEUROLOGICAL
HIGHER MENTAL FUNCTION SPEECH CRANIAL NERVES MOTOR SYSTEM SENSORY SYSTEM AUTONOMIC
CARDIOVASCULAR CARDIAC CAROTIDS
PYRAMIDAL PARALYSIS/HEMIPLEGIA DYSPHSIA HEMISENSORY LOSS HEMIANOPIA CN PALSIES INCREASED REFLEXES PLANTARS ARE EXTENSORS SPASTICITY AND DRAGGING GAIT SEIZURES
FEATURES OF CEREBELLAR LESION ATAXIA NYSTAGMUS DYSARTHRIA INTENSION TREMOR PAST POINTING HYPOTONIA DYSDIADOKOKINESIA WIDE BASED GAIT PLANATRS ARE FLEXORS PARALYSIS LESS LIKELY
EXTRA PYRAMIDALBRADYKINESIAFESTINANT GAITRESTING TREMORSRIGIDITYPARALYSIS LESS LIKELYPLANTARS ARE FLEXORSINVOLUNTARY MOVEMENT
TIPS SPINOTHALMIC TRACTS CROSS THE MIDLINE SOON
AFTER ENTERING THE SPINAL CORD DORSAL COLUMN TRACTS DO NOT CROSS IN SPINAL
CORD.THEY INSTEAD CROSS IN MEDULLA OBLONGA PYRAMIDAL TRACTS CROSS IN THE MEDULLA
OBLONGATA BRAIN STEM LESIONS PRODUCE CROSSED HEMIPLEGIA CEREBELLAR LESIONS PRODUCE IPSILATERAL
HEMIPLEGIA CRANIAL NERVES LESIONS ARE MOSTLY IPSILATERAL CORTICAL LESIONS PRODUCE CONTRALATERAL
HEMIPLEGIA
LACUNAR INFARCTION SMALL LESIONS USUALLY LESS THAN 5 MM INVOLVES ARTERIOLES IN THE
BASAL GANGLIA PONS CEREBELUM INTERNAL CAPSULE THALAMUS
DEFICIT PROGRESSES OVER HOURS BEFORE STABILIZING
PROGNOSIS IS GOOD PARTIAL OR COMPLETE RESOLUTION OVER WEEKS
CEREBRAL INFARCTIONTHROMBOTIC OR EMBOLIC OCCLUSION
OF MAJOR ARTERYMCA INFARCTACA INFARCT PCA INFARCTPICA
EXAMINATION FOCUS CONSCIOUSNESS SPEECH
FLUENT WITHOUT COMPREHENSION(SENSELESS)
NONFLUENT WITH BROKEN SENTENCE(TELEGRAPHIC)
SWALLOW CRANIAL NERVES POWER/TONE REFLEXES AND PLANTARS PRONATOR DRIFT COORDINATION GAIT
MIDDLE CEREBRAL ARTERY INFARCTHEMIPLEGIA, ON OPPOSITE SIDE/CONTRALATERAL
HEMISENSORY LOSSHOMONYMOUS HEMIANOPIAEYES DEVIATION,TO THE SIDE OF LESIONAPHASIA/DYSPHASIA
GLOBALMOTOR/EXPRESSIVESENSORY/RECEPTIVE
CASE SCENARIO :EXPRESSIVE APHASIA A 60-YEAR-OLD MALE IS BROUGHT TO EMERGENCY DEPARTMENT WITH
SUDDEN WEAKNESS OF RIGHT SIDE OF THE BODY AND DIFFICULTY IN SPEECH.ON EXAMINATION OF RIGHT LIMBS,THE MUSCLE POWER IS REDUCED (3/5),TONE IS INCREASED,AND REFLEXES ARE BRISK WITH UPGOING PLANTAR.
HE UNDERSTANDS AND OBEY THE COMMAND,BUT HE FINDS DIFFICULTY IN SPEAKING.HIS SPEECH IS HALTING AND EFFORTFUL AND INCLUDE IMPORTANT CONTENTS OF WORDS WITH OUT GRAMMAR.HE FELT DEPRESSED WITH IMPAIRED SPEECH.
WHAT IS THE LIKELY PROBLEM… WHERE IS THE LESION…. WHAT IS THE LESION WHICH CIRCULATION OR ARTERY IS INVOLVED…
CASE SCENARIO: RECEPTIVE APHASIA A 60-YEAR-OLD MALE IS BROUGHT TO EMERGENCY DEPARTMENT WITH
SUDDEN WEAKNESS OF RIGHT SIDE OF THE BODY AND APPARENTLY CONFUSED STATES.ON EXAMINATION OF RIGHT LIMBS,THE MUSCLE POWER IS REDUCED (3/5),TONE IS INCREASED,AND REFLEXES ARE BRISK WITH UPGOING PLANTAR.
HE APPEARED TALKATIVE BUT FAILED TO UNDERSTAND AND MISINTERPRET THE COMMAND.SPEECH CONTENT LOOKED GRAMMATICAL BUT LACK SENSE AND SOME TIME USE NEW WORDS.HE APPEARED UNAWARE OF HIS SPEECH PROBLEM.
WHAT IS THE LIKELY PROBLEM… WHERE IS THE LESION…. WHAT IS THE LESION WHICH CIRCULATION OR ARTERY IS INVOLVED…
ANTERIOR CEREBRAL ARTERYLIMITED WEAKNESS,MONOPLEGIACORTICAL SENSORY LOSS
Stereognosis, graphesthesia, position sense
CONFUSION/MEMORY DISTURBANCEREEMERGENCE OF PRIMITIVE
REFLEXESPalmomental reflex, grasp reflex
URINARY INCONTINENCE
POSTERIOR CEREBRAL ARTERY
HEMISENSORY DISTURBANCETHALMIC PAINHEMIPARESIS
WEBER’S SYNDROME: MIDBRAIN STROKE A 60-YEAR-OLD FEMALE IS PRESENTED TO EMERGENCY
DEPARTMENT WITH WEAKNESS OF LEFT SIDE OF BODY ,DIPLOPIA AND DROPPING OF RIGHT EYE. ON EXAMINATION OF LEFT LIMBS,THE MUSCLE POWER IS REDUCED (3/5),TONE IS INCREASED,AND REFLEXES ARE BRISK WITH UPGOING PLANTAR.
THE RIGHT EYE HAS A COMPLETE PTOSIS.THE EYE BALL IS DOWN AND OUT.THE PUPIL IS FULLY DILATED AND NON REACTIVE TO LIGHT OR ACCOMODATION. WHAT IS THE LIKELY PROBLEM…
WHERE IS THE LESION…. WHAT IS THE LESION WHICH CIRCULATION OR ARTERY IS INVOLVED…
PICA /LAT MED SYNDROME /WALLENBERG IPSILATERAL SPINOTHALAMIC SENSORY LOSS
FACEV CNX CN
IPSILATERAL LIMB ATAXIA IPSILATERAL HORNER SYNDROMECONTRALATERAL SPINOTHALAMIC SENSORY
LOSS OF LIMBS
WALLENBERG’S SYNDROME: LATERAL MEDULLARY SYNDROME
A 65-YEAR-OLD MALE IS PRESENTED TO EMERGENCY DEPARTMENT WITH ACUTE ONSET OF VOMITING,VERTIGO AND UNSTEADINESS WITH TENDENCY TO FALL ON RIGHT SIDE.HE ALSO COMPLAINTS OF DIPLOPIA ,DYSPHAGIA AND DYSARTHRIA.
ON EXAMINATION,HIS MUSCLE POWER IS ALMOST NORMAL WITH NORMAL REFLEXES AND EQUIVOCAL PLANTARS,BUT HAS ATAXIA ON RIGHT SIDE.
HE HAS PARTIAL PTOSIS AND A CONSTRICTED PUPIL OF RIGHT EYE.NYSTAGMUS IS NOTED IN BOTH EYES
HE HAS LOSS OF PAIN AND TEMPERATURE SENSATION OVER RIGHT FACE AND LEFT SIDE OF BODY.
AAH TEST AND GAG REFLEX WERE ABSENT.
BASILAR ARTERY OR BOTH VERTEBRAL ARTERIES
COMA WITH PINPOINT PUPILFLACCID QUADRIPLEGIALOCKED-IN SYNDROMESENSORY LOSSVARIABLE CN PALSIES
CEREBELLAR ARTERIESVERTIGONAUSEAVOMITINGNYSTAGMUS IPSILATERAL LIMB ATAXIACONTRALATERAL SPINOTHALAMIC SENSORY
LOSS
ANTERIOR VS POSTERIOR CIRCULATION STROKECLINICAL FEATURES POSTERIOR CIRCULATION
(VA,BA,PCA)ANTERIOR CIRCULATION(MCA,ACA)
VERTIGO AND UNSTEADINESS YES NO
VOMITING YES NO
CROSSED HEMIPLEGIA YES NO
BILATERAL DEFICIT YES NO
CEREBELLAR SIGNS YES NO
HORNER’S SYNDROME YES NO
DISSOCIATED/ CROSSED SENSORY LOSS
YES NO
DIPLOPIA/ III CN PALSY YES NO
APHASIA NO YES
SIMPLIFIED CLASSIFICATION OF STROKEOXFORD CLASSIFICATION OR
BAMFORD CLASSIFICATION
THREE IMPORTANT FEATURES IN ANTERIOR CIRCULATION
1. HEMIPLEGIA
2. HEMIANOPIA
3. APHASIA
IMPORTANT FEATURES IN POSTERIOR CIRCULATION
1. CEREBELLAR
2. BRAINSTEM( CRANIAL NERVE PALSY)
3. VERTIGO/VOMITING
4. HORNER’S SYNDROME
INVESTIGATIONS 1. NON CONTRAST CT SCAN BRAIN TO R/O HAEMORRHAGE MRI BRAIN WITH DIFFUSION WEIGHTED SEQUENCE FOR
DISTRIBUTION AND EXTENT OF INFARCT OR TO R/O OTHER CAUSES
CT ANGIOGRAPHY HEAD AND NECK MR ANGIOGRAPHY CAROTID DUPLEX ULTRASONOGRAPHY TRANSCRANIAL DOPPLER ULTRASONOGRAPHY CONVENTIONAL CATHETER ANGIOGRAPHY ECHOCARDIOGRAPHY
TRANSTHORACIC
TRANSOESOPHAGEAL
ECG CXR
CASE SCENARIO A 30-YEAR-OLD MALE IS BROUGHT TO EMERGENCY DEPARTMENT WITH
SUDDEN SEIZURE AND LOSS OF CONSCIOUSNESS.
HIS FRIENDS INFORMED ABOUT SUDDEN SEVERE HEADACHE AND VOMITING BEFORE HE LOST HIS CONCIOUSNESS.
ON EXAMINATION, HE IS HYPERTENSIVE WITH BP 220/140
HIS NECK IS STIFF AND DEMONTRATED POSITIVE KERNIG’S SIGN.
HIS LEFT PUPIL IS FULLY DILATED
PLANTARS ARE UPGOING
PATIENT DIED AFTER 2 HOURS.
INVESTIGATIONS 2.BLOOD CP AND PLATBLOOD SUGARLIPID PROFILEPT/INRPTTK(APTT)THROMBIN TIME
HYPERCOAGULABLE STUDIES 3.PROTEIN CPROTEIN SANTITHROMBIN IIILUPUS ANTICOAGULANTANTICARDIOLIPIN ANTIBODIESFACTOR V LEIDENHOMOCYSTEINE
STROKE MIMICS SEIZURES
POSTICTAL TODD’S PARESIS
ASSOCIATION
HYPOGLYCEMIA SYNCOPE MIGRAINE FUNCTIONAL/CONVERSION DISORDER
NO DEFINITE PATTERN
ANXIETY/DEPRESSION/PANIC
HOOVER’ TEST
BRAIN TUMOURS METABOLIC ENCEPHALOPATHY
THANKS
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