ischemic stroke by bhanu prakash. definition acute cerebral focal defecit lasting for greater than...
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classification
STROKE
Ischemic hemorrhagic
• Reduction of blood flow that lasts longer than several seconds• Blood flow
0 ml ------------- brain death<16ml/100gm/min ------------- infarction within an hour<20ml/100gm/min ------------- ischemia without infarction
Transient ischemic attack(TIA)
complete recovery of symptoms in 24hr most TIA’s last 5-20 minutes
if >1hr usually small infarction on MRITIA’s predict future strokes30% TIA will have a stroke in 5yrs, 20% in 1 monthHigh risk TIA: ABCD
Age>60,BP > 140/90,Clinical weakness or speech,Duration >10min, diabetes
if all 5 factors 40% risk stroke in 7 days urgent workup
Lazarus effect, + emboli detection
TIA Syndromes
Amaurosis fugaxsudden onset painless vision loss, curtain over
one eye, brief 1-5minophthalmic artery emboli
Subclavian stealgives B/S ischemia, worse with arm exercise
Transient global amnesiareversible antegrade + retrograde memory loss,
repetitive questionsCrescendo TIA’s
cerebral ischemia increasing in frequency, severity and duration
Capsular warning syndrome: repeated weakness face, arm, leg
DDx TIA
Migraine, Seizure, SyncopeTumor, Subdural, SAHHypoglycemiaLabyrinthine dz
TIA rarely march across bodysuggests Sz, migraineinvoluntary movements more Szfortification/scintillating light more migraine
Embolic stroke
Cardio embolic Artery-to-artery
Atrial fibrillationMural thrombusMyocardial infarctionDilated cardiomyopathyValvular lesions
Mitral stenosisMechanical valveBacterial endocarditis
Paradoxical embolusPatent foramen ovaleAtrial septal defect
Atrial fibrillation Mural thrombus Myocardial infarction Dilated cardiomyopathy Valvular lesions
Mitral stenosisMechanical valveBacterial endocarditis
Paradoxical embolusPatent foramen ovaleAtrial septal defect
Cardio embolic
Uncommon causes
Hypercoagulable disordersVenous sinus thrombosisFibromuscular dysplasiaVasculitisCardiogenicDrugsEclampsiaMoya moya disease
Signs and symptoms of MCAO
Proximal MCAcontralateral hemiplegia, conjugate eye deviation,
hemisanesthesia,homonymous hemianopsia, aphasia or neglect
Upper MCAface + arm affected more than leg, Broca’s aphasia
Lower MCAleg> face + arm, Wernicke aphasia or behavioural
disturbance (nondominant hemisphere), homonymous hemianopia
Angular gyrusGerstmann’s syndrome: finger agnosia, acalculia, R-L
disorientation,agraphiaRight parietal
anosognosia, neglect, apraxia, impaired prosody, confusion/delirium
ACA stroke
less common 3%weakness LE >UEabulia, akinetic mutism, emotional
disturbancetranscortical motor aphasiahead deviation toward lesionParatoniaAnt choroidal a. syndrome –ant limb int
capsulehemiparesis, hemisensory loss, hemianopia
PCA syndromes
Weber SyndromeEponym: Weber SyndromeAnatomy: Midbrain: BaseVascular: Posterior cerebral artery:
Penetrating branches to midbrain
Side Manifestation comments
C Weakness- upper and lower extremity
Corticospinal tract
I Lateral gaze weakness
CN3
Symptoms and signs
PCA syndromes
Claude SyndromeEponym: Claude SyndromeAnatomy: Midbrain: TegmentumVascular: Posterior cerebral artery
Side Manifestation
c Ataxia- arm and leg
PCA syndromes
Thalamic pain syndromeEponym: Dejerine Roussy syndromeAnatomy: ThalamusVascular: Posterior cerebral artery:
Pentrating branches to thalamus
Side Manifestation
C Hemisensory loss – all modalities
C Hemibody pain
PCA syndromes
Alexia without agraphiaAnatomy:
Cerebral hemisphere: Left occipital region plus splenium of corpus collosum
Vascular: Posterior cerebral artery: Collosal branches
side manifestations comments
N Alexia Splenium of corpus
callosum
C Visual loss- homonymous hemianopia
Left occipital region
Signs and symptoms
PCA syndromes
Cortical blindnessEponym: Anton SyndromeAnatomy: Cerebral hemisphere: Bilateral
occipital lobesVascular: Posterior cerebral artery:
BilateralBasilar artery: Top of the basilar
Signs and symptoms
side manifestation
N Bilateral visual loss
C Unawareness of/ denial of blindness
PCA syndrome
Balint SyndromeEponym: Balint SyndromeAnatomy: Cerebral hemisphere: Bilateral
parietaloccipital lobesVascular: Posterior cerebral artery:
Bilateral
Side Manifestation
B Loss of voluntary but not reflex eye movements
B Optic ataxia poor visual motor coordination
B Asimultagnosia inability to understand visual objects
PCA syndromes
Posterior cerebral artery unilateral occipital
Anatomy: Cerebral hemisphere: Occipital and inferomedial temporal lobes.
Vascular: Posterior cerebral artery
Side Manifestation comments
C Visual loss – homonymous hemianopia
Optic pathway, calcrine cortex
Vertebral artery syndromes
Medial medullary syndromeEponym: Dejerine SyndromeAnatomy: Medulla: Medial medullaVascular:
Vertebral artery: Anteromedial artery Anterior spinal artery: Anteromedial artery
Basilar arterySIDE MANIFESTATIONS COMMENTS
C Weakness UL & LL Pyramidal tract
C Hemisensory loss _ vibration & proprioseption
Medial lemniscus
I Tongue weakness +/_ atrophy Cn 12 nucleus
WALLENBERG SYNDROME
Eponym: Wallenberg SyndromeAnatomy:LATERAL MEDULLAVascular: Vertebral artery
SIDE MANIFESTATION COMMENT
I SENSORY LOSS_FACE_TEMP PAIN C5 NUCLEUS
I ATAXIA RESTIFORM BODY CEREBELLUM
I NYSTAGMUS ,NAUSEA VOMITING, VERTIGO
VESTIBULAR
I HOARSENESS,DYSPHGIA NUCLEUS AMBIGOUS
I HORNERS SYNDROME DES SYMPAT
C HEMISENSORY LOSS PAIN AND TEMPERATURE
SPINO THALAMIC
Basilar artery occlusion
Locked in Syndrome Anatomy: Pons: Bilateral ventral
pons Vascular: Basilar artery
Side Manifestation Comment
B Weakness UL&LL B/L corticospinal
B Weakness face entire & dysarthria
B/L corticobulbar
B Lateral gaze weakness B/L fasiculus VI cn
Millard gublar syndrome
Anatomy: Pons: Basis pontis and fascicles of CN VI amd VII
VascularBasilar artery: Short circumferential
branchesBasilar artery: Paramedian branches
side Manifestation Comment
C Weakness UL&LL Pyramidal tract
I Lateral gaze weakness Cn VI nuc
I Weak face_ entire Cn VII nuc
Foville Syndrome
Anatomy: Pons: Unilateral lesion in the dorsal pontine tegmentum in the caudal third of the pons
Vascular: Basilar artery: Paramedian branches Basilar artery: Short circumferential
arteries
Side manifestations Comment
C Weakness UL&LL Corticospinal.t
I Weakness of face entire CN VII NUC
Lacunar strokes
Infarct from small penetrating arteries1. Pure motor –weakness face, arm and leg2. Pure sensory –paresthesias & numbness,
face, armand leg3. Sensory-Motor –weakness and sensory
loss4. Ataxia hemiparesis -weakness LE,
incoordinationipsilateral arm and leg5. Dysarthria-Clumsy hand syndrome dysarthria, dysphagia, dec fine motor hand
Ddx of ishcemic stroke
Bell’s Palsy Todd’s Paralysis Hemorrhagic Stroke Subdural HematomaHypoglycemiaMetabolic conditions – fever, hyponatremia,
drugs, etc. Psychogenic Complex migraines Hypertensive crisis