NeuroanatomyStrokeSyndromesLinkingImagingtoSymptoms

D R . W I E S L AW O C Z KOWS K I

P RO F E S S O R , D E PA R TM EN T O F M E D I C I N E ( N E U RO LOGY )

M E D I C A L D I R E C TO R R E G I ONA L S T RO K E P ROG R AM

MCMA S T E R U N I V E R S I T Y, H AM I LTON H E A LT H S C I E N C E S

None

DisclosuresandConflictsofInterest

Overviewoftheneurologicalassessment

Whyisissoimportantinstroke

Neurologicalsignsandimaging

Neurologicallocalizationwithcases

Objectives

Bill

72yearoldmale

§Hypertension

§Smoker

Strokecall:dizzy,facialdroop,slurredspeech

NeurologicalExam:

§Ptosisandmiosis onleft

§Numbleftface

§ Leftpalatalweakness

§Dysarthria

§Ataxicleftarmandleftleg

§Numbrightarmandleg

NIHStrokeScale

LOC:a,b,c_________________

Bestgaze__________________

Visualfields________________

Facialpalsy________________

Motorarmandleg__________

Limbataxia________________

Sensory_______________________

BestLanguage______________

Dysarthria_________________

Extinctionandinattention____§ (tone,reflexes,distalsensation,gait)

Score

0

0

0

0

0

2

1

0

1

0

-

-Left Ptosis

-Left miosis

-Weakness of

left palate

EKGofStroke

6

TroponinofStroke

8

It’s all about Stroke!

FocalMotororSensory

Presentation

Stroke NotStroke

AMeasuringandMonitoringNeurologicalExamination

LOC:a,b,c_________________

Bestgaze__________________

Visualfields________________

Facialpalsy________________

Motorarmandleg__________

Limbataxia________________

Sensory___________________

BestLanguage______________

Dysarthria_________________

Extinctionandinattention____§ (tone,reflexes,distalsensation,gait)

Score

Top - Down

Left - Right

Patient - Examiner

Hemispheres

Brainstem

Spinal Cord

Nerves

Muscles

Neuromuscular

Junction

Assess orientation (“How old are you?, What month is it?”)

Assesstheabilitytodescribethepicture

Assesstheabilitytoreadthesentences

Assessvisualfieldsandassessforinattention(4quadrants)

Assessthepupillarylightreflex

Assess eye movements following the “H” pattern

Assessfacialsensation(leftandrightcheekusingsharpanddull)

Assessfacialmovements(closeeyes,smile)

Assess palatal and tongue movements (say “ah”, stick out tongue)

Assesstoneinthe4limbsAssessstrengthusingdriftandarmrollingtests

Assessdistalsharp-dullandvibrationsensationandsensoryinattention

Assessreflexes(biceps,brachioradialis,triceps,quadriceps,AchillesandBabinski)

Assess limb coordination (finger to nose, heel – knee – shin)

Assessgaitandtandemwalking(tandemgait,normalgait)

TheNervousSystemisDistributed

AspectScoring

ASPECTSCORING

Roger57yearoldmale

◦ Atrialfibrillation

◦ CAD,CHF

◦ Pacemaker

◦ DM2

◦ HTN,DL

Presentedwithsuddenleftsidedweakness

Roger

Maria

66yearoldfemale

◦ HTN

◦ DL

◦ Depression

Foundathomeonthefloorunabletotalkandwithrightsidedweakness

Maria

Virginia91yearoldfemale

◦ Atrialflutter

◦ CHADS=1

Medications:ASA

Presentedwithsuddenonsetofinabilitytospeak

Virginia

Livia70yearoldfemale

◦ Hypertension

◦ Dyslipidemia

◦ Anxietyanddepression

Coronaryangiography

Postangiogramheadache

unabletosee

Livia

Christinia82yearoldfemale

◦ Hypertension

◦ Diabetes

◦ Dyslipidemia

Collapsewithsuddenrightlegweakness

Christina

Gladys85yearoldfemale

◦ Hypertension

◦ Dyslipidemia

FoundonthefloorwithadecreasedLOC

Slurredspeech,vomiting,andrightarmweakness

Gladys

Wayne68yearoldmale

◦ Atrialfibrillation

◦ PreviousTIA

◦ Hypertension

Hikingwithhiswife

Dizziness,lossofbalance,doublevision,leftweakness

Wayne

Complete ptosis

Eye laterally deviated

Greg31yearoldmale

◦ Well

Collapsed

BroughttoERwithleftweakness

Greg

Linda63female

◦ Previousstrokewith complete recovery

◦ Atrialfibrillation

◦ Diabetestype2

Presentedwithseveredysarthria,andleftweakness

Bill72yearoldmale

◦ Hypertension

◦ Smoker

Strokecall?

Bill

Left Ptosis

Left miosis

Weakness of left palate

Harry65yearoldmale

◦ Smoker

◦ COPD

Difficultywalking

Difficultybreathing

Admittedtostepdownandthenward

Unabletourinateandambulate

Harry

Sensory level at T4

NeuroanatomyStrokeSyndromesLinkingImagingtoSymptoms

D R . W I E S L AW O C Z KOWS K I

P RO F E S S O R , D E PA R TM EN T O F M E D I C I N E ( N E U RO LOGY )

M E D I C A L D I R E C TO R R E G I ONA L S T RO K E P ROG R AM

MCMA S T E R U N I V E R S I T Y, H AM I LTON H E A LT H S C I E N C E S