Clinical Presentation of Stroke Syndromes
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Transcript of Clinical Presentation of Stroke Syndromes
Clinical Presentation of Stroke Syndromes
By Ken Hui Yee for PBL group 7Case 24
Ischaemic Stroke
Causes: Thrombosis & Embolism (65% of strokes)▪ Artery-to-artery▪ Cardioembolic▪ Thrombosis in-situ
Small vessel (lacunar) strokes (20% of strokes)▪ atherothrombotic or lipohyalinotic occlusion
of a small intracranial artery▪ Often symptomless
Artery-to-Artery Embolic Stroke
Thrombus formation on atherosclerotic plaques embolize to intracranial arteries▪ Carotid bifurcation ▪ most common site (10% of ischaemic strokes)
Diseased vessel may acutely thrombose▪ Including aortic arch, common carotid,
internal carotid, vertebral, and basilar a.
Cardioembolic
Arrhythmias AF
Mural thrombus DCM Valvular lesions
Mitral stenosis, Endocarditis, Rheumatic fever
Paradoxical embolus Atrial septal defect, Patent foramen ovale,
Atrial septal aneurysm
Less Common Causes of Ischaemic Stroke Venous sinus thrombosis
Complication of:▪ OCP▪ Pregnancy & the postpartum period▪ Inflammatory bowel disease▪ Intracranial infections (meningitis)▪ Dehydration
Haemorrhagic Stroke
Less common (only 15% of all strokes)
Higher mortality rate than Ischaemic
Haemorrhagic Stroke
Causes: Head trauma▪ Most common cause of SAH
Hypertensive haemorrhage Aneurysm
Hypertensive Haemorrhage Spontaneous
rupture of small penetrating artery
Common sites: Basal ganglia
(especially the putamen), thalamus, cerebellum, and pons.
Aneurysm
SAH from berry aneurysm▪ AcomA, PcomA, MCA (locations from most
common to less common) Mycotic aneurysm▪ Eg. Endocarditis
Other Causes of Hemorrhage Stroke
Amyloid angiopathy▪ Degen of intracranial vessels▪ Rare in <60
Tumour Drugs (eg. Cocaine)▪ Young pts
Ischaemic vs. Haemorrhagic Stroke Can’t be distinguished on basis of the
history or clinical examination
Ischaemic stroke tends to be painless However h/a may still occur
Haemorrhagic stroke causes h/a esp. If ICP is raised
Ischaemic vs. Haemorrhagic Stroke Investigations:
Determine between ischaemic and haemorrhagic
CT MRI CSF
Acute Onset vs. Stuttering OnsetAcute StutteringSudden onset
Abrupt neurological deficit
More likely to be thrombotic and lacunar onsetNeurological deficits wax and waneProceeds towards complete neurological deficits
Case 1
HOPC:▪ Pt describes a shade or curtain being pulled
over the front of the eye (right)▪ Vision in right eye is lost only for a short time
(seconds to minutes)▪ On examination patient has carotid bruits▪ Painless
Amaurosis Fugax
Ddx: Amaurosis Fugax▪ Central retinal artery occlusion
Retinal migraine▪ Develops more slowly (15 to 20mins)
Rise in ICP▪ Can compromise optic disc perfusion
Case 2
HOPC:▪ Sudden onset of headache with aura▪ Nausea and vomiting▪ Tingling, numbness and vague weakness on
the right side of the body▪ Patient prefers a dark room▪ Patient reports that the aura has persisted for
more than a week. IX:▪ CT and MRI show focal ischaemia
Migrainous Infarction
Rare complication of migraines
Definition: Aura and a migraine headache, with the
aura symptom persisting > 7/7 + neuroimaging focal ischaemia
Complete vs Incomplete StrokesComplete IncompleteTotal area of the brain supplied by an occluded vessel is damagedFurther prophylaxis Rx is pointless
some cellular damageAdditional tissue in the affected vascular distribution is at riskProphylaxis Rx is useful
Not that practical as distinction based on clinical findings can be impossible
Case 3
HOPC: A 62-year-old woman was admitted to
MMC with acute onset of left-sided hemiparesis. On admission, she had left-sided hemiplegia and facial palsy with minor dysarthria
Case 3
IX: CT▪ right MCA mainstem occlusion but no early
ischemic changes Thrombolysis commenced pt
improved initially but then developed sudden decline of consciousness
Case 3
Repeat CT Ruled out ICH
MRI New occlusion in Left MCA discovered
Underlying cause was due to cardioembolic ischaemic stroke due to AF
Case 4
HOPC: Pt presents to ED with global aphasia Pt’s partner reports that pt is right
handed
MCA
Case 5
HOPC: Pt presents to ED with right leg and foot
paralysis Sensory impairment (pain, temperature)
over right lower limb Examination of upper limb = normal Impairment of gait
ACA
Case 6
HOPC: Pt presents with homonymous
hemianopia Has a failure to see to-and-fro
movements, inability to perceive objects not centrally located
Case 6
HOPC: Pt presents with homonymous
hemianopia Has a failure to see to-and-fro
movements, inability to perceive objects not centrally located
Reports peduncular hallucinosis
PCA
PCA – Specific Named Syndromes Midbrain – Subthalamic -Thalamic
Weber Syndrome▪ Contralateral hemiplegia
Thalamic Dejerine-Roussy▪ Contralateral hemisensory loss
Claude’s Syndrome▪ Third nerve palsy Contralateral ataxia
PCA – Specific Named Syndromes Anton's syndrome
Bilateral infarction in the distal PCAs producing cortical blindness
Pt maybe unaware of blindness and may deny it
Balint’s syndrome Watershed infarction between PCA and
MCA Disorder of the orderly visual scanning of
the environment
Watershed Infarction
Hypotension due to eg. AMI low perfusion in borderzones/junctional territories of the cerebral end arteries
Watershed Infarction
Clinical Presentation: “Man-in-the-barrel” clinical presentation Optic ataxia Cortical blindness Difficulty in judging size, distance, and
movement Memory loss Dysgraphia
Case 7
81 yr old man with HT and AF on anticoagulants, right-handed
HOPC: h/a, diaphoresis, dizziness, diplopia Sudden onset of R arm tingling,
numbness and weakness Progressive slurred speech
Case 7
Signs & Symptoms continued: Horizontal eye movements/conjugated gaze
restricted Jaw deviation to the right Bilateral facial weakness▪ Difficulty wrinkling forehead or close eyes
Dysphagia Balance issues Cheyne-Stokes breathing Dry oral pharynx
Case 7
IX: CT - progressive hemorrhagic stroke
intrinsic to the pontine tegmentum of the brain stem, with rupture into the fourth ventricle
Basilar Artery – Midbrain
Basilar Artery Mid pons
Basilar Artery Inferior Pons
Vertebral and Posterior Inferior Cerebellar Arteries Medulla
Presentation of Brainstem InfarctionClinical Feature Structure InvolvedHemiparesisSensory lossDiplopiaFacial numbnessFacial weaknessNystagmus & vertigoDysphagia & dysarthria
Presentation of Brainstem Infarction
Clinical Feature Structure Involved
Hemiparesis Corticospinal tracts Medial midpontine syndrome,Medial inferior pontine syndrome
Sensory loss Medial lemniscus and spinothalamic tracts
Lateral midpontine syndrome
Diplopia Oculomotor/Adducens
Medial inferior pontine syndrome
Facial numbness Trigeminal Lateral midpontine syndrome,Lateral inferior pontine syndrome
Facial weakness Facial Lateral inferior pontine syndrome
Nystagmus & vertigo
Vestibular Medial inferior pontine syndrome
Dysphagia & dysarthria
Glossopharyngeal & vagus
Medullary Syndrome
SummaryOccluded Blood Vessel Clinical ManifestationsICA Ipsilateral blindness (variable) MCA syndromeMCA Contralateral hemiparesis, sensory loss (arm,
face worst)Expressive aphasia (dominant) or anosognosia and spatial disorientation (nondominant)
Contralateral inferior quadrantanopsiaACA Contralateral hemiparesis, sensory loss (worst
in leg)PCA Contralateral homonymous hemianopia or
superior quadrantanopia Memory impairmentBasilar apex Bilateral blindness AmnesiaBasilar artery Contralateral hemiparesis, sensory loss
Ipsilateral bulbar or cerebellar signsVertebral artery or PICA Ipsilateral loss of facial sensation, ataxia,
contralateral hemiparesis, sensory lossSuperior cerebellar artery Gait ataxia, nausea, dizziness, headache
progressing to ipsilateral hemiataxia, dysarthria, gaze paresis, contralateral hemiparesis, somnolence