localization of stroke, CVS, stroke, for post graduates
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Transcript of localization of stroke, CVS, stroke, for post graduates
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Localization of stroke syndromes
Dr.M.Dhanaraj
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Localization of stroke syndromes
Three steps
1.Clinical localization of the site of the lesion.
2.Identifying the vascular territory and the vessel involved.
3.Correlating with the imaging findings.
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Clinical localization of stroke syndromes
Prerequisites
1.Functional anatomy of brain.
2.Blood supply to the different parts of brain.
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Blood supply of brain-Carotid Arteries
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Vertebral artery Circle of willis
Blood supply of brain – vertebral artery and circle of Willis
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Blood supply of brain
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ANTERIOR CIRCULATION STROKE SYNDROMES
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Anterior circulation
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Blood supply-Lateral view
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Blood supply-Medial view
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Blood supply-Coronal view
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Blood supply-Axial view
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Middle cerebral artery infarction - superior branch
Clinical features
1.Contralateral hemiplegia – face and
upper limb more involved than lower
limb.
2. Contralateral hemisensory loss.
3.Conjugate gaze paresis(patient looks
towards the side of lesion.
4.Broca’s dysphasia (if left sided)
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Middle cerebral artery infarction - Inferior branch
Clinical features
1.Contralateral hemianopia.
2.Wernicke’s dysphasia ( if left sided )
3.Left spatial neglect ( if right sided )
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Middle cerebral artery infarction - stem occlusion
Clinical features
1.Contralateral hemiplegia
2. Contralateral hemisensory loss
3. Contralateral gaze palsy
4. Contralateral hemianopia
5.Global dysphasia (Left sided lesion)
6.Anosognosia and amorphosynthesis
(Right sided lesion)
7.Altered sensorium (due to edema)
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Middle cerebral artery infarction -
Clinical features
1.Contralateral hemiparesis
2.Contralateral sensory loss
3.Transcortical motor / sensory
aphasia ( left sided lesion)
Lenticular striate artery occlusion
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Anterior cerebral artery infarctionClinical features 1.Contralateral a.paralysis of leg and foot with paresis of arm b.cortical sensory loss over leg and foot c.presence of primitive reflexes 2.Urinary incontinence 3.Gait apraxia 4.Mutism, delay and lack of spontaneity of motor acts 5.Apraxia of left sided limbs(with left sided lesion and
corpus callosum involvement)
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Internal carotid artery infarction Clinical features Variable - based on the
collaterals and mechanism of stroke (embolism, extension of thrombus , low flow)
1.Amaurosis fugax2. Watershed infarctions3.MCA/ACA- either alone or in
combinations
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Posterior circulation stroke syndromes
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Posterior circulation
Lateral view
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Posterior circulation
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Medulla
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Lateral medullary syndromeA. IPSILATERAL1.Xth cranial nerve palsy2.Cerebellar signs3.Horner’s syndrome4.Impaired pain, temperature
and touch on the upper half of face
B. CONTRA LATERAL1.Impaired pain and
temperature over the body
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Medial medullary syndrome
A.IPSILATERAL
1.XIIth nerve palsy
B.CONTRALATERAL
1.Hemiplegia – sparing the
face
2.Hemianaesthesia sparing the
face.
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Pons-Lower
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Medial pontine syndrome – occlusion of paramedian branch of basilar artery
A.IPSILATERAL
1.Gaze paresis
2.Cerebellar signs
B.CONTRALATERAL
1.Hemiparesis
2.Hemianaesthesia
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Lateral pontine syndrome-occlusion of anterior inferior cerebellar artery
A.IPSILATERAL1.LMN VIIth nerve palsy2.Gaze palsy3.Deafness,tinnitus4.Cerebellar signs
B.CONTRALATERAL1.Impairment of pain and
temperature on the body
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MID BRAIN
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Weber syndrome-occlusion of perforating branch of posterior cerebral
arteryClinical features
1.Ipsilateral
a.3rd nerve palsy
2.Contralateral
a.hemiplegia
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Benedikt syndrome-occlusion of perforating branch of posterior cerebral
Clinical features
1.Ipsilateral
a.3rd nerve palsy
2.Contralateral
a.cerebellar ataxia
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Thalamus-occlusion of thalamo geniculate branches of posterior
cerebral artery Contralateral
1.Sensory loss
2.Spontaneous pain
3.Choreo athetosis
4.Ataxic tremor
5.Mild hemiparesisTHALAMUS
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Occipital lobe-optic pathway and visual reflexes
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Occipital lobe-occlusion of left calcarine artery
Clinical features
1.Right Hemianopia
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Occipital lobe-occlusion of both calcarine arteries
Clinical features
1.Bilateral hemianopia-
cortical blindness (light
reflex preserved)
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Left occipital lobe with corpus callosum infarction
Left
Clinical features
1.Right hemianopia
2.Alexia without
agraphia
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Basilar artery occlusionClinical features
1.Paralysis of all four limbs2.Bulbar paralysis3.Eye movements abnormalities4.Nystagmus5.Coma
Note: The neurological deficit is variable depending upon the ischemia – modifying factors.
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Differentiating features between anterior and posterior circulation stroke
Clinical features Posterior circulation Anterior circulation
A.History
1.Vertigo Present Absent
2.Unsteadiness Present Absent
B.Physical findings
1.Crossed hemiplegia Present Absent
2.Bilateral deficits Present Absent
3.Cerebellar signs Present Absent
4.Ocular findings(LMN/INO/Gaze deviation to paralysed side) Present Absent
5.Dissociated sensory loss Present Absent
6.Sensory loss over V1 and V2 Present Absent
7.Horners syndrome Present Absent
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Importance of clinical localisation of stroke
1. Careful clinical evaluation in combination with imaging
helps to find out the etiology of stroke and plan the
appropriate treatment.
2. Clinical observations in correlation with imaging helps to
understand neurology / neurophysiology better.
Note:Neurological examination must be tailored
according to the clinical scenario .
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Limitations of clinical localisation of stroke syndromes
1. A single syndrome may occur due to lesion at different sites
Eg. Pure motor hemiplegia
2.A vascular occlusion at a specific site can produce varying clinical
manifestations.
3.Clinical examination may not detect very small or multiple
infarctions(as in SBE).
Note:Imaging is very useful in the above situations.
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