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VASCULAR DISTRIBUTIONS AND STROKE
SYNDROMES :
APPROACH TO THE PATIENT SUFFERING STROKE
Christine Holmstedt, D.O.
Assistant Professor of Neurology
Medical Director of Clinical Stroke Services
MUSC
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OBJECTIVES
Help develop a systematic approach to
the patient suffering stroke
Recognize specific stroke syndromes
based on clinical presentations and
physical exam findings
Correlate syndrome to vascular
distribution
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Sidenotes
These are the SICKESTpatients in your ED
WE NEED YOUR HELP
Dont leave the bedside
Concurrent medical issues
Get the right story
LAST KNOWN NORMAL
MEDICATIONS
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Question
You are called emergently to see a stroke
patient in the ED, the first thing you assess on
arrival is?
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INITIALPATIENTSURVEY
ABCs, ABC, ABCs,
Vital signsBlood pressure
Pulse rate and rhythmRespiratory rate
Saturations
General survey
Mental Status Level of consciousness
Distress
Trauma
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SECONDARYSURVEY
Quick patient neurologic overview
Forced deviation
Plegia
AphasicDysarthria
Which hemisphere is affected
Anterior verses posterior Cortical verses subcortical
Large vessel verses small vessel
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NIHSS
Standardized exam designed to improvecommunication between health care providers
Measure the level of impairment caused by astroke.
Scores should reflect what the patient does, notwhat the clinician thinks the patient can do
Main use in clinical medicine is during theassessment of whether or not the degree of
disability caused by a given stroke meritstreatment with tPA
Useful for data collection
Not a neurologic exam
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Physical Exam
Complete physical exam
Neurologic exam
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Question?
While doing the NIHSS, do you include a
patients previous neurologic disability?
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Anterior circulation
Internal Carotid arteries
Anterior cerebral arteries
Middle cerebral arteries
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Internal Carotid Artery
Internal carotid artery
Branch of the common carotid
Bifurcates in the neck
Divides into
ACA
MCA Posterior communicating artery
Circle of Willis
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Internal Carotid Artery
Cervical C1
Petrous C2
Lacerum C3
Cavernous C4
Clinoid C5
Ophthalmic C6
Communicating C7
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Clinical Syndromes
Variable depending on territorial strokeMCA
ACA
MCA/ACA
MCA/ACA/Occipital lobe
Depends on hemisphere involved
Depends on dominance of brain
Depends on acuity of occlusionYounger more acute occlusion typically more
devastating
More chronic occlusion may by asymptomatic
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Clinical Syndrome
Dominant hemisphere
Aphasia
Contralateral hemiplegia/paresis face, arm and leg
Visual field cut
Sensory loss
Gaze preference
Dysarthria
Non-Dominant hemisphere
Contralateral hemiplegia/paresis face, arm and leg
Visual field cut
Sensory loss
Gaze preference
Dysarthria
Neglect
Personality changes
Apraxia
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Anterior Cerebral Arteries
Surface branches supply cortex and white matter of : inferior frontal lobe
medial surface of the frontal and parietal lobes
anterior corpus callosum
Penetrating branches supply:deeper cerebrum
diencephalon
limbic structures
head of caudateanterior limb of internal capsule
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Clinical Syndrome
Left ACA
Right leg weakness
Right leg sensory loss
Grasp reflex
Frontal lobe behavior abnormalities
Motor aphasia
Larger infarcts can cause hemiplegia
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Clinical Syndrome
Right ACA
Left leg weakness
Left leg sensory loss
Grasp reflex
Frontal lobe behavior abnormalities
Left hemi-neglect
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Middle Cerebral Arteries
Surface branches supply
Cortex & white matter of hemispheric
convexity
All four lobes.
Penetrating branches
Deep matter
Some diencephalic structures
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Middle Cerebral Arteries
Horizontal segment M1
Lateral lenticulostriate vessels
Sylvian segment M2
Cortical Segment M3
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Middle Cerebral Arteries
Left MCA Stem M1
Right hemiplegia/paresis
Right sensory loss
Right VF cut
Global aphasia
Left Gaze preference
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Middle Cerebral Arteries
Left anterior (superior) division
Right face, arm>leg weakness
Motor aphasia
Some right face and arm
sensory loss
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Middle Cerebral Arteries
Left posterior (inferior) MCA
Fluent sensory aphasia
Right VF cut
Right face, arm and leg sensory loss
May appear confused or crazy
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Middle Cerebral Arteries
Right MCA Branch (M1)
Left hemiplegia/paresis
Left sensory loss
Left VF cut
Left hemi-neglect
Right gaze preference
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Middle Cerebral Arteries
Right anterior (superior) division
Left face, arm>leg weakness
Left hemi-neglect
Gaze preference
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Middle Cerebral Arteries
Right posterior (inferior) division
Left hemi-neglect
Left VF cut
Left sensory loss
Decreased voluntary movements
Left motor neglect (normal strength)
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Lacunar infarcts
Occlusion of one of the penetrating arteries thatprovides blood to the brain's deep structures
Lacunes are caused by occlusion of a single deeppenetrating arteries that arises directly from the
constituents of the Circle of Willis, cerebellararteries, and basilar artery.
37% putamen
14% thalamus
10% caudate
16% pons
10% posterior limb of the internal capsule
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Lacunar infarcts Pure motor stroke/hemiparesis33-50%
Posterior limb of the internal capsule, or the basis pontis Weakness face, arm, or leg
May have dysarthria, dysphagia and transient sensory symptoms
Ataxic hemiparesis
Posterior limb of the internal capsule, basis pontis, and corona radiata Weakness and clumsiness arm, or leg
Dysarthria/clumsy hand Basis pontis
Dysarthria and clumsiness (i.e., weakness) of the hand, which often are most prominentwhen the patient is writing.
Pure sensory stroke
Thalamus Persistent or transient numbness, tingling, pain, burning, or another unpleasant sensation on
one side of the body. Mixed sensorimotor stroke
Thalamus and adjacent posterior internal capsule Hemiparesis or hemiplegia with ipsilateral sensory impairment
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Posterior circulation
Posterior cerebral arteries
Cerebellar arteries
Vertebral arteries
Basilar artery
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Posterior cerebral Artery
Supply midbrain, cerebral peduncles, medial
temporal lobes, medial thalami, splenium of
the corpus callosum,lateral ventriclar
choroid plexus and bilateral occipital lobes. Arises at the intersection of the posterior
communicating artery and the basilar artery
Connects with the ipsilateral MCA andinternal cerebral artery via the posterior
communicating artery PCommA
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Clinical Syndrome
Contralateral weakness
Contralateral VF cut with macular sparing
Contralateral sensory loss
Posterior headache
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Cerebellar arteries
Posterior inferior cerebellar artery
Anterior inferior cerebellar artery
Superior cerebellar artery
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Posterior inferior cerebellar artery
Last branch off the vertebral artery
Supplies lateral medulla
Most of the inferior cerebellum and
inferior vermis
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Clinical syndrome
Dysphagia
Dysarthria
Gait unsteadiness
Ipsilateral limb ataxia
Vertigo
Hoarseness
Ipsilateral Horners syndrome
Ipsilateral hemianesthesia of the face
Contralateral hemianesthesia of the limbs
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Anterior inferior cerebellar artery
First paired branches off the basilar
Supplies the inferior, lateral pons
Middle cerebellar peduncle
Strip of the ventral, anterior
cerebellum(between the PICA and the
SCA)
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Clinical syndrome
Vertigo
Nystagmus
Facial weakness
Gait ataxia
Acute unilateral deafness (internal
auditory artery)
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Superior cerebellar artery
Paired branches off basilar artery
Supplies upper, lateral pons
Superior cerebellar peduncle
Most of the superior cerebellar
hemisphere
Superior vermis
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Clinical syndrome
Ipsilateral cerebellar ataxias (middle and/orsuperior cerebellar peduncles)
Nausea and vomiting
Slurred (pseudobulbar) speech
Loss of pain and temperature over theopposite side of the body
Partial deafness
Tremor of the upper extremity
Ipsilateral Horner syndrome
Palatal myoclonus
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Brainstem infarctions
Basilar occlusion
Small vessel lacunar infarctions
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Basilar artery occlusion
Most important artery in the posterior
circulation (the body)
Formed at the pontomedullary junction by the
confluence of both vertebral arteries
Lies on the ventral surface of the pons
Gives off its median, paramedian, short, and
long circumferential branches
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Clinical presentation
Hemiparesis or tetraparesis and facial paresis - 40-67% of cases Dysarthria and speech impairment - 30-63% of cases
Vertigo, nausea, and vomiting - 54-73% of cases
Visual disturbances - 21-33% of cases
Altered consciousness - 17-33% of cases
Convulsive-like movements along with hemiparesis (herald hemiparesis)
Oculomotor signsIpsilateral abducens palsy
Ipsilateral conjugate gaze palsy
Internuclear ophthalmoplegia
One-and-a-half syndromeOcular bobbing
Skew deviation
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Clinical presentation
Locked-in syndrome: Infarction of the basis pontis
Secondary to occlusive disease of the proximal and middle segments of the basilarartery, which leads to quadriplegia. spared level of consciousness, preserved vertical eyemovements, and blinking.
Coma associated with oculomotor abnormalities and quadriplegia also indicatesproximal basilar and midbasilar occlusive disease with pontine ischemia.
Top-of-the-basilar syndrome: Upper brainstem and diencephalic ischemia caused by occlusion of the rostral basilar
artery
Patients present with changes in the level of consciousness
Visual symptoms Hallucinations and/or blindness.
Third nerve palsy and pupillary abnormalities are also frequent.
Motor abnormalities include abnormal movements or posturing. Other reported signs of pontine ischemia include limb shaking, ataxia (usually
associated with mild hemiparesis), facial weakness, dysarthria, dysphagia, andhearing loss.
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Syndrome?
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