Stroke Stroke or cerebrovascular acciden(CVA) is defined as sudden, focal neurological deficit resulting from ischemia or hemorrhage in the brain Stroke = CVA = infarction or hemorrhage + sudden onset focal neurological deficit Rt. CVA with Lt. Hemiparesis(hemiplegia)

The neurological deficits persist longer than 24hours. Accompany Motor paralysis Sensory disturbances Perception dysfunction Visual disturbances Personality and intellectual changes Language disorders The neurological deficits persist longer than 24hours.

Causes of CVA Essentially a disease of the cerebral vasculature in which failure to supply oxygen to the brain cells. Ischemic stroke 80% Hemorrhagic stroke 20%

Ischemia Embolisms to the brain from cardiac or arterial sources. Cardiac sources Atrial fibrillation Sino-atrial disorders Acute myocardiac infarction Endocarditis Cardiac tumors Valvular disorders Arterial sources Carotid and basilar arteries severe stenosis

High risk factors Hypertension Cardiac disease Diabetes and glucose metabolism Smoking Excessive use of alcohol Use of illegal drugs Lifestyle factors

Risk factor Hyperlipidemia Ischemic heart disease 대한뇌졸중학회, 추계학술대회, 배희준

Brain infarction Infarcts: when an embolus or thrombus lodges in a vessel, obstructing blood flow Embolus: abruptly deprives an area of blood, resulting in almost immediate onset of deficits Thrombus : abrupt or may worsen over several days Lacunar infarcts : obstructions of blood flow in small, deep arteries(20%) Slowly develop, either purely motor or purely sensory, and good recovery is the norm

Subarchnoid hemorrhage: deprives the downstream vessels of blood(10%) Exerts pressure on the surrounding brain by extravascular blood Worst deficits within hours of onset Subarchnoid hemorrhage: sudden, excruciating headache with a brief loss of consciousness Progressive because of continued bleeding or secondary hydrocephalus

Transient ischemic attacks TIA Symptoms that develop suddenly, last from a few minutes to several hours but not longer than 24 hours, and clear completely. Is seen as a sign of impending CVA Estimate One third will sustain a completed stroke Another third will continue to have additional TIAs without stroke One third will experience no further incident.

Effects of CVA CT, MRI, PET, SPECT Medical chart C.C. PMH Surgical history DX Current pharmacological OT develop hypothesis identify pt.

Internal Carotid Artery Occlusion of ICA Contralateral hemiplegia Hemianesthesia Homonymous hemianopsia Involvement of the dominant hemisphere Aphasia, agraphia, dysgraphia, acalculia, dyscalculia, right-left confusion, finger agnosia Involvement of the nondominant hemisphere Visual perceptual dysfunction, unilateral neglect, anosognosia, contructional or dressing apraxia, attention deficts, and loss of topographic memory.

Blood supply1 Ant. Circulation(=carotid system) Internal Carotid Artery(ICA) Opthalmic artery MCA Ant. Choroidal artery Lenticulostriate artery ACA A-com PCA P-com

Blood supply2 Post. Circulation(=vertebrobasilar sys) Spinal artery PCA Superior Cerebellar Artery(SCA) Basilar artery Pontine artery AICA PICA Spinal artery

Middle cerebral artery Dominant hemisphere. Contralateral hemiplegia with greater involvement of the arm, face and tongue Sensory deficits Contralateral homonymous hemianopsia Aphasia Nondominant hemisphere. Perceptual deficits Anosognosia, unilateral neglect, impaired vertical perception, visual spatial deficits, perseveration

MCA M1 Anterior choroidal artery. BG Thalamus Middle cerebral a.(lateral striate branch) Anterior cerebral a.(medial striate branch, of Huebner) Thalamus

MCA

Basal Ganglia

MCA ACA anterior chor.. Caudate nucleaus Head Body Tail Putamen Rostral Caudal Globus pallidus Lateral Medial

BG ICH & IVH Physical state Sensation Cognitive & perception ADL U/E; flaccide / shoulder(subluxation) Sensation NT(observation-proprioception;absent) Cognitive & perception Unilateral visual neglect severe Cognition ↓(drowsy) ADL Total dependent

Putamen ICH Physical state Sensation Cognitive-intact ADL U/E; flaccide Sensation Intact Cognitive-intact ADL maximal assist(sitting balance↓)

Choroidal artery Anterior choroidal (a branch of the internal carotid) : optic tract, choroid plexus in the lateral ventricles, part of the optic radiations, putamen, thalamus, internal capsule, hippocampus Posterior choroidal ( a branch of the posterior cerebral artery) : choroid plexus of the third ventricles and parts of the thalamus and hippocampus

Ant. Choroidal artery Contralateral hemiplegia Hemianesthesia(hypesthesia) Homonymous hemianopsia

Ant. Choroidal inf. Physical state Sensation Cognitive & perception U/E; functional use Sensation Intact Cognitive & perception hemianopsia ADL moderate assist

Thalamus

thalamus Thalamic syndrome: Thalamoperforate syndrome: Sensory loss, intention tremor,spasm of hand, mild hemiparesis Posteroventral nu. Thalamoperforate syndrome: Crossed cbll ataxia with ipsilateral 3rd palsy Dentatothalamic tract Weber’s syndrome: 3rd palsy, contralateral hemiplegia Paralysis or paresis of vertical eye move Cbll peduncle

Thalamic ICH & IVH Physical state Sensation U/E; movement-clumsy/non functional Sensation Intact Cognitive and perception-good ADL maximal assist(sitting balance↓)

MCA M2 Insular IC CR SC M3 Superior Inferior

Internal Capsula infarct Physical state U/E; proximal(poor)/distal(mass grip&release) Sensation Intact Cognitive ADL Feeding-independent Other-moderate assist

Corona Radiate infarct Physical state U/E; shoulder(fair-)/distal(grip&release) Sensation Intact Cognitive-good ADL Feeding-independent Other-maximal assist(sitting balance↓)

Striate-Capsular infact Physical state U/E; shoulder(subluxation)/distal(flaccide) Sensation Intact Cognitive-good ADL Feeding&grooming-independent Other-moderate assist

MCA infarct Physical state Sensation Cognitive & perception-good ADL U/E; Proximal(poor)/distal(flaccide) Sensation Proprioception loss Cognitive & perception-good ADL Feeding and grooming-independent Other-moderate assist

MCA inferior division inf. Physical state U/E; fine motor coordination↓/clumsy Sensation Intact Aphasia Cognitive-impaired & ADL Feeding & grooming-supervision Other-minimal assist

Anterior cerebral artery Occlusion of the ACA Contralateral LE >> UE Apraxia, mental changes, primitive reflexes, and bowel and bladder incontinence Total occlusion of ACA Contralateral hemiplegia with severe weakness of the face, tongue, and proximal arm muscles and marked spastic paralysis of the distal LE. LE cortical sensory loss Intellectual change Confusion, disorientation, abulia, whispering, slowness, distractibility, limited verbal output, perseveration, and amnesia may be seen.

ACA A1 A2 Anterior limb of the IC Anterior perforate substance Amygdala Anterior hypothalamus Inferior part of the head of the caudate nu. A2 Abulia(a delay in verbal and motor response) Urinary incontienence

ACA infarct Physical state Sensation Cognitive & perception ADL U/E; movement good/Arian hand syndrome Sensation Intact Cognitive & perception Sequence↓ Constructional apraxia ADL Minimal assist

Posterior cerebral artery Symptoms is potentially broad & varied Artery supplies the upper brainstem Temporal and occipital lobes. Some possible outcome Sensory and motor deficits Involuntary movement disorders Memory loss Alexia Astereognosis Dysesthesia Cnotralateral homonymous hemianopsia Anomia Topographic disorientation Visual agnosia

PCA P1 syndromes P2 syndromes Post choroidal a. Thalamic Dejerine-Roussy syndrome P2 syndromes Anton’s syndrome Balint’s syndrome Post choroidal a.

Thalamic Dejerine-Roussy syndrome Penetrating branches of thalamic & thalamogeniculate a, thalamocapsular lacunar syndrome Contralateral hemisensory loss By agonizing, searing or burning pain Motor; hemiparesis, intention tremor, incoordination

P2 Anton’s syndrome Balint’s syndrome Blindness Visual association area lesion Optic ataxia Ocular ataxia Sumultagnosia

Post choroidal a. inf. Physical state Sensation Cognitive-good ADL U/E; shoulder(fair-)/distal(grip&release) Sensation Intact Cognitive-good ADL Feeding-independent Other-maximal assist(sitting balance↓)

Vertebrobailar artery system Combination of bilateral or crossed sensory and motor abnormalities Cerebellar dysfunction Loss of proprioception Hemiplegia Quadriplegia Sensory disturbances With unilateral or bilateral cranial nerve involvement of nerves 3 to 12.

VA/Basilar a. SCA AICA PICA

Vascular supply to brain stem and cerebellum Brain stem and cerebellum : by branches of the vertebral arteries and branches of the basilar artery Each vertebral artery : three main branches: the anterior and posterior spinal arteries and the posterior inferior cerebellar artery Medulla : receives blood from all three branches of the vertebral arteries Cerebellum : posterior inferior cerebellar artery Pons and most of the cerebellum : basilar artery and its branches(anterior inferior cerebellar, superior cerebellar) Midbrain : posterior cerebral artery

Cerebellar artery system Cerebellar artery occlusion results Ipsilateral ataxia Contralateral loss of pain & temperature Ipsilateral facial analgesia dysphagia and dysathria caused by weakness of the ipsilateral muscle of the palate Nystagmus Contralateral hemiparesis

AICA infarct Physical state Sensation Cognitive and perception-good U/E; functional use Sensation Hearing loss Severe Dizziness Cognitive and perception-good ADL Modified independent

Lateral medullory inf. Physical state Sensation Cognitive-good ADL U/E; fine motor coordination ↓/ataxia Sensation Intact DZ Cognitive-good ADL Complete independent

Pons & midbrain ICH Physical state Sensation Cognitive-good ADL U/E; good grade/Ataxia severe-nonfunction Facial N. palsy Sensation Neurogenic bladder Cognitive-good ADL Feeding-moderate assit Other-maximal assist(sitting balance↓)

basi basi vert

Spinal a. ASA PSA

Spinal artery

ASA infarct Physical state Sensation Cognitive-good ADL U/E; C4<G/G>/C5<F+/F+>/C6<F-/F-> Sensation C7level Cognitive-good ADL Maximal assist