Ischemic Stroke By Bhanu Prakash

definition Acute cerebral focal defecit lasting for greater than 24hrs

classification Reduction of blood flow that lasts longer than several seconds Blood flow 0 ml  brain death <16ml/100gm/min  infarction within an hour <20ml/100gm/min  ischemia without infarction

Ischemic pathway

Transient ischemic attack(TIA)

TIA Syndromes

DDx TIA Migraine, Seizure, Syncope Tumor, Subdural, SAH Hypoglycemia Labyrinthine dz TIA rarely march across body  suggests Sz, migraine  involuntary movements more Sz  fortification/scintillating light more migraine

 Atrial fibrillation  Mural thrombus  Myocardial infarction  Dilated cardiomyopathy  Valvular lesions Mitral stenosis Mechanical valve Bacterial endocarditis  Paradoxical embolus Patent foramen ovale Atrial septal defect

 Atrial fibrillation  Mural thrombus  Myocardial infarction  Dilated cardiomyopathy  Valvular lesions Mitral stenosis Mechanical valve Bacterial endocarditis  Paradoxical embolus Patent foramen ovale Atrial septal defect

Artery-to-artery embolism Carotid bifurcation Aortic arch Arterial dissection

Artery to artery embolism

Thrombotic stroke Small vessel thrombosis (lacunar stroke) Large vessel thrombosis

Uncommon causes Hypercoagulable disorders Venous sinus thrombosis Fibromuscular dysplasia Vasculitis Cardiogenic Drugs Eclampsia Moya moya disease

Stroke syndromes Anterior Circulation MCA ACA Posterior Circulation PCA Basilar Vertebral Lacunar

Signs and symptoms of MCAO Proximal MCA contralateral hemiplegia, conjugate eye deviation, hemisanesthesia,homonymous hemianopsia, aphasia or neglect Upper MCA face + arm affected more than leg, Broca’s aphasia Lower MCA leg> face + arm, Wernicke aphasia or behavioural disturbance (nondominant hemisphere), homonymous hemianopia Angular gyrus Gerstmann’s syndrome: finger agnosia, acalculia, R-L disorientation,agraphia Right parietal anosognosia, neglect, apraxia, impaired prosody, confusion/delirium

Hemineglect

ACA

ACA stroke less common 3% weakness LE >UE abulia, akinetic mutism, emotional disturbance transcortical motor aphasia head deviation toward lesion Paratonia Ant choroidal a. syndrome –ant limb int capsule hemiparesis, hemisensory loss, hemianopia

Circle of willis

PCA syndromes Weber Syndrome Eponym: Weber Syndrome Anatomy: Midbrain: Base Vascular: Posterior cerebral artery: Penetrating branches to midbrain SideManifestationcomments CWeakness- upper and lower extremity Corticospinal tract ILateral gaze weakness CN3 Symptoms and signs

PCA syndromes Claude Syndrome Eponym: Claude Syndrome Anatomy: Midbrain: Tegmentum Vascular: Posterior cerebral artery SideManifestation cAtaxia- arm and leg

PCA syndromes Thalamic pain syndrome Eponym: Dejerine Roussy syndrome Anatomy: Thalamus Vascular: Posterior cerebral artery: Pentrating branches to thalamus SideManifestation CHemisensory loss – all modalities CHemibody pain

PCA syndromes Alexia without agraphia Anatomy: Cerebral hemisphere: Left occipital region plus splenium of corpus collosum Vascular: Posterior cerebral artery: Collosal branches sidemanifestationscomments NAlexiaSplenium of corpus callosum CVisual loss- homonymous hemianopia Left occipital region Signs and symptoms

PCA syndromes Cortical blindness Eponym: Anton Syndrome Anatomy: Cerebral hemisphere: Bilateral occipital lobes Vascular: Posterior cerebral artery: Bilateral Basilar artery: Top of the basilar Signs and symptoms sidemanifestation NBilateral visual loss CUnawareness of/ denial of blindness

PCA syndrome Balint Syndrome Eponym: Balint Syndrome Anatomy: Cerebral hemisphere: Bilateral parietaloccipital lobes Vascular: Posterior cerebral artery: Bilateral SideManifestation BLoss of voluntary but not reflex eye movements BOptic ataxia poor visual motor coordination BAsimultagnosia inability to understand visual objects

PCA syndromes Posterior cerebral artery unilateral occipital Anatomy: Cerebral hemisphere: Occipital and inferomedial temporal lobes. Vascular: Posterior cerebral artery SideManifestationcomments CVisual loss – homonymous hemianopia Optic pathway, calcrine cortex

Vertebral artery syndromes Medial medullary syndrome Eponym: Dejerine Syndrome Anatomy: Medulla: Medial medulla Vascular: Vertebral artery: Anteromedial artery Anterior spinal artery: Anteromedial artery Basilar artery SIDEMANIFESTATIONSCOMMENTS CWeakness UL & LLPyramidal tract CHemisensory loss _ vibration & proprioseption Medial lemniscus ITongue weakness +/_ atrophyCn 12 nucleus

CS AT MEDULLA

WALLENBERG SYNDROME Eponym: Wallenberg Syndrome Anatomy:LATERAL MEDULLA Vascular: Vertebral artery SIDEMANIFESTATIONCOMMENT I SENSORY LOSS _ FACE_TEMP PAIN C5 NUCLEUS IATAXIA RESTIFORM BODY CEREBELLUM I NYSTAGMUS,NAUSEA VOMITING, VERTIGO VESTIBULAR IHOARSENESS,DYSPHGIA NUCLEUS AMBIGOUS IHORNERS SYNDROMEDES SYMPAT CHEMISENSORY LOSS PAIN AND TEMPERATURE SPINO THALAMIC

Basilar artery occlusion Locked in Syndrome  Anatomy: Pons: Bilateral ventral pons  Vascular: Basilar artery SideManifestationComment BWeakness UL&LLB/L corticospinal BWeakness face entire & dysarthria B/L corticobulbar BLateral gaze weaknessB/L fasiculus VI cn

Millard gublar syndrome Anatomy: Pons: Basis pontis and fascicles of CN VI amd VII Vascular Basilar artery: Short circumferential branches Basilar artery: Paramedian branches sideManifestationComment CWeakness UL&LLPyramidal tract ILateral gaze weaknessCn VI nuc IWeak face_ entireCn VII nuc

Foville Syndrome Anatomy: Pons: Unilateral lesion in the dorsal pontine tegmentum in the caudal third of the pons Vascular: Basilar artery: Paramedian branches Basilar artery: Short circumferential arteries SidemanifestationsComment CWeakness UL&LLCorticospinal.t IWeakness of face entireCN VII NUC

Lacunar strokes Infarct from small penetrating arteries 1. Pure motor –weakness face, arm and leg 2. Pure sensory –paresthesias & numbness, face, armand leg 3. Sensory-Motor –weakness and sensory loss 4. Ataxia hemiparesis -weakness LE, incoordinationipsilateral arm and leg 5. Dysarthria-Clumsy hand syndrome dysarthria, dysphagia, dec fine motor hand

Lacunar strokes

Ddx of ishcemic stroke Bell’s Palsy Todd’s Paralysis Hemorrhagic Stroke Subdural Hematoma Hypoglycemia Metabolic conditions – fever, hyponatremia, drugs, etc. Psychogenic Complex migraines Hypertensive crisis

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