1. Seminar on… Territorial Localization and Management of Stroke
Prepared by…
Dr. Salman Abdul Qayyum,
House Physician, MU II, HFH,
Dated: February 27, 2006.

2. Major Vessels

4. Stroke Syndromes: Classification

5. Stroke within anterior circulation

6. Anterior Cerebral Artery
Paralysis of opposite foot and leg
A lesser degree of paresis of opposite arm
Cortical sensory loss over toes, foot and leg
Urinary incontinence
Contralateral grasp reflex, suckling reflex, gegenhalten
Abulia, slowness, delay, intermittent interuption, lack of spontaneity, whispering, reflex distraction to sights and sounds
Impairement of gait and stance

7. Middle Cerebral Artery
Paralysis of contralateral face, arm and leg
Sensory impairement over the same area (pinprick, cotton touch, vibration,position, two-point stereognosis, tactile localization)
Motor aphasia
Central aphasia, word deafness, anomia, jargon speech, sensory agraphia, acalculia, alexia, finger agnosia, right-left cofusion
Conduction aphasia
Homonymous hemianopia
Paralysis of conjugate gaze to the opposite side

8. Stroke within posterior circulation

9. Posterior Cerebral Artery
Peripheral territory:
Homonymous hemianopia
Bilateral homonymous hemianopia, cortical blindness, awareness or denial of blindness
Verbal dyslexia without agraphia, color anomia
Memory defect
Topographic disorientation and prosopagnosia
Simultagnosia, hemivisual neglect
Unformed visual hallucinations

10. Central territory:
Thalmic sydrome
Weber’s syndrome: third nerve palsy and contralateral hemiplegia
Contralateral hemiplegia
Paralysis or paresis of vertical eye movement, skew deviation, sluggish pupillary responses to light, slight miosis and ptosis
Contralateral rhythmic , ataxic action tremor

11. Medullary syndrome
Medial medullary syndrome(occlusion of vertebral artery or of branch of vertebral or lower basilar artery)
On side of lesion
Paralysis with atrophy of half the tongue
On side opposite lesion
Paralysis of arm and leg, sparing face; impaired tactile and proprioceptive sense over half of the body

12. Lateral medullary syndrome(occlusion of any of the five vessels may be responsible –vertebral, posterior inferior cerebellar, superior, middle or inferior lateral medullary arteries)
On side of lesion
Pain, numbness, impaired sensation over half the face
Ataxia of limbs, falling to side of lesion
Nystagmus, diplopia, oscillopsia, vertigo, nausea, vomiting
Horner’s syndrome
Dysphagia, hoarseness, paralysis of palate, paralysis of vocal cords, diminished gag reflex
Loss of taste
Numbness of ipslateral arm, trunk or leg
On side of opposite lesion
Impaired pain and thermal sense over half of the body, sometines face

13. Total Unilateral medullary syndrome (occlusion of vertebral artery)
Combination of medial and lateral syndromes
Lateral pontomedullary syndrome (occlusion of vertebral artery)
Combination of lateral medullary and lateral inferior pontine syndrome
Basilar artery syndrome
Combination of brainstem syndromes plus those arising in PCA distribution

14. Superior pontine syndrome
Medial Superior pontine syndrome(paramedian branches of upper basilar artery)
On side of lesion
Cerebellar ataxia
Internuclear ophthalmoplegia
Myoclonic syndrome, palate, pharynx, vocal cords, respiratory apparatus, face oculomotor apparatus
On side opposite lesion
Paralysis of face, arm, and leg
Rarely touch, vibration, and position are effected

15. Lateral superior pontine syndrome(Syndrome of superior cerebellar artery)
On side of lesion
Ataxia of limbs and gait, falling to side of lesion
Dizziness, nausea, vomiting; horizontal nystagmus
Pariesis of conjugate gaze(ipsilateral)
Skew deviation
Horner’s Syndrome
On side opposite lesion
Impaired pain and thermalsense on face, limbs and trunk
Impaired touch, vibration and position sense, more in leg than arm

16. Midpontine syndrome
Medial midpontine syndrome(paramedian branch of midbasilar artery)
On side of lesion
Ataxia of limbs and gait
On side opposite lesion
Paralysis of face, arm and leg
Variable impaired touch sensation touch and proprioception when lesion extends posteriorly

17. Lateral midpontine syndrome(Short circumferential artery)
On side of lesion
Ataxia of limbs
Parlysis of muscles of mastication
Impaired sensation over side of face
On side opposite lesion
Impaired pain and thermal sense on limbs and trunk

18. Inferior pontine syndrome
Medial inferior pontine syndrome(occlusion of paramedian branch of basilar artery)
On side of lesion
Paralysis of conjugate gaze to side of lesion
Nystagmus
Ataxia of limbs and gait
Diplopia on lateral gaze
On side opposite lesion
Paralysis of face, arm and leg
Impaired tactile and proprioceptive sense over half of the body

19. Lateral inferior pontine syndrome (occlusion of anterior inferior cerebellar artery)
On side of lesion
Horizontal and vertical nystagmus, vertigo, nausea, vomiting, oscillopsia
Facial paralysis
Paralysis of conjugate gaze to side of lesion
Deafness, tinnitus
Ataxia
Impaired sensation over face
On side opposite lesion
Impaired pain and thermal sense over half the body

20. Significance of territorial localization?

21. Hemorrhagic stroke Intracerebral and cerebellar hemorrhage
Subarchnoid hemorrhage
Subdural and extradural hemorrhage/ hematoma

22. Cause of Coma in Stroke

23. Diffuse brain dysfunction
SAH
Direct effect within brainstem
Brainstem hemorrhage or infarction (Posterior circulation stroke)
Pressure effect on brainstem
Hematoma
Infarction

24. Management of Stroke

25. Emergency Management

26. No

27. Fibrinolytic therapy Tissue plasminogen activator Dose:
Total dose 0.9 mg/kg(max 90 mg)
10% of total dose as initial intravenous bolus over 1 minute. Remainder infused intravenously over 60 minutes

28. Therapy for Cerebral Edema and raised ICP
Mannitol
IV steroids

29. Investigations helping confirm the diagnosisCT
MRI
Carotid doppler and duplex scanning
Vascular imaging
Magnetic resonance angiography or digital subtraction angiography

30. Long-term management
All risk factors should be identified and if possible treated.
Antihypertensive therapy
Antiplatelet therapy
Aspirin 75mg daily(thromboembolic TIA or stroke)
Clopidogrel, dipyridamole and ticlopidine

31. Anticoagulants Heparin & Warfarin Valvular heart disease Recent MI
Intracardiac thrombus
Atrial fibrillation
Acute internal carotid artery thrombus
Acute basilar artery thrombus
Internal carotid artery dissection
Extracranial vertebral artery dissection
Prothrombic states, e.g. protein C deficiency
Recurrent TIAs or stroke on full antiplatelet therapy
Cerebral venous thrombosis including sinus thombosis

32. Other measures
Polycythemia
Clotting abnormalities

33. Surgical approaches
Internal carotid endartectomy

34. Rehabilitation
Physiotherapy
Speech therapy

35. Management of Hemorrhagic Stroke
Intracerebral and cerebellar hemorrhage
Urgent neurosurgical clot evacuation is considered when an intracerebral hematoma expands.
Antiplatelet and anticoagulants are contraindicated
Control of hypertension

36. Subarachnoid hemorrhage
Poor prognosis
Bed rest and supportive measures
Control of hypertension
Dexametasone
Calcium channel blocker(Nimodipine)
Surgical interventions
Direct approach to clip the neck of the aneurysm
Focal radiotherapy

37. Subdural and extradural hemorrhage/ hematoma
Extradural bleeding
Urgent neurosurgery
Surgical drianage through a Burr-hole
Subdural bleeding
Conservative management
Neurosurgery

38. Care of Unconscious Patient
Care of airway
Vital and intake/output monitoring
Skin care
Oral hygiene
Eye care
Fluids
Calories
Sphinters

39. Thanks