1. 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)

2. 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.

3. 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%

4. 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

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

6. Risk factor
Hyperlipidemia
Ischemic heart disease
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7. 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

8. 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

9. 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.

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

13. 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.

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

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

18. 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

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

21. MCA

22. Basal Ganglia

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

24. 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

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

28. 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

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

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

32. Thalamus

33. 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

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

36. MCA M2
Insular IC CR SC M3
Superior
Inferior

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

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

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

41. 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

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

44. 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.

45. 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

49. 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

50. 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

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

53. 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

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

59. 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↓)

61. 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.

62. VA/Basilar a.
SCA
AICA
PICA

63. 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

67. 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

68. 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

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

72. 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↓)

75. basi
basi
vert

78. Spinal a.
ASA
PSA

79. Spinal artery

81. 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