1. Clinical Presentation of Stroke Syndromes
By Ken Hui Yee for PBL group 7
Case 24
Clinical Presentation of Stroke Syndromes

2. Ischaemic Stroke Causes: Thrombosis & Embolism (65% of strokes)
Artery-to-artery
Cardioembolic
Thrombosis in-situ
Small vessel (lacunar) strokes (20% of strokes)
atherothrombotic or lipohyalinotic occlusion of a small intracranial artery
Often symptomless
Artery-to-Artery Embolic Stroke
Thrombus formation on atherosclerotic plaques may embolize to intracranial arteries producing an artery-to-artery embolic stroke. Alternatively, a diseased vessel may acutely thrombose; the resulting blockage causes stroke by producing ischemia within the region of brain it supplied. Unlike the myocardial vessels, artery-to-artery embolism, rather than local thrombosis, appears to be the dominant vascular mechanism causing ischemia. Any diseased vessel may be a source, including the aortic arch, common carotid, internal carotid, vertebral, and basilar arteries. Carotid bifurcation atherosclerosis is the most common source of artery-to-artery embolus
lipohyalinotic - Degenerative changes in small blood vessels, marked by the accumulation of a glassy- or waxy-appearing lipid within the vessel wall. This type of vascular degeneration occurs in hypertension and atherosclerosis, and predisposes patients to small infarcts, esp. in penetrating arteries of the brain.

3. Artery-to-Artery Embolic Stroke
Thrombus formation on atherosclerotic plaques embolize to intracranial arteries
Carotid bifurcation
most common site (10% of ischaemic strokes)
Diseased vessel may acutely thrombose
Including aortic arch, common carotid, internal carotid, vertebral, and basilar a.
Thrombus formation on atherosclerotic plaques may embolize to intracranial arteries producing an artery-to-artery embolic stroke. Alternatively, a diseased vessel may acutely thrombose; the resulting blockage causes stroke by producing ischemia within the region of brain it supplied. Unlike the myocardial vessels, artery-to-artery embolism, rather than local thrombosis, appears to be the dominant vascular mechanism causing ischemia. Any diseased vessel may be a source, including the aortic arch, common carotid, internal carotid, vertebral, and basilar arteries. Carotid bifurcation atherosclerosis is the most common source of artery-to-artery embolus

4. Cardioembolic Arrhythmias Mural thrombus DCM Valvular lesionsAF
Mural thrombus
DCM
Valvular lesions
Mitral stenosis, Endocarditis, Rheumatic fever
Paradoxical embolus
Atrial septal defect, Patent foramen ovale, Atrial septal aneurysm
mural thrombosisn.Formation of a thrombus in contact with the endocardial lining of a cardiac chamber or, if not occlusive, with a wall of a large blood vessel. Mural Thrombi 2^0 to AMI
Dilated cardiomyopathy or DCM is a condition in which the heart becomes weakened and enlarged, and cannot pump blood efficiently.

5. Less Common Causes of Ischaemic Stroke
Venous sinus thrombosis
Complication of:
OCP
Pregnancy & the postpartum period
Inflammatory bowel disease
Intracranial infections (meningitis)
Dehydration

6. Haemorrhagic Stroke Less common (only 15% of all strokes)
Higher mortality rate than Ischaemic

7. Haemorrhagic Stroke Causes: Head trauma Hypertensive haemorrhage
Most common cause of SAH
Hypertensive haemorrhage
Aneurysm

8. Hypertensive Haemorrhage
Spontaneous rupture of small penetrating artery
Common sites:
Basal ganglia (especially the putamen), thalamus, cerebellum, and pons.

9. Aneurysm SAH from berry aneurysm Mycotic aneurysm
AcomA, PcomA, MCA (locations from most common to less common)
Mycotic aneurysm
Eg. Endocarditis

10. Other Causes of Hemorrhage Stroke
Amyloid angiopathy
Degen of intracranial vessels
Rare in <60
Tumour
Drugs (eg. Cocaine)
Young pts

11. Ischaemic vs. Haemorrhagic Stroke
Can’t be distinguished on basis of the history or clinical examination
Ischaemic stroke tends to be painless
However h/a may still occur
Haemorrhagic stroke causes h/a esp. If ICP is raised
Dura is stretched

12. Ischaemic vs. Haemorrhagic Stroke
Investigations:
Determine between ischaemic and haemorrhagic CT
MRI
CSF

14. Acute Onset vs. Stuttering Onset
Sudden onset
Abrupt neurological deficit
More likely to be thrombotic and lacunar onset
Neurological deficits wax and wane
Proceeds towards complete neurological deficits

15. Case 1
HOPC:
Pt describes a shade or curtain being pulled over the front of the eye (right)
Vision in right eye is lost only for a short time (seconds to minutes)
On examination patient has carotid bruits
Painless

16. Amaurosis Fugax Ddx: Amaurosis Fugax Retinal migraine Rise in ICP
Central retinal artery occlusion
Retinal migraine
Develops more slowly (15 to 20mins)
Rise in ICP
Can compromise optic disc perfusion

17. Case 2 HOPC: IX: Sudden onset of headache with aura
Nausea and vomiting
Tingling, numbness and vague weakness on the right side of the body
Patient prefers a dark room
Patient reports that the aura has persisted for more than a week.
IX:
CT and MRI show focal ischaemia

18. Migrainous Infarction
Rare complication of migraines
Definition:
Aura and a migraine headache, with the aura symptom persisting > 7/7
+ neuroimaging  focal ischaemia

19. Complete vs Incomplete Strokes
Total area of the brain supplied by an occluded vessel is damaged
Further prophylaxis Rx is pointless
some cellular damage
Additional tissue in the affected vascular distribution is at risk
Prophylaxis Rx is useful
Not that practical as distinction based on clinical findings can be impossible

20. Case 3
HOPC:
A 62-year-old woman was admitted to MMC with acute onset of left-sided hemiparesis. On admission, she had left-sided hemiplegia and facial palsy with minor dysarthria

21. Case 3
IX: CT
right MCA mainstem occlusion but no early ischemic changes
Thrombolysis commenced  pt improved initially but then developed sudden decline of consciousness

22. Case 3
Repeat CT
Ruled out ICH
MRI
New occlusion in Left MCA discovered
Underlying cause was due to cardioembolic ischaemic stroke due to AF

23. Case 4 HOPC: Pt presents to ED with global aphasia
Pt’s partner reports that pt is right handed

24. MCA

25. Case 5 HOPC: Pt presents to ED with right leg and foot paralysis
Sensory impairment (pain, temperature) over right lower limb
Examination of upper limb = normal
Impairment of gait

26. ACA

27. Case 6 HOPC: Pt presents with homonymous hemianopia
Has a failure to see to-and-fro movements, inability to perceive objects not centrally located

28. Case 6 HOPC: Pt presents with homonymous hemianopia
Has a failure to see to-and-fro movements, inability to perceive objects not centrally located
Reports peduncular hallucinosis

29. PCA

30. PCA – Specific Named Syndromes
Midbrain – Subthalamic -Thalamic
Weber Syndrome
Contralateral hemiplegia
Thalamic Dejerine-Roussy
Contralateral hemisensory loss
Claude’s Syndrome
Third nerve palsy Contralateral ataxia

31. PCA – Specific Named Syndromes
Anton's syndrome
Bilateral infarction in the distal PCAs producing cortical blindness
Pt maybe unaware of blindness and may deny it
Balint’s syndrome
Watershed infarction between PCA and MCA
Disorder of the orderly visual scanning of the environment

32. Watershed Infarction
Hypotension due to eg. AMI  low perfusion in borderzones/junctional territories of the cerebral end arteries
Ischemia between the territories of the ACA and MCA bilaterally may result in bibrachial cortical sensorimotor impairment (person-in-a-barrel)

33. Watershed Infarction Clinical Presentation:
“Man-in-the-barrel” clinical presentation
Optic ataxia
Cortical blindness
Difficulty in judging size, distance, and movement
Memory loss
Dysgraphia

34. Case 7 81 yr old man with HT and AF on anticoagulants, right-handed
HOPC:
h/a, diaphoresis, dizziness, diplopia
Sudden onset of R arm tingling, numbness and weakness
Progressive slurred speech

35. Case 7 Signs & Symptoms continued:
Horizontal eye movements/conjugated gaze restricted
Jaw deviation to the right
Bilateral facial weakness
Difficulty wrinkling forehead or close eyes
Dysphagia
Balance issues
Cheyne-Stokes breathing
Dry oral pharynx
Sign Implicated Neural Structure Vertical movements and adduction CN III, IV, oculomotor and of the eyes trochlear
Deviation of the jaw CN V, trigeminal motor
Conjugated gaze and horizontal adduction of the eyes CN VI, abducent
Facial weakness and difficulties closing the eyes CN VII, facial
Balance/equilibrium CN VIII, vestibular components Audition CN VIII, cochlear components
Salivatory function CN IX, glossopharyngeal
Cheyne-Stokes breathing CN X, vagus Trapezius and levator scapulae muscle function
CN XI, spinal accessory Tongue movement and gag reflex
CN XII, hypoglossal Contralateral cerebellar signs Central tegmental tract Arousal Nucleus raphe magnus and pontis Discriminative touch/proprioception Medial lemniscus Pain and temperature sensation Anterolateral tract

36. Case 7
IX:
CT - progressive hemorrhagic stroke intrinsic to the pontine tegmentum of the brain stem, with rupture into the fourth ventricle

37. Basilar Artery – Midbrain

38. Basilar Artery  Mid pons

39. Basilar Artery  Inferior Pons

40. Vertebral and Posterior Inferior Cerebellar Arteries  Medulla

41. Presentation of Brainstem Infarction
Clinical Feature
Structure Involved
Hemiparesis
Sensory loss
Diplopia
Facial numbness
Facial weakness
Nystagmus & vertigo
Dysphagia & dysarthria

42. Presentation of Brainstem Infarction
Clinical Feature
Structure Involved
Hemiparesis
Corticospinal tracts
Medial midpontine syndrome,
Medial inferior pontine syndrome
Sensory loss
Medial lemniscus and spinothalamic tracts
Lateral midpontine syndrome
Diplopia
Oculomotor/Adducens
Facial numbness
Trigeminal
Lateral midpontine syndrome,
Lateral inferior pontine syndrome
Facial weakness
Facial
Nystagmus & vertigo
Vestibular
Dysphagia & dysarthria
Glossopharyngeal & vagus
Medullary Syndrome

43. Summary Occluded Blood Vessel Clinical Manifestations ICA
Ipsilateral blindness (variable)
MCA syndrome
MCA
Contralateral hemiparesis, sensory loss (arm, face worst)
Expressive aphasia (dominant) or anosognosia and spatial disorientation (nondominant)
Contralateral inferior quadrantanopsia
ACA
Contralateral hemiparesis, sensory loss (worst in leg)
PCA
Contralateral homonymous hemianopia or superior quadrantanopia
Memory impairment
Basilar apex
Bilateral blindness
Amnesia
Basilar artery
Contralateral hemiparesis, sensory loss Ipsilateral bulbar or cerebellar signs
Vertebral artery or PICA
Ipsilateral loss of facial sensation, ataxia, contralateral hemiparesis, sensory loss
Superior cerebellar artery
Gait ataxia, nausea, dizziness, headache progressing to ipsilateral hemiataxia, dysarthria, gaze paresis, contralateral hemiparesis, somnolence