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Definations Stroke TIA HIE Pathophysiology Classical Symtoms Weakness Vision loss Gait Ability to speak or understand Severe Headache TOAST classification Small vessel Large vessel Cardiogenic Iatrogenic Cryotogenic Oxford Classification Anterior Partial Ant Posterior Localization Cortical signs Subcorical Brainstem Spinal cord Others Thomas Willis Galen Dr. C. Miller Fisher Dr. Louis Caplan Ford FDR Nixon Wilson D. Ambani J. Nehru Circle of Willis Cerebral circulation Cerebral circulation MRA circle of Willis Normal blood flow Thrombosis Artery Blood supply Blood clot Oxygen starved brain tissue ACA Syndrome Supply: Frontal pole Superomedial border and medial frontal and parietal lobes including paracentral lobule and cingulate Anterior 4/5 of corpus callosum Heubner’s: Anterior limb of the internal capsule, head of caudate ACA Syndrome Classic: Contralateral hemiparesis with crural predominance (86%) with sparing of face, tongue and sensations Contralateral hemiparesis with brachial predominance in 7% (Heubner’s) Contralateral crural monoparesis in 7% ACA Syndrome R ACA: Left motor neglect L ACA: Transcortical motor aphasia Bilat. ACA: Akinetic mutism (Unilat.Abulia), Emotional lability, Witzelsucht, Euphoria and incontinence Caudate: Restlessness, confusion, hyperactivity, anxiety, depression Alien limb syndrome, Diagnostic dyspraxia, Apraxia, Agraphia, Tactile anomia (rarer syndromes) ? MCA Syndrome Supply: Entire lateral hemisphere including sensorimotor cortex, language areas Lenticulostriate: Caudate, putamen and posterior limb of internal capsule, corona radiata Figure 1 (A) Fluid attenuation inversion recovery imaging demonstrating left-hemispheric ischaemia with secondary oedema and obliteration of cerebrospinal fluid spaces. An old right middle cerebral artery stroke is also shown (arrow). (B) Further images demonstrating uncal herniation (arrow 1) with secondary midbrain compression and infarction (arrow 2), as well as subfalcine herniation (arrow 3). Thrombus is shown within the middle cerebral artery (arrow 4). Kumar, K R et al. J Neurol Neurosurg Psychiatry 2009;80:87 Copyright ©2009 BMJ Publishing Group Ltd. Broca’s W E R N I C K E’ S Carl Wernicke Paul Broca MCA Syndrome Stem Superior Inferior Consciousness Impaired Head and eyes (I) Forced (I) Gaze Deviation Preference Vision HH © Normal Normal Normal Normal HH or SQ © MCA Syndrome Stem Other Apraxia (I) Superior Inferior Apraxia (I) Confusion Depression(L) ® Sensori- Contralat. Contralat. Contralat. motor dense motor sensory Language Global Broca’s Wernicke’s (left) aphasia aphasia aphasia Cortical +++ -++/ +++ sensory ® Branch MCA Syndromes Anterior Parietal branch: Pseudothalamic syndrome Conduction aphasia with left affection Visual-spatial disturbance with right Distal UE disproportionately affected Posterior parietal branch: Impaired cortical senses with preserved touch, pain, temperature Branch MCA Syndromes Angular artery: Gerstmann syndrome with left affection Agraphia without alexia, Right/left confusion, Acalculia, Finger agnosia Impaired optokinetic response Lacunar MCA Syndromes Pure motor stroke Sensori-motor stroke Ataxic hemiparesis AChA Syndrome Supply: Posterior limb of internal capsule, posterior corona radiata, Globus pallidus, LGB, Optic tract AChA Syndrome Triple “H”: Contralateral hemiparesis, hemisensory loss and homonymous hemianopsia Classic visual field defect: Contralateral quadruple sectoranopia Adolf Wallenberg PICA Syndrome Supply: Posterolateral medulla and posterior and inferior cerebellum PICA/Lat. Medullary Wallenberg Syndrome Ipsilateral: Contralateral: Ataxia Limb Horner’s Miscellaneous: Facial Vertigo sensory loss 9th/10th palsy sensory loss Nystagmus Rarely facial palsy and diplopia Medial Medullary Syndrome Ipsilateral: Tongue paresis Contralateral: Hemiparesis sparing the face Post. Column sensory loss Weber Weber’s Ipsilateral: 3rd nerve palsy Contralateral: Hemiparesis Benedikt/Claude Ipsilateral: 3rd nerve palsy Contralateral: Ataxia and tremor (Claude) Ataxia, tremor, hemiparesis (Benedikt) Millard-Gubler Ipsilateral: 6th/7th palsy Contralateral : Hemiparesis Foville Ipsilateral: Gaze palsy +/- 6th/7th palsy Contralateral: Hemiparesis Raymond-Cestan Ipsilateral: 6th nerve palsy Contralateral : Hemiparesis Brissaud’s Ipsilateral: Facial hemispasm Contralateral : Hemiparesis Jackson Ipsilateral: Soft palate, vocal cord (Avellis), tongue palsy Contralateral: Hemianesthes ia AICA Syndrome Supply: Anterior and inferior cerebellum and posterolateral pons AICA Syndrome Ipsilateral: Facial numbness 6th/7th (Diplopia) Horner’s Ataxia Deafness Gaze palsy Contralateral: Hemisensory loss +/- hemiparesis AICA Infarct SCA Syndrome Supply: Superior cerebellum and posterolateral midbrain SCA Syndrome Classic (3%): Ipsilateral ataxia, Horner’s Contralateral 4th nerve palsy +/long tract signs Part of top-of-basilar syndrome Partial PCA Syndrome Supply: Thalamus Midbrain crus cerebri Hemispheric: Medial temporal and occipital cortex including visual cortex, posterior 3/5 of corpus callosum including splenium PCA Syndrome Pre-communal: Contralateral hemiparesis, hemisensory loss +/- HH Post-communal ambient cistern segment: Contralateral hemisensory loss +/- HH PCA Syndrome Right LHH, Left PCA: Confusion PCA: RHH, Amnesia Alexia without agraphia Transcortical sensory aphasia Bilateral PCA: Anton’s, Amnesia Agitated delirium Achromatopsia Balint’s (Sup.) Sup. Altitudinal hemianopsia (Inf.) PChA Syndrome Supply: Pulvinar, posterior thalamus, anterior nucleus, geniculate bodies Syndrome: Contralateral horizontal sectoranopia with variable sensori-motor deficits Lacunar Syndromes Pure motor stroke Pure sensory stroke Ataxic hemiparesis Dysarthria-Clumsy hand syndrome Sensori-motor stroke Aphasias Disorder of language, acquired secondary to brain damage. Dysphasia: Developmental language disorder Differentiate from dysarthria, dysphonia, stuttering, speech apraxia, thought disorders Aphasias Language components: Spontaneous speech Naming Auditory comprehension Repetition Reading Writing Language processing Spoken words (Cochlea, auditory pathway) Heschl’s gyrus (Sup. Temporal gyrus) Decoding of sounds into linguistic information in posterior left sup. Temporal gyrus (Wernicke’s area 22) Transmitted to Broca’s area (Post. Inf. Frontal gyrus area 44) Motor cortex Broca’s Wernicke’s Global Sp. speech Nonfluent Fluent/Hyper Nonfluent Naming Impaired Impaired Impaired Repetition Impaired Impaired Impaired C’hension Intact ?? Impaired Impaired Reading Impaired Impaired Impaired Writing Impaired Well-formed Impaired Ass. Signs Hemiparesis H’anopia Both Paraphasia Errors in speech output “Literal”: Substitution of an incorrect sound (Shoon for Spoon) “Verbal”: Substitution of an incorrect word (Fork for Spoon) Neologisms, Jargon speech, Word salad Figure 1 (A) Fluid attenuation inversion recovery imaging demonstrating left-hemispheric ischaemia with secondary oedema and obliteration of cerebrospinal fluid spaces. An old right middle cerebral artery stroke is also shown (arrow). (B) Further images demonstrating uncal herniation (arrow 1) with secondary midbrain compression and infarction (arrow 2), as well as subfalcine herniation (arrow 3). Thrombus is shown within the middle cerebral artery (arrow 4). Kumar, K R et al. J Neurol Neurosurg Psychiatry 2009;80:87 Copyright ©2009 BMJ Publishing Group Ltd. Broca’s W E R N I C K E’ S TCM TCS Isolation Sp. speech Nonfluent Fluent Nonfluent Naming Impaired Impaired Impaired Repetition Intact Intact Intact C’hension Intact Impaired Impaired Reading +/- Intact Impaired Impaired Writing +/- Intact Impaired Impaired Ass. signs Hemiparesis Echolalia Echolalia Pure word deafness Alexia without agraphia Alexia with agraphia Sp. speech Fluent Fluent Fluent Naming Intact +/- Impaired +/- Impaired Repetition Impaired Intact Intact C’hension Impaired--A Intact Intact Reading Intact Impaired Impaired 3+ Writing Intact Intact Impaired 3+ Ass. signs Paraphasia RHH RHH Conduction Anomic Sp. speech Fluent Fluent Naming Mod. impaired Impaired Repetition Impaired 3+ Intact Comprehension Intact Intact Reading +/- Impaired Intact Writing Variable deficits Intact Associated signs R hemiparesis Variable or none Subcortical Aphasias Left thalamus: Wernicke’s-like fluent aphasia Left Putamen: Global or Wernicke’s like or Broca’s-like Large subcortical: Global aphasia Right hemispheric infarcts: Motor or sensory “Aprosody” Recognize stroke Sudden weakness, numbness or loss of control of face, arm &/or leg on one side of body Sudden dimness or loss of vision in one or both eyes Loss of or slurring of speech Sudden severe headache Sudden dizziness, unsteadiness, falls or difficulty in swallowing Acute Stroke: Rapid clinical assessment Management Urgent plain head CT CBC, Electrolytes, Sugar, PT/aPTT Consider thrombolysis if <3 hours Other drug options, medical management CXR, EKG, Carotid doppler, 2D echo MRA or DSA Other tests as indicated Acute Stroke: General Rx Management of HTN: Do Not lower unless > 220/120 Do Not use sublingual preparations IV Labetelol or Enalaprilet, Oral Captopril, Candesartan Avoid direct arterial vasodilators Lower BP if specific indications Acute Stroke: General RX DM: Euglycemia (Avoid hypo.) Temperature regulation Fluid management Prevention and Rx of aspiration pneumonia Prevention and Rx of DVT Gastric prophylaxis Management of seizures Acute Stroke: General RX Cardio-respiratory care Bladder and bowel care Prevention and Rx of spasticity Prevention and Rx of contractures Prevention and Rx of bed sores Always aim for early mobilization and ambulation Acute Stroke: Specific RX Recanalization therapies: IV, IA Antithrombotics: Heparin, LMWH Antiplatelets: Aspirin Neuroprotectives Quote Law of encounters: The probability of meeting someone you know increases when you are with someone you don’t want to be seen with!
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