STROKE SYNDROMES

(ETIOLOGY & CLINICAL FEATURES)

Ischemic Strokes

Thrombosis-most common cause Etiology

Atherosclerotic disease-most common Vasculitis Dissection Polycythemia Hypercoagulable states Infectious Diseases-HIV, TB, syphilis

Ischemic Strokes

1/5th due to Embolism Etiology

Cardiac

Valvular Vegetations Mural thrombi- caused by A-fib, MI, or dysrhythmias Paradoxical emboli-from ASD, VSD Cardiac tumors-myxoma

Fat emboli Particulate emboli IV drug injections Septic Emboli

Ischemic Strokes

Hypo perfusion- less common mechanism Typically caused by cardiac failure More diffuse injury pattern vs. thrombosis or embolism Usually occur in watershed regions of brain

Hemorrhagic Strokes

Intracerebral hemorrhage (ICH)

- approx. 10% of all strokes Risk Factors
HTN Increasing Age Race: Asians and Blacks Amyloidosis- esp. in the elderly AVMs or tumors Anticoagulants/Thrombolitic use History of previous stroke Tobacco, and cocaine use

Hemorrhagic Stroke
Subarachnoid hemorrhage (SAH) Result from rupture of berry aneurysm or rupture of AVMs

Stroke Syndromes

Classic physical exam findings that assist in localizing the lesion.

Ischemic Stroke Syndrome

Transient Ischemic Attack (TIA)

Neurologic deficit that resolves within 24 hours

Most TIAs resolve < 30 minutes Approx. 10% of patients will have a stroke in 90 days

Half of these in just 2 days

Ischemic Stroke Syndromes

Anterior Cerebral Artery Infarction

Contralateral weakness/numbness greater in leg than arm Dyspraxia Speech perseveration Slow responses

Ischemic Stroke Syndromes

Middle cerebral artery occlusion

Dominant Hemisphere (usually the left)

Contralateral weakness/numbness in arm and face greater than leg Contralateral hemianopsia Gaze preference toward side of infarct Aphasia (Wernickes -receptive, Brocas expressive or may have both) Dysarthria

Ischemic Stroke Syndromes Middle cerebral artery occlusion

Nondominant hemisphere
Contralateral weakness/numbness in arm and face greater than in the leg Constructional Apraxia Dysarthria Inattention, neglect, or extinction

Ischemic Stroke Syndromes

Posterior Cerebral Artery Infarct

Often unrecognized by patientminimal motor involvement Light-touch/pinprick may be significantly reduced Visual cortex abnormalities also minimal

Ischemic Stroke Syndromes

Vertebrobasilar Syndrome

Posterior circulation supplies brainstem, cerebellum, and visual cortex

Dizziness, vertigo, diplopia, dysphagia, ataxia, cranial nerve palsies, and b/l limb weakness, singly or in combination HALLMARK: Crossed neurological deficits: ipsilateral CN deficits with contralateral motor weakness

Ischemic Stroke Syndromes

Lateral Medullary (Wallenburg) Syndrome

Specific post. Circulation infarct involving vertebrobasilar and/or post inferior cerebellar Art.
Signs:

Ipsilateral loss of facial pain and temperature with contralateral loss of these senses over the body Gait and limb ataxia Partial ipsilateral loss of CN V, IX, X, and XI Ipsilateral Horner Syndrome may be present

Ischemic Stroke Syndromes

Basilar Artery Occlusion

Severe quadriplegia Coma Locked-in syndrome-complete muscle paralysis except for upward gaze

Ischemic Stroke Syndromes

Cerebellar Infarction-subset of post. circ. infarcts

Symptoms: drop attack with sudden inability to walk or stand, often a/w vertigo, HA, nausea/vomiting, neck pain

Diagnosis: MRI, MRA as bone artifact obscures CT Cerebral edema develops w/in 6-12 hrs increased brainstem pressure and decreased LOC Treatment: decrease ICP and emergent surgical decompression

Ischemic Stroke Syndrome

Lacunar Infarction
Infarction of small penetrating arteries in pons and basal ganglia Associated with chronic HTN present in 8090% Pure motor or sensory deficits

Arterial Dissection

Often a/w severe trauma, headache, and neck pain hours to days prior to onset of neuro symptoms

HTN risk factor for spontaneous dissection

Blood Supply to the Medulla

The Medulla is supplied by the; 1. Anterior spinal artery, sends blood to the paramedian region of the caudal medulla.

2. Posterior spinal artery, supplies rostral areas, including the gracile and cuneate fasiculi and nuclei, along with dorsal areas of the inferior cerebellar peduncle. 3. Vertebral artery, bulbar branches supply areas of both the caudal and rostral medulla.
4. Posterior inferior cerebellar artery, supplies lateral medullary areas.

Stroke syndromes - Medulla

Occlusion of branches of the anterior spinal artery will produce a inferior alternating hemiplegia (aka medial medullary syndrome), characterized by; 1. A contralateral hemiplegia of the limbs, due to damage to the pyramids or the corticospinal fibers 2. A contralateral loss of position sense, vibratory sense and discriminative touch, due to damage to the medial leminiscus 3. An ipsilaterally deviation and paralysis of the tongue, due to damage to the hypoglossal nucleus or nerve

Stroke syndromes - Medulla

Occlusion of the posterior inferior cerebellar artery (or contributing vertebral) will produce a lateral medullary syndrome or Wallenbergs syndrome, characterized by
1. A contralateral loss of pain and temperature sense, due to damage to the anterolateral system (spinothalamic tract) 2. An ipsilateral loss of pain and temperature sense on the face, due to damage to the spinal trigeminal nucleus and tract 3. Vertigo, nausea and vomiting, due to damage to the vestibular nuclei 4. Hornors syndrome, (miosis [contraction of the pupil], ptosis [sinking of the eyelid], decreased sweating), due to damage to the descending hypothalamolspinal tract

Blood Supply to the Pons

The Pons is supplied by the; 1. The Basilar artery, contributions of this main artery can be further subdivided; a. paramedian branches, to medial pontine region b. short circumferential branches, supply anterolateral pons c. long circumferential branches, run laterally over the anterior surface of the Pons to anastomose with branches of the anterior inferior cerebellar artery (AICA). 2. Some reinforcing contributions by the anterior inferior cerebellar and superior cerebellar arteries

Blood Supply to the Pons

Stroke syndromes - Pons

Obstruction of the paramedian pontine arteries will produce a middle alternating hemiplegia (also termed medial pontine syndrome) which is characterized by; 1. Hemiplegia of the contralateral arm and leg, due to damage to the corticospinal tracts 2. Contralateral loss of tactile discrimination, vibratory and position sense, due to damage to the medial leminiscus 3. Ipsilateral lateral rectus muscle paralysis, due to damage to the abducens nerve or tract (can cause diplopia double vision)

Stroke syndromes - Pons

Occlusions of long branches circumferential branches of the basilar artery produce a lateral pontine syndrome, characterized by;
1. Ataxia, due to damage to the cerebral peduncles (middle and superior) 2. Vertigo, nausea, nystagmus, deafness, tinnitus, vomiting, due to damage to vestibular and cochlear nuclei and nerves 3. Ipsilateral pain and temperature deficits from face, due to damage to the spinal trigeminal nucleus and tract 4. Contralateral loss of pain and temperature sense from the body, due to damage to the anterolateral system (spinothalamic) 5. Ipsilateral paralysis of facial muscles and masticatory muscles, due to damage to the facial and trigeminal motor nuclei (cranial nerves VII and V)

Blood Supply to the Midbrain

The major blood supply to the midbrain is derived from branches of the basilar artery; 1. Posterior cerebral artery, forms a plexus with the posterior communicating arteries in the interpeduncular fossa, branches from this plexus supply a wide area if the midbrain 2. Superior cerebellar artery, supplies dorsal areas around the central gray and inferior colliculus with support from branches of the posterior cerebral artery. 3. Quadrigeminal, (some posterior choroidal) a branch of the posterior cerebral, provides support for the tectum (superior and inferior colliculus) 4. Posterior communicating artery, derived from the internal carotid, joins the posterior cerebral to form portions of the circle of Willis (arterial circle). Contributes to the interpeduncular plexus 5. Branches of these arteries are best understood when grouped into paramedian, short circumferential and long circumferential

Stroke syndromes- Midbrain

Occlusion of midbrain paramedian branches produces a medial midbrain or superior alternating hemiplegia (or Webers syndrome) characterized by;
1. Contralateral hemiplegia of the limbs, and contralateral face and tongue due to damage to the descending motor tracts (crus cerebri).

2. Ipsilateral deficits in eye motor activity, caused by damage to the oculomotor nerve

Other Clinical Points

Substantial infarcts within the Pons are generally rapidly fatal, due to failure of central control of respiration Infarcts within the ventral portion of the Pons can produce paralysis of all movements except the eyes. Patient is conscious but can communicate only with eyes. LOCKED-IN-SYNDROME

Focal ischemia

Focal ischemia

Focal ischemia

Focal ischemia
Watershed infarcts

Hemorrhagic Syndromes

Intracerebral Hemorrhage
ICH sudden onset HA, N/V, elevated BP Progressive focal neurologic deficits over minutes Patients may rapidly deteriorate Exertion commonly triggers symptoms Bleeding localized to Putamen, thalamus, pons-pinpoint pupils, and cerebellum

Hemorrhagic Syndromes

Cerebellar Hemorrhage
Sudden onset dizziness, vomiting, truncal ataxia, inability to walk Possible gaze palsies and increasing stupor Treatment: urgent surgical decompression or hematoma evacuation

Hemorrhagic Syndrome

Subarachnoid hemorrhage
Severe HA, vomiting, decreasing LOC HA- often occipital or nuchal in location Sudden onset of symptoms history may reveal activities a/w HTN such as defecation, coughing or intercourse