Clinical Presentation of Stroke Syndromes
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Transcript Clinical Presentation of Stroke Syndromes
By Ken HuiYee for PBL group 7
Case 24
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
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.
Arrhythmias
AF
Mural thrombus
DCM
Valvular lesions
Mitral stenosis, Endocarditis, Rheumatic fever
Paradoxical embolus
Atrial septal defect, Patent foramen ovale, Atrial
septal aneurysm
Venous sinus thrombosis
Complication of:
▪ OCP
▪ Pregnancy & the postpartum period
▪ Inflammatory bowel disease
▪ Intracranial infections (meningitis)
▪ Dehydration
Less common (only 15% of all strokes)
Higher mortality rate than Ischaemic
Causes:
Head trauma
▪ Most common cause of SAH
Hypertensive haemorrhage
Aneurysm
Spontaneous rupture
of small penetrating
artery
Common sites:
Basal ganglia (especially
the putamen), thalamus,
cerebellum, and pons.
SAH from berry aneurysm
▪ AcomA, PcomA, MCA (locations from most common to
less common)
Mycotic aneurysm
▪ Eg. Endocarditis
Amyloid angiopathy
▪ Degen of intracranial vessels
▪ Rare in <60
Tumour
Drugs (eg. Cocaine)
▪ Young pts
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
Investigations:
Determine between ischaemic and haemorrhagic
CT
MRI
CSF
Acute
Stuttering
Sudden onset
More likely to be
thrombotic and lacunar
onset
Neurological deficits
wax and wane
Proceeds towards
complete neurological
deficits
Abrupt neurological
deficit
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
Ddx:
Amaurosis Fugax
▪ Central retinal artery occlusion
Retinal migraine
▪ Develops more slowly (15 to 20mins)
Rise in ICP
▪ Can compromise optic disc perfusion
HOPC:
▪ 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
Rare complication of migraines
Definition:
Aura and a migraine headache, with the aura
symptom persisting > 7/7
+ neuroimaging focal ischaemia
Complete
Incomplete
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
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
IX:
CT
▪ right MCA mainstem occlusion but no early ischemic
changes
Thrombolysis commenced pt improved
initially but then developed sudden decline of
consciousness
Repeat CT
Ruled out ICH
MRI
New occlusion in Left MCA discovered
Underlying cause was due to cardioembolic
ischaemic stroke due to AF
HOPC:
Pt presents to ED with global aphasia
Pt’s partner reports that pt is right handed
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
HOPC:
Pt presents with homonymous hemianopia
Has a failure to see to-and-fro movements,
inability to perceive objects not centrally located
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
Midbrain – Subthalamic -Thalamic
Weber Syndrome
▪ Contralateral hemiplegia
Thalamic Dejerine-Roussy
▪ Contralateral hemisensory loss
Claude’s Syndrome
▪ Third nerve palsy Contralateral ataxia
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
Hypotension due to eg. AMI low perfusion
in borderzones/junctional territories of the
cerebral end arteries
Clinical Presentation:
“Man-in-the-barrel” clinical presentation
Optic ataxia
Cortical blindness
Difficulty in judging size, distance, and movement
Memory loss
Dysgraphia
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
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
IX:
CT - progressive hemorrhagic stroke intrinsic to
the pontine tegmentum of the brain stem, with
rupture into the fourth ventricle
Clinical Feature
Hemiparesis
Sensory loss
Diplopia
Facial numbness
Facial weakness
Nystagmus & vertigo
Dysphagia & dysarthria
Structure Involved
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
Medial inferior pontine syndrome
Facial numbness
Trigeminal
Lateral midpontine syndrome,
Lateral inferior pontine syndrome
Facial weakness
Facial
Lateral inferior pontine syndrome
Nystagmus & vertigo
Vestibular
Medial inferior pontine syndrome
Dysphagia &
dysarthria
Glossopharyngeal &
vagus
Medullary Syndrome
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