stroke or cerebrovascular accident

STROKESQN LDR DR AAMIR HUSSAIN

ASSTT PROF AND MEDICAL SPECIALIST

INTRODUCTIONSUDDEN

WEAKNESS OF ARM,LEG OR FACENUMBNESSCONFUSIONDIFFICULTY IN SPEAKING OR UNDERSTANDINGVISUAL PROBLEMDIZZINESSVOMITINGHEADACHE

DEFINITIONSTROKE

SUDDEN ONSET OF FOCAL NEUROLOGICAL DEFICIT THAT PERSISTS FOR MORE THAN 24 HOURS

TRANSIENT ISCHEMIC STROKESUDDEN ONSET OF FOCAL NEUROLOGICAL DEFICIT

THAT RESOLVES WITHIN 24 HOURS

DEFINITION STROKE IN EVOLUTION

FOCAL NEUROLOGICAL DEFICIT WORSENS WITH TIME

COMPLETED STROKE FOCAL NEUROLOGICAL DEFICIT PERSISTS AND DO NOT

WORSEN WITH TIME

REVERSIBLE ISCHEMIC NEUROLOGICAL DEFICIT FOCAL NEUROLOGICAL DEFICIT FROM WHICH THE PATIENT

RECOVERS WITHIN A FEW DAYS TO A WEEK

EPIDEMIOLOGY THIRD MOST COMMON CAUSE OF DEATH MOST COMMON CAUSE OF DISABILITY IN ADULTS NINETY-FIVE 95 % OF ALL STROKES OCCUR IN

PEOPLE AGED OVER 65 YEARS MALES ARE MORE AT RISK OF STROKE THAN

FEMALES ACCORDING TO WHO,

15 MILLION PEOPLE WORLDWIDE SUFFER A STROKE EACH YEAR

5 MILLION ARE LEFT PERMANENTLY DISABLED AND NEARLY 5 MILLION DIE

TYPES ISCHEMIC STROKE 80%

THROMBUSEMBOLUS

HAEMORRHAGIC STROKE 20%ANEURYSMSAV MALFORMATIONINTRACEREBRAL OR SUBARACHNOID

RISK FACTORS INCREASING AGESMOKINGHYPERTENSIONDIABETES MELLITUSHYPERLIPIDEMIAALCOHOLATRIAL FIBRILLATIONHYPERCOAGULABLE STATES

ANATOMY ANTERIOR CIRCULATION STROKE(80%)

OPHTHALMIC ARTERY ANTERIOR CEREBRAL ARTERY MIDDLE CEREBRAL ARTERY POSTERIOR COMMUNICATING ARTERY

POSTERIOR CIRCULATION STROKE(20%) VERTEBRAL ARTERY FROM SUBCLAVIAN ARTERY PICA BASILAR ARTERY POSTERIOR CEREBRAL ARTERY

HISTORY ONSET

PROGRESSION

RECOVERY

TIA AND RISK FACTORS

LEVEL OF CONSCIOUSNESS

PARALYSIS

SPEECH

BOWEL CONTROL

BLADDER CONTROL

FITS

ASPIRATION

MEDICATIONS

EXAMINATION NEUROLOGICAL

HIGHER MENTAL FUNCTION SPEECH CRANIAL NERVES MOTOR SYSTEM SENSORY SYSTEM AUTONOMIC

CARDIOVASCULAR CARDIAC CAROTIDS

PYRAMIDAL PARALYSIS/HEMIPLEGIA DYSPHSIA HEMISENSORY LOSS HEMIANOPIA CN PALSIES INCREASED REFLEXES PLANTARS ARE EXTENSORS SPASTICITY AND DRAGGING GAIT SEIZURES

FEATURES OF CEREBELLAR LESION ATAXIA NYSTAGMUS DYSARTHRIA INTENSION TREMOR PAST POINTING HYPOTONIA DYSDIADOKOKINESIA WIDE BASED GAIT PLANATRS ARE FLEXORS PARALYSIS LESS LIKELY

EXTRA PYRAMIDALBRADYKINESIAFESTINANT GAITRESTING TREMORSRIGIDITYPARALYSIS LESS LIKELYPLANTARS ARE FLEXORSINVOLUNTARY MOVEMENT

TIPS SPINOTHALMIC TRACTS CROSS THE MIDLINE SOON

AFTER ENTERING THE SPINAL CORD DORSAL COLUMN TRACTS DO NOT CROSS IN SPINAL

CORD.THEY INSTEAD CROSS IN MEDULLA OBLONGA PYRAMIDAL TRACTS CROSS IN THE MEDULLA

OBLONGATA BRAIN STEM LESIONS PRODUCE CROSSED HEMIPLEGIA CEREBELLAR LESIONS PRODUCE IPSILATERAL

HEMIPLEGIA CRANIAL NERVES LESIONS ARE MOSTLY IPSILATERAL CORTICAL LESIONS PRODUCE CONTRALATERAL

HEMIPLEGIA

LACUNAR INFARCTION SMALL LESIONS USUALLY LESS THAN 5 MM INVOLVES ARTERIOLES IN THE

BASAL GANGLIA PONS CEREBELUM INTERNAL CAPSULE THALAMUS

DEFICIT PROGRESSES OVER HOURS BEFORE STABILIZING

PROGNOSIS IS GOOD PARTIAL OR COMPLETE RESOLUTION OVER WEEKS

CEREBRAL INFARCTIONTHROMBOTIC OR EMBOLIC OCCLUSION

OF MAJOR ARTERYMCA INFARCTACA INFARCT PCA INFARCTPICA

EXAMINATION FOCUS CONSCIOUSNESS SPEECH

FLUENT WITHOUT COMPREHENSION(SENSELESS)

NONFLUENT WITH BROKEN SENTENCE(TELEGRAPHIC)

SWALLOW CRANIAL NERVES POWER/TONE REFLEXES AND PLANTARS PRONATOR DRIFT COORDINATION GAIT

MIDDLE CEREBRAL ARTERY INFARCTHEMIPLEGIA, ON OPPOSITE SIDE/CONTRALATERAL

HEMISENSORY LOSSHOMONYMOUS HEMIANOPIAEYES DEVIATION,TO THE SIDE OF LESIONAPHASIA/DYSPHASIA

GLOBALMOTOR/EXPRESSIVESENSORY/RECEPTIVE

CASE SCENARIO :EXPRESSIVE APHASIA A 60-YEAR-OLD MALE IS BROUGHT TO EMERGENCY DEPARTMENT WITH

SUDDEN WEAKNESS OF RIGHT SIDE OF THE BODY AND DIFFICULTY IN SPEECH.ON EXAMINATION OF RIGHT LIMBS,THE MUSCLE POWER IS REDUCED (3/5),TONE IS INCREASED,AND REFLEXES ARE BRISK WITH UPGOING PLANTAR.

HE UNDERSTANDS AND OBEY THE COMMAND,BUT HE FINDS DIFFICULTY IN SPEAKING.HIS SPEECH IS HALTING AND EFFORTFUL AND INCLUDE IMPORTANT CONTENTS OF WORDS WITH OUT GRAMMAR.HE FELT DEPRESSED WITH IMPAIRED SPEECH.

WHAT IS THE LIKELY PROBLEM… WHERE IS THE LESION…. WHAT IS THE LESION WHICH CIRCULATION OR ARTERY IS INVOLVED…

CASE SCENARIO: RECEPTIVE APHASIA A 60-YEAR-OLD MALE IS BROUGHT TO EMERGENCY DEPARTMENT WITH

SUDDEN WEAKNESS OF RIGHT SIDE OF THE BODY AND APPARENTLY CONFUSED STATES.ON EXAMINATION OF RIGHT LIMBS,THE MUSCLE POWER IS REDUCED (3/5),TONE IS INCREASED,AND REFLEXES ARE BRISK WITH UPGOING PLANTAR.

HE APPEARED TALKATIVE BUT FAILED TO UNDERSTAND AND MISINTERPRET THE COMMAND.SPEECH CONTENT LOOKED GRAMMATICAL BUT LACK SENSE AND SOME TIME USE NEW WORDS.HE APPEARED UNAWARE OF HIS SPEECH PROBLEM.

WHAT IS THE LIKELY PROBLEM… WHERE IS THE LESION…. WHAT IS THE LESION WHICH CIRCULATION OR ARTERY IS INVOLVED…

ANTERIOR CEREBRAL ARTERYLIMITED WEAKNESS,MONOPLEGIACORTICAL SENSORY LOSS

Stereognosis, graphesthesia, position sense

CONFUSION/MEMORY DISTURBANCEREEMERGENCE OF PRIMITIVE

REFLEXESPalmomental reflex, grasp reflex

URINARY INCONTINENCE

POSTERIOR CEREBRAL ARTERY

HEMISENSORY DISTURBANCETHALMIC PAINHEMIPARESIS

WEBER’S SYNDROME: MIDBRAIN STROKE A 60-YEAR-OLD FEMALE IS PRESENTED TO EMERGENCY

DEPARTMENT WITH WEAKNESS OF LEFT SIDE OF BODY ,DIPLOPIA AND DROPPING OF RIGHT EYE. ON EXAMINATION OF LEFT LIMBS,THE MUSCLE POWER IS REDUCED (3/5),TONE IS INCREASED,AND REFLEXES ARE BRISK WITH UPGOING PLANTAR.

THE RIGHT EYE HAS A COMPLETE PTOSIS.THE EYE BALL IS DOWN AND OUT.THE PUPIL IS FULLY DILATED AND NON REACTIVE TO LIGHT OR ACCOMODATION. WHAT IS THE LIKELY PROBLEM…

WHERE IS THE LESION…. WHAT IS THE LESION WHICH CIRCULATION OR ARTERY IS INVOLVED…

PICA /LAT MED SYNDROME /WALLENBERG IPSILATERAL SPINOTHALAMIC SENSORY LOSS

FACEV CNX CN

IPSILATERAL LIMB ATAXIA IPSILATERAL HORNER SYNDROMECONTRALATERAL SPINOTHALAMIC SENSORY

LOSS OF LIMBS

WALLENBERG’S SYNDROME: LATERAL MEDULLARY SYNDROME

A 65-YEAR-OLD MALE IS PRESENTED TO EMERGENCY DEPARTMENT WITH ACUTE ONSET OF VOMITING,VERTIGO AND UNSTEADINESS WITH TENDENCY TO FALL ON RIGHT SIDE.HE ALSO COMPLAINTS OF DIPLOPIA ,DYSPHAGIA AND DYSARTHRIA.

ON EXAMINATION,HIS MUSCLE POWER IS ALMOST NORMAL WITH NORMAL REFLEXES AND EQUIVOCAL PLANTARS,BUT HAS ATAXIA ON RIGHT SIDE.

HE HAS PARTIAL PTOSIS AND A CONSTRICTED PUPIL OF RIGHT EYE.NYSTAGMUS IS NOTED IN BOTH EYES

HE HAS LOSS OF PAIN AND TEMPERATURE SENSATION OVER RIGHT FACE AND LEFT SIDE OF BODY.

AAH TEST AND GAG REFLEX WERE ABSENT.

BASILAR ARTERY OR BOTH VERTEBRAL ARTERIES

COMA WITH PINPOINT PUPILFLACCID QUADRIPLEGIALOCKED-IN SYNDROMESENSORY LOSSVARIABLE CN PALSIES

CEREBELLAR ARTERIESVERTIGONAUSEAVOMITINGNYSTAGMUS IPSILATERAL LIMB ATAXIACONTRALATERAL SPINOTHALAMIC SENSORY

LOSS

ANTERIOR VS POSTERIOR CIRCULATION STROKECLINICAL FEATURES POSTERIOR CIRCULATION

(VA,BA,PCA)ANTERIOR CIRCULATION(MCA,ACA)

VERTIGO AND UNSTEADINESS YES NO

VOMITING YES NO

CROSSED HEMIPLEGIA YES NO

BILATERAL DEFICIT YES NO

CEREBELLAR SIGNS YES NO

HORNER’S SYNDROME YES NO

DISSOCIATED/ CROSSED SENSORY LOSS

YES NO

DIPLOPIA/ III CN PALSY YES NO

APHASIA NO YES

SIMPLIFIED CLASSIFICATION OF STROKEOXFORD CLASSIFICATION OR

BAMFORD CLASSIFICATION

THREE IMPORTANT FEATURES IN ANTERIOR CIRCULATION

1. HEMIPLEGIA

2. HEMIANOPIA

3. APHASIA

IMPORTANT FEATURES IN POSTERIOR CIRCULATION

1. CEREBELLAR

2. BRAINSTEM( CRANIAL NERVE PALSY)

3. VERTIGO/VOMITING

4. HORNER’S SYNDROME

INVESTIGATIONS 1. NON CONTRAST CT SCAN BRAIN TO R/O HAEMORRHAGE MRI BRAIN WITH DIFFUSION WEIGHTED SEQUENCE FOR

DISTRIBUTION AND EXTENT OF INFARCT OR TO R/O OTHER CAUSES

CT ANGIOGRAPHY HEAD AND NECK MR ANGIOGRAPHY CAROTID DUPLEX ULTRASONOGRAPHY TRANSCRANIAL DOPPLER ULTRASONOGRAPHY CONVENTIONAL CATHETER ANGIOGRAPHY ECHOCARDIOGRAPHY

TRANSTHORACIC

TRANSOESOPHAGEAL

ECG CXR

CASE SCENARIO A 30-YEAR-OLD MALE IS BROUGHT TO EMERGENCY DEPARTMENT WITH

SUDDEN SEIZURE AND LOSS OF CONSCIOUSNESS.

HIS FRIENDS INFORMED ABOUT SUDDEN SEVERE HEADACHE AND VOMITING BEFORE HE LOST HIS CONCIOUSNESS.

ON EXAMINATION, HE IS HYPERTENSIVE WITH BP 220/140

HIS NECK IS STIFF AND DEMONTRATED POSITIVE KERNIG’S SIGN.

HIS LEFT PUPIL IS FULLY DILATED

PLANTARS ARE UPGOING

PATIENT DIED AFTER 2 HOURS.

INVESTIGATIONS 2.BLOOD CP AND PLATBLOOD SUGARLIPID PROFILEPT/INRPTTK(APTT)THROMBIN TIME

HYPERCOAGULABLE STUDIES 3.PROTEIN CPROTEIN SANTITHROMBIN IIILUPUS ANTICOAGULANTANTICARDIOLIPIN ANTIBODIESFACTOR V LEIDENHOMOCYSTEINE

STROKE MIMICS SEIZURES

POSTICTAL TODD’S PARESIS

ASSOCIATION

HYPOGLYCEMIA SYNCOPE MIGRAINE FUNCTIONAL/CONVERSION DISORDER

NO DEFINITE PATTERN

ANXIETY/DEPRESSION/PANIC

HOOVER’ TEST

BRAIN TUMOURS METABOLIC ENCEPHALOPATHY

THANKS