Clinical Presentation of Stroke Syndromes

By Ken Hui Yee for PBL group 7Case 24

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 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.

Cardioembolic

Arrhythmias AF

Mural thrombus DCM Valvular lesions

Mitral stenosis, Endocarditis, Rheumatic fever

Paradoxical embolus Atrial septal defect, Patent foramen ovale,

Atrial septal aneurysm

Less Common Causes of Ischaemic Stroke

Venous sinus thrombosis Complication of:▪ OCP▪ Pregnancy & the postpartum period▪ Inflammatory bowel disease▪ Intracranial infections (meningitis)▪ Dehydration

Haemorrhagic Stroke

Less common (only 15% of all strokes)

Higher mortality rate than Ischaemic

Haemorrhagic Stroke

Causes: Head trauma▪ Most common cause of SAH

Hypertensive haemorrhage Aneurysm

Hypertensive Haemorrhage Spontaneous

rupture of small penetrating artery

Common sites: Basal ganglia

(especially the putamen), thalamus, cerebellum, and pons.

Aneurysm

SAH from berry aneurysm▪ AcomA, PcomA, MCA (locations from most

common to less common) Mycotic aneurysm▪ Eg. Endocarditis

Other Causes of Hemorrhage Stroke

Amyloid angiopathy▪ Degen of intracranial vessels▪ Rare in <60

Tumour Drugs (eg. Cocaine)▪ Young pts

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

Ischaemic vs. Haemorrhagic Stroke

Investigations: Determine between ischaemic and

haemorrhagic

CT MRI CSF

Acute Onset vs. Stuttering Onset

Acute StutteringSudden onset

Abrupt neurological deficit

More likely to be thrombotic and lacunar onsetNeurological deficits wax and waneProceeds towards complete neurological deficits

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

Amaurosis Fugax

Ddx: Amaurosis Fugax▪ Central retinal artery occlusion

Retinal migraine▪ Develops more slowly (15 to 20mins)

Rise in ICP▪ Can compromise optic disc perfusion

Case 2

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

Migrainous Infarction

Rare complication of migraines

Definition: Aura and a migraine headache, with the

aura symptom persisting > 7/7 + neuroimaging focal ischaemia

Complete vs Incomplete Strokes

Complete IncompleteTotal area of the brain supplied by an occluded vessel is damagedFurther prophylaxis Rx is pointless

some cellular damageAdditional tissue in the affected vascular distribution is at riskProphylaxis Rx is useful

Not that practical as distinction based on clinical findings can be impossible

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

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

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

Case 4

HOPC: Pt presents to ED with global aphasia Pt’s partner reports that pt is right

handed

MCA

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

ACA

Case 6

HOPC: Pt presents with homonymous

hemianopia Has a failure to see to-and-fro

movements, inability to perceive objects not centrally located

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

PCA

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

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

Watershed Infarction

Hypotension due to eg. AMI low perfusion in borderzones/junctional territories of the cerebral end arteries

Watershed Infarction

Clinical Presentation: “Man-in-the-barrel” clinical presentation Optic ataxia Cortical blindness Difficulty in judging size, distance, and

movement Memory loss Dysgraphia

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

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

Case 7

IX: CT - progressive hemorrhagic stroke

intrinsic to the pontine tegmentum of the brain stem, with rupture into the fourth ventricle

Basilar Artery – Midbrain

Basilar Artery Mid pons

Basilar Artery Inferior Pons

Vertebral and Posterior Inferior Cerebellar Arteries Medulla

Presentation of Brainstem Infarction

Clinical Feature Structure InvolvedHemiparesisSensory lossDiplopiaFacial numbnessFacial weaknessNystagmus & vertigoDysphagia & dysarthria

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

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

SummaryOccluded 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