Types of cva and stroke syndromes

Covers types of strokes and common stroke syndromes. Most of the pictures are from the anatomy book of BD Chaurasia for easy understanding.

1. I mportance of taking AP and lateral views in x-rays

2. Types of CVA and stroke syndromes Dr. Darendrajit MD (PMR) Department of Physical Medicine and Rehabilitation AIIMS, Bhubaneswar

3. Cerebrum Diencephalon Thalamus , hypothalamus , pituitary and pineal glands Brain stem Medulla, pons, midbrain Cerebellum C ortex B asal ganglia Limbic system Frontal Parietal Occipital T emporal Parts of brain

4. Motor homunculus Sensory homunculus

5. “Typical ” anatomy in 35% of humans Ophthalmic artery

6. Internal capsule

7. Middle cerebral artery

8. Anterior cerebral artery

9. Posterior cerebral artery

10. CLINICAL CLASSIFICATION

11. AHA/ACC (2009) defines TIA as: “a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia , without acute infarction .’’ TIA

12. Types of stroke

13. Types of stroke

14. Cerebral Venous Thrombosis Uncommon cause of cerebral infarction Thrombosis of one of the venous sinuses M ay present as headache, with or without cranial nerve palsies More severely affected patients may present with seizures and/or coma Papilledema is frequently present

15. Blood supply to the brain is autoregulated Blood flow If zero leads to death of brain tissue within 4-10min <16-18ml/100g tissue/min infarction within an hour Ischemia leads to development of an ischemic core and an ischemic penumbra Pathophysiology of Ischemic Stroke

16. Ischemic Penumbra Tissue surrounding the core region of infarction which is ischemic but reversibly dysfunctional Maintained by collaterals Can be salvaged if reperfused in time Primary goal of revascuralization therapies

17. Pathophysiology Of Hemorrhagic Stroke Explosive entry of blood into the brain parenchyma structurally disrupts neurons White matter fibre tracts are split Immediate cessation of neuronal function Expanding hemorrhage can act as a mass lesion and cause further progression of neurological deficits Large hemorrhages can cause transtentorial coning and rapid death

18. Stroke Syndromes Stroke syndromes are divided into: 1 . L arge-vessel stroke within the anterior circulation 2 . L arge-vessel stroke within the posterior circulation 3 . S mall-vessel disease of either vascular bed Basis of stroke syndrome: Predictable anatomy of the brain’s vascular supply L ocalization of particular functions to certain areas of the brain P redilection of stroke for certain vascular territories

19. Internal carotid artery syndrome Clinical features: ICA occlusions often asymptomatic ( 30–40% of cases ) Amaurosis fugax - “curtain dropping over the eye and rising again” 2. Watershed infarct (distal MCA) -partial contralateral hemiplegia and a sensory deficit affecting the shoulder more than the hand and leg

20. Anterior choroidal artery syndrome C ontralateral hemiplegia ( injury to the posterior limb of the internal capsule) Contralateral hemianopsia and reduced pupillary reaction (injury to the optic tract), also in lesion to the geniculocalcarine tract in the medial temporal lobe Contralateral hemianopsia with median horizontal sparing (lateral geniculate nucleus is injured): diagnostic of an AChA occlusion

21. Anterior cerebral artery s yndrome C onstitutes 3% or fewer of all strokes complex physical and cognitive deficits U nilateral ACA infarcts: contralateral hemiplegia worse in the leg and shoulder than in the arm, hand, and face If facial weakness is noted, the recurrent artery of Heubner likely occluded Sensory loss minimal , usually impaired two-point discrimination if present, and in the same distribution as the motor impairment

22. Urinary incontinence Gait apraxia Mutism , delay and lack of spontaneity of motor acts Apraxia of left sided limbs ( with left sided lesion and corpus callosum involvement) Anterior cerebral artery s yndrome

23. Primitive reflexes: -the grasp reflex of the affected hand - frontal release signs - palmomental or snout reflexes - paratonia ( a force-dependent limb rigidity that becomes more prominent with an increase in effort by the examiner during muscle stretches) Anterior cerebral artery s yndrome

24. Middle Cerebral Artery Syndromes Mainstem Middle Cerebral Artery (M1 Segment) Those who survive M1 infarcts usually have significant neurologic impairment Complete contralateral hemiplegia Contralateral hemisensory loss or hemianesthesia (injury to subcortical sensory tracts and the S1 cortex) D ominant MCA distribution infarct: Broca’s aphasia Non-dominant MCA distribution: severe visual and perceptual deficits with disrupted spatial body orientation, dressing apraxia, constructional apraxia, and a severe left hemineglect syndrome

25. Superior-Division Middle Cerebral Artery Results in infarct of the frontal lobe convexity, sparing the medial frontal lobe and subcortical tissue Symptoms include contralateral hemiplegia affecting the arm and hand more than the leg, and loss only of two-point discrimination in the same distribution as the weakness Patients may have transient head and eye deviation away from the hemiplegia, but visual fields are usually spared

26. Inferior-Division Middle Cerebral Artery Results in primarily cortical infarct of the lateral convexity of the parietal , occipital, and temporal lobes No motor or somatosensory deficits, but may have a partial contralateral hemianopsia Dominant hemisphere: Wernicke aphasia Non-dominant: hemineglect syndrome Sensory aprosodia , or affective agnosia , individual has difficult time comprehending the prosody in another’s speech

27. Posterior Cerebral Artery Syndromes O cclusion occurs in the P1 segment, hypoperfusion occurs in the distal PCA and the thalamoperforating arteries supplying the thalamus Results in contralateral sensory syndrome with hypoesthesia, and in some cases dysesthesia ( Déjerine-Roussy syndrome) C ontralateral homonymous hemianopsia from direct injury to the primary visual cortex

28. PCA infarct in the left occipital lobe: alexia without agraphia Posterior Cerebral Artery Syndromes

29. Lacunar Stroke Syndromes Infarcts are 1.5 cm or less in the largest diameter associated with hypertension C aused by small-vessel occlusion from lipohyalinosis of the vascular intima 5 commonly seen lacunar syndromes P ure sensory stroke : N umbness in the face, arm, and leg on one side of the body No associated motor or cognitive deficits The infarct is usually located in the thalamus C an develop late or chronic pain syndromes as a result of disruptions of normal sensory tracts

30. 2. Pure motor hemiparesis: O nly motor loss in the face, arm , and leg, with or without spastic dystonia S troke usually occurs in the posterior limb of the internal capsule, cerebral peduncle, or in the base of the pons Prognosis for functional recovery is good because patients lack other symptoms, such as language, visual deficits, or apraxia Spastic dystonia may complicate the rehabilitation process Lacunar Stroke Syndromes

31. 3. Dysarthria-clumsy hand syndrome L esions in the base of the pons caused by occlusions of the paramedian pontine perforating vessels from the basilar artery, infarcts of the genu of the internal capsule in the somatotopic regions for face and hand, as well as other areas of subcortical white matter D ysarthria and unilateral facial weakness without language deficits, and a mild hemiparesis of the upper limb on one side of the body Prognosis for recovery is usually very good Lacunar Stroke Syndromes

32. 4. Ataxic hemiparesis: occlusions of the paramedian pontine perforating vessels from the basilar artery Patients with ataxic hemiparesis often have a considerable challenge regaining independence in mobility because of problems with dynamic balance The prognosis is still very good, because the ataxic component often recovers more rapidly than the hemiparesis Lacunar Stroke Syndromes

33. 5. Sensorimotor strokes Occurs at the junction of the ventrolateral thalamus and the internal capsule, resulting in sensory and motor loss on the contralateral side of the body Because the vascular supplies to thalamus and internal capsule are distinct, the likely explanation is that edema from a thalamic stroke compresses adjacent motor fibers in the internal capsule Lacunar Stroke Syndromes

34. Syndromes of the Vertebrobasilar System I. Lateral Medullary (Wallenberg’s ) Syndrome Occlusion of the following: 1. V ertebral arteries (involved in 8 out of 10 cases ) 2. Posterior inferior cerebellar artery (PICA) 3. Superior lateral medullary artery 4. Middle lateral medullary artery 5. Inferior lateral medullary artery

35. Wallenberg’s syndrome S/S - Ipsilateral side Horner’s syndrome (ptosis, anhydrosis , and miosis ) D ecrease in pain and temperature sensation on the face C erebellar signs such as ataxia on extremities (patient falls to side of lesion) - Contralateral side Decreased pain and temperature - Dysphagia , dysarthria, hoarseness, paralysis of vocal cord -Vertigo ; nausea and vomiting -Hiccups - Nystagmus , diplopia Note: No facial or extremity muscle weakness seen in this syndrome

36. II. Benedikt’s Syndrome ( Red Nucleus/ Tegmentum of Midbrain ) Obstruction of interpeduncular branches of basilar or posterior cerebral artery or both Ipsilateral III nerve paralysis with mydriasis Contralateral hypesthesia (medial lemniscus ), hyperkinesia (ataxia, tremor, chorea, athetosis ) due to damage to red nucleus

37. III. Syndromes of the Paramedian Area (Medial Brainstem): Paramedian area contains: • Motor nuclei of CNs • Cortico -spinal tract • Medial lemniscus • Cortico -bulbar tract Signs/symptoms include: • contralateral hemiparalysis • ipsilateral CN paralysis

38. Syndromes of the Paramedian Area (Medial Brainstem)

39. Weber Syndrome Obstruction of interpeduncular branches of posterior cerebral artery or posterior choroidal artery or both. Ipsilateral CN 3 palsy C ontralateral hemiplegia, Parkinson’s signs, dystaxia (mild degree of ataxia ) Millard- Gubler Syndrom Obstruction of circumferential branches of basilar artery Ipsilateral facial (CN 7) and abducens (CN 6) palsy C ontralateral hemiplegia, analgesia, hypoesthesia . Extension to medial lemniscus = Raymond- Foville’s Syndrome (with gaze palsy to side of lesion )

40. Medial Medullary Syndrome: Caused by infarction of the medial medulla due to occlusion (usually atherothrombotic ) of penetrating branches of the vertebral arteries (upper medulla) or anterior spinal artery (lower medulla and medullo -cervical junction) Rare ; ratio of medial medullary infarct to lateral medullary infarct ~ 1–2 : 10 Typical syndrome: – Ipsilateral CN 12 palsy (with deviation toward the side of the lesion) – Contralateral hemiparesis – Contralateral lemniscal sensory loss (proprioception and position sense)

41. IV. Basilar Artery Occlusion Syndrome Occlusion may arise in several ways: • atherosclerotic plaque in the basilar artery itself (usually lower third) • occlusion of both vertebral arteries • occlusion of one vertebral artery when it is the only one of adequate size

42. Basilar artery occlusion Clinical features 1 . Paralysis of all four limbs 2 . Bulbar paralysis 3 . Eye movements Abnormalities- Nystagmus 4 . Coma Note: The neurological deficit is variable depending upon the ischemia –modifying factors

43. Locked-In Syndrome O cclusion of the basilar artery causing infarction of the basis pontis bilaterally C orticospinal and corticobulbar tracts are interrupted, resulting in tetraplegia and paralysis of all cranial nerve muscles except for those controlling eye movements V ertical eye movements are preserved H orizontal eye movements may be affected ( paramedian pontine reticular formation ) R emain awake and aware M eans of communication is systematic eye movements or with augmentative communication devices

44. Differentiating features between anterior and posterior circulation stroke

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