Seminar on… Territorial Localization and Management of Stroke

1. Seminar on…Territorial Localization and Management of Stroke Prepared by… Dr. Salman Abdul Qayyum, House Physician, MU II, HFH, Dated: February 27, 2006.

2. Major Vessels

4. Stroke Syndromes: Classification

5. Stroke within anterior circulation

6. Anterior Cerebral Artery • Paralysis of opposite foot and leg • A lesser degree of paresis of opposite arm • Cortical sensory loss over toes, foot and leg • Urinary incontinence • Contralateral grasp reflex, suckling reflex, gegenhalten • Abulia, slowness, delay, intermittent interuption, lack of spontaneity, whispering, reflex distraction to sights and sounds • Impairement of gait and stance

7. Middle Cerebral Artery • Paralysis of contralateral face, arm and leg • Sensory impairement over the same area (pinprick, cotton touch, vibration,position, two-point stereognosis, tactile localization) • Motor aphasia • Central aphasia, word deafness, anomia, jargon speech, sensory agraphia, acalculia, alexia, finger agnosia, right-left cofusion • Conduction aphasia • Homonymous hemianopia • Paralysis of conjugate gaze to the opposite side

8. Stroke within posterior circulation

9. Posterior Cerebral Artery Peripheral territory: • Homonymous hemianopia • Bilateral homonymous hemianopia, cortical blindness, awareness or denial of blindness • Verbal dyslexia without agraphia, color anomia • Memory defect • Topographic disorientation and prosopagnosia • Simultagnosia, hemivisual neglect • Unformed visual hallucinations

10. Central territory: • Thalmic sydrome • Weber’s syndrome: third nerve palsy and contralateral hemiplegia • Contralateral hemiplegia • Paralysis or paresis of vertical eye movement, skew deviation, sluggish pupillary responses to light, slight miosis and ptosis • Contralateral rhythmic , ataxic action tremor

11. Medullary syndrome • Medial medullary syndrome(occlusion of vertebral artery or of branch of vertebral or lower basilar artery) • On side of lesion • Paralysis with atrophy of half the tongue • On side opposite lesion • Paralysis of arm and leg, sparing face; impaired tactile and proprioceptive sense over half of the body

12. Lateral medullary syndrome(occlusion of any of the five vessels may be responsible –vertebral, posterior inferior cerebellar, superior, middle or inferior lateral medullary arteries) • On side of lesion • Pain, numbness, impaired sensation over half the face • Ataxia of limbs, falling to side of lesion • Nystagmus, diplopia, oscillopsia, vertigo, nausea, vomiting • Horner’s syndrome • Dysphagia, hoarseness, paralysis of palate, paralysis of vocal cords, diminished gag reflex • Loss of taste • Numbness of ipslateral arm, trunk or leg • On side of opposite lesion • Impaired pain and thermal sense over half of the body, sometines face

13. Total Unilateral medullary syndrome (occlusion of vertebral artery) • Combination of medial and lateral syndromes • Lateral pontomedullary syndrome (occlusion of vertebral artery) • Combination of lateral medullary and lateral inferior pontine syndrome • Basilar artery syndrome • Combination of brainstem syndromes plus those arising in PCA distribution

14. Superior pontine syndrome • Medial Superior pontine syndrome(paramedian branches of upper basilar artery) • On side of lesion • Cerebellar ataxia • Internuclear ophthalmoplegia • Myoclonic syndrome, palate, pharynx, vocal cords, respiratory apparatus, face oculomotor apparatus • On side opposite lesion • Paralysis of face, arm, and leg • Rarely touch, vibration, and position are effected

15. Lateral superior pontine syndrome(Syndrome of superior cerebellar artery) • On side of lesion • Ataxia of limbs and gait, falling to side of lesion • Dizziness, nausea, vomiting; horizontal nystagmus • Pariesis of conjugate gaze(ipsilateral) • Skew deviation • Horner’s Syndrome • On side opposite lesion • Impaired pain and thermalsense on face, limbs and trunk • Impaired touch, vibration and position sense, more in leg than arm

16. Midpontine syndrome • Medial midpontine syndrome(paramedian branch of midbasilar artery) • On side of lesion • Ataxia of limbs and gait • On side opposite lesion • Paralysis of face, arm and leg • Variable impaired touch sensation touch and proprioception when lesion extends posteriorly

17. Lateral midpontine syndrome(Short circumferential artery) • On side of lesion • Ataxia of limbs • Parlysis of muscles of mastication • Impaired sensation over side of face • On side opposite lesion • Impaired pain and thermal sense on limbs and trunk

18. Inferior pontine syndrome • Medial inferior pontine syndrome(occlusion of paramedian branch of basilar artery) • On side of lesion • Paralysis of conjugate gaze to side of lesion • Nystagmus • Ataxia of limbs and gait • Diplopia on lateral gaze • On side opposite lesion • Paralysis of face, arm and leg • Impaired tactile and proprioceptive sense over half of the body

19. Lateral inferior pontine syndrome (occlusion of anterior inferior cerebellar artery) • On side of lesion • Horizontal and vertical nystagmus, vertigo, nausea, vomiting, oscillopsia • Facial paralysis • Paralysis of conjugate gaze to side of lesion • Deafness, tinnitus • Ataxia • Impaired sensation over face • On side opposite lesion • Impaired pain and thermal sense over half the body

20. Significance of territorial localization ?

21. Hemorrhagic stroke • Intracerebral and cerebellar hemorrhage • Subarchnoid hemorrhage • Subdural and extradural hemorrhage/ hematoma

22. Cause of Coma in Stroke

23. Diffuse brain dysfunction • SAH • Direct effect within brainstem • Brainstem hemorrhage or infarction (Posterior circulation stroke) • Pressure effect on brainstem • Hematoma • Infarction

24. Management of Stroke

25. Emergency Management

26. No

27. Fibrinolytic therapy • Tissue plasminogen activator • Dose: • Total dose 0.9 mg/kg(max 90 mg) • 10% of total dose as initial intravenous bolus over 1 minute. Remainder infused intravenously over 60 minutes

28. Therapy for Cerebral Edema and raised ICP • Mannitol • IV steroids

29. Investigations helping confirm the diagnosis • CT • MRI • Carotid doppler and duplex scanning • Vascular imaging • Magnetic resonance angiography or digital subtraction angiography

30. Long-term management All risk factors should be identified and if possible treated. • Antihypertensive therapy • Antiplatelet therapy • Aspirin 75mg daily(thromboembolic TIA or stroke) • Clopidogrel, dipyridamole and ticlopidine

31. Anticoagulants • Heparin & Warfarin • Valvular heart disease • Recent MI Intracardiac thrombus Atrial fibrillation • Acute internal carotid artery thrombus • Acute basilar artery thrombus • Internal carotid artery dissection • Extracranial vertebral artery dissection • Prothrombic states, e.g. protein C deficiency • Recurrent TIAs or stroke on full antiplatelet therapy • Cerebral venous thrombosis including sinus thombosis

32. Other measures • Polycythemia • Clotting abnormalities

33. Surgical approaches • Internal carotid endartectomy

34. Rehabilitation • Physiotherapy • Speech therapy

35. Management of Hemorrhagic Stroke • Intracerebral and cerebellar hemorrhage • Urgent neurosurgical clot evacuation is considered when an intracerebral hematoma expands. • Antiplatelet and anticoagulants are contraindicated • Control of hypertension

36. Subarachnoid hemorrhage Poor prognosis • Bed rest and supportive measures • Control of hypertension • Dexametasone • Calcium channel blocker(Nimodipine) • Surgical interventions • Direct approach to clip the neck of the aneurysm • Focal radiotherapy

37. Subdural and extradural hemorrhage/ hematoma • Extradural bleeding • Urgent neurosurgery • Surgical drianage through a Burr-hole • Subdural bleeding • Conservative management • Neurosurgery

38. Care of Unconscious Patient • Care of airway • Vital and intake/output monitoring • Skin care • Oral hygiene • Eye care • Fluids • Calories • Sphinters

39. Thanks