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Clinical Presentation of Stroke Syndromes

By Ken Hui Yee for PBL group 7 Case 24. Clinical Presentation of Stroke Syndromes. Ischaemic Stroke. Causes: Thrombosis & Embolism (65% of strokes) Artery-to-artery Cardioembolic Thrombosis in-situ Small vessel ( lacunar ) strokes (20% of strokes)

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Clinical Presentation of Stroke Syndromes

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  1. By Ken Hui Yee for PBL group 7 Case 24 Clinical Presentation of Stroke Syndromes

  2. 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

  3. 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.

  4. Cardioembolic • Arrhythmias • AF • Mural thrombus • DCM • Valvular lesions • Mitral stenosis, Endocarditis, Rheumatic fever • Paradoxical embolus • Atrialseptal defect, Patent foramen ovale, Atrialseptal aneurysm

  5. Less Common Causes of Ischaemic Stroke • Venous sinus thrombosis • Complication of: • OCP • Pregnancy & the postpartum period • Inflammatory bowel disease • Intracranial infections (meningitis) • Dehydration

  6. Haemorrhagic Stroke • Less common (only 15% of all strokes) • Higher mortality rate than Ischaemic

  7. Haemorrhagic Stroke • Causes: • Head trauma • Most common cause of SAH • Hypertensive haemorrhage • Aneurysm

  8. Hypertensive Haemorrhage • Spontaneous rupture of small penetrating artery • Common sites: • Basal ganglia (especially the putamen), thalamus, cerebellum, and pons.

  9. Aneurysm • SAH from berry aneurysm • AcomA, PcomA, MCA (locations from most common to less common) • Mycotic aneurysm • Eg. Endocarditis

  10. Other Causes of Hemorrhage Stroke • Amyloidangiopathy • Degen of intracranial vessels • Rare in <60 • Tumour • Drugs (eg. Cocaine) • Young pts

  11. 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

  12. Ischaemic vs. Haemorrhagic Stroke • Investigations: • Determine between ischaemic and haemorrhagic • CT • MRI • CSF

  13. Acute Onset vs. Stuttering Onset

  14. 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

  15. AmaurosisFugax • Ddx: • AmaurosisFugax • Central retinal artery occlusion • Retinal migraine • Develops more slowly (15 to 20mins) • Rise in ICP • Can compromise optic disc perfusion

  16. 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 showfocal ischaemia

  17. Migrainous Infarction • Rare complication of migraines • Definition: • Aura and a migraine headache, with the aura symptom persisting > 7/7 • + neuroimaging focal ischaemia

  18. Complete vs Incomplete Strokes Not that practical as distinction based on clinical findings can be impossible

  19. 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 hemiplegiaand facial palsy with minor dysarthria

  20. 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

  21. Case 3 • Repeat CT • Ruled out ICH • MRI • New occlusion in Left MCA discovered • Underlying cause was due to cardioembolicischaemic stroke due to AF

  22. Case 4 • HOPC: • Pt presents to ED with global aphasia • Pt’s partner reports that pt is right handed

  23. MCA

  24. 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

  25. ACA

  26. Case 6 • HOPC: • Pt presents with homonymous hemianopia • Has a failure to see to-and-fro movements, inability to perceive objects not centrally located

  27. 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 peduncularhallucinosis

  28. PCA

  29. PCA – Specific Named Syndromes • Midbrain – Subthalamic -Thalamic • Weber Syndrome • Contralateralhemiplegia • Thalamic Dejerine-Roussy • Contralateralhemisensoryloss • Claude’s Syndrome • Third nerve palsy Contralateral ataxia

  30. 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

  31. Watershed Infarction • Hypotension due to eg. AMI  low perfusion in borderzones/junctional territories of the cerebral end arteries

  32. Watershed Infarction • Clinical Presentation: • “Man-in-the-barrel” clinical presentation • Optic ataxia • Cortical blindness • Difficulty in judging size, distance, and movement • Memory loss • Dysgraphia

  33. 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

  34. 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

  35. Case 7 • IX: • CT - progressive hemorrhagic stroke intrinsic to the pontinetegmentum of the brain stem, with rupture into the fourth ventricle

  36. Basilar Artery – Midbrain

  37. Basilar Artery  Mid pons

  38. Basilar Artery  Inferior Pons

  39. Vertebral and Posterior Inferior CerebellarArteries  Medulla

  40. Presentation of Brainstem Infarction

  41. Presentation of Brainstem Infarction

  42. Summary

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