Stroke syndromes
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Stroke Syndromes. Dr. Meg- angela Christi Amores. Stroke. Cerebrovascular disease ischemic stroke, hemorrhagic stroke, and cerebrovascular anomalies such as intracranial aneurysms and arteriovenous malformations (AVMs) Stroke

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Stroke Syndromes

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Stroke Syndromes

Dr. Meg-angela Christi Amores


Stroke

  • Cerebrovascular disease

    • ischemic stroke, hemorrhagic stroke, and cerebrovascular anomalies such as intracranial aneurysms and arteriovenous malformations (AVMs)

  • Stroke

    • abrupt onset of a neurologic deficit that is attributable to a focal vascular cause

    • Ischemic or hemorrhagic


  • Stroke

    • Ischemic Stroke

      • Acute occlusion of an intracranial vessel causes reduction in blood flow to the brain region it supplies

      • A fall in cerebral blood flow to zero causes death of brain tissue within 4–10 min

      • values <16–18 mL/100 g tissue per min cause infarction within an hour

      • values <20 mL/100 g tissue per min cause ischemia without infarction unless prolonged for several hours or days


    Ischemic stroke

    • Ischemic penumbra

      • Tissue surrounding the core region of infarction that is ischemic but reversibly dysfunctional

      • will eventually infarct if no change in flow occurs

  • Fever dramatically worsens ischemia, as does hyperglycemia[glucose > 11.1 mmol/L (200 mg/dL)], so it is reasonable to suppress fever and prevent hyperglycemia as much as possible


  • Ischemic Stroke

    • Pathophysiology

      • 1) occlusion of an intracranial vessel by an embolus that arises at a distant site

      • (2) in situ thrombosis of an intracranial vessel, typically affecting the small penetrating arteries that arise from the major intracranial arteries

      • (3) hypoperfusion caused by flow-limiting stenosis of a major extracranial


    Stroke Syndromes

    • Patient presentation can localized area of the brain affected/ blood vessel occluded

    • Divided into:

      • (1) large-vessel stroke within the anterior circulation

      • (2) large-vessel stroke within the posterior circulation

      • (3) small-vessel disease of either vascular bed


    Stroke within the Anterior Circulation


    Middle Cerebral Artery


    Middle Cerebral Artery

    • If occluded at its origin:

      • contralateralhemiplegia

      • Hemianesthesia

      • homonymous hemianopia

      • gaze preference to the ipsilateral side

      • If dominant hemisphere: global aphasia

      • If non-dominant hemisphere: anosognosia, constructional apraxia, and neglect


    Middle Cerebral Artery

    • Somatic motor area for face and arm and the fibers descending from the leg area to enter the corona radiata and corresponding somatic sensory system

      • Paralysis of the contralateral face, arm, and leg;

      • sensory impairment over the same area (pinprick, cotton touch, vibration, position, two-point discrimination, stereognosis, tactile localization, barognosis, cutaneographia)


    Middle Cerebral Artery


    Middle Cerebral Artery

    • Motor aphasia: Motor speech area of the dominant hemisphere

    • Central aphasia, word deafness, anomia, jargon speech, sensory agraphia, acalculia, alexia, finger agnosia, right-left confusion (the last four comprise the Gerstmann syndrome): Central, suprasylvian speech area and parietooccipital cortex of the dominant hemisphere

    • Conduction aphasia: Central speech area (parietal operculum)


    Middle Cerebral Artery

    • Homonymous hemianopia (often homonymous inferior quadrantanopia): Optic radiation deep to second temporal convolution

    • Paralysis of conjugate gaze to the opposite side: Frontal contraversive eye field or projecting fibers


    Anterior Cerebral Artery


    Anterior Cerebral Artery


    Anterior Cerebral Artery

    • anterior limb of the internal capsule, the anterior perforate substance, amygdala, anterior hypothalamus, and the inferior part of the head of the caudate nucleus

    • Occlusion of the proximal ACA is usually well tolerated because of collateral flow through the anterior communicating artery and collaterals through the MCA and PCA


    Anterior Cerebral Artery

    • Paralysis of opposite foot and leg: Motor leg area

    • A lesser degree of paresis of opposite arm: Arm area of cortex or fibers descending to corona radiata

    • Cortical sensory loss over toes, foot, and leg: Sensory area for foot and leg

    • Urinary incontinence: Sensorimotor area in paracentral lobule


    Anterior Cerebral Artery


    Anterior Cerebral Artery

    • Abulia (akineticmutism), slowness, delay, intermittent interruption, lack of spontaneity, whispering, reflex distraction to sights and sounds: Uncertain localization—probably cingulategyrus and medial inferior portion of frontal, parietal, and temporal lobes

    • Impairment of gait and stance (gait apraxia): Frontal cortex near leg motor area

    • Dyspraxia of left limbs, tactile aphasia in left limbs: Corpus callosum


    Stroke within the Posterior Circulation

    • Posterior Cerebral Artery

      • result from atheroma formation or emboli that lodge at the top of the basilar artery


    Posterior Cerebral Artery

    • P1 Syndromes

      • third nerve palsy with contralateral ataxia (Claude's syndrome) or with contralateralhemiplegia (Weber's syndrome)

      • contralateralhemiballismus (if subthalamic n)

      • thalamic Déjerine-Roussy syndrome - contralateralhemisensory loss followed later by an agonizing, searing or burning pain in the affected areas


    Posterior Cerebral Artery

    • P2 Syndromes

      • infarction of the medial temporal and occipital lobes

      • Contralateral homonymous hemianopia with macula sparing

      • acute disturbance in memory (hippocampus)

      • peduncularhallucinosis - visual hallucinations of brightly colored scenes and objects

      • infarction in the distal PCAs produces cortical blindness

      • Anton's syndrome – unaware of blindness and in denial


    Basilar Artery

    • Complete basilar occlusion :

      • a constellation of bilateral long tract signs (sensory and motor) with signs of cranial nerve and cerebellar dysfunction

  • “locked-in" state of preserved consciousness with quadriplegia and cranial nerve signs suggests complete pontine and lower midbrain infarction


  • Imaging

    • CT Scan

      • identify or exclude hemorrhage as the cause of stroke

      • the infarct may not be seen reliably for 24–48 h

      • may fail to show small ischemic strokes in the posterior fossa

  • MRI

    • reliably documents the extent and location of infarction in all areas of the brain

    • less sensitive than CT for detecting acute blood


  • Imaging

    • Cerebral Angiography

      • "gold standard" for identifying and quantifying atherosclerotic stenoses of the cerebral arteries

      • used to deploy stents within delicate intracranial vessels

      • intraarterial delivery of thrombolytic agents


    Primary and Secondary Prevention

    • General Principles

      • medical and surgical interventions

      • lifestyle modifications

      • Evaluation of a patient's clinical risk profile

  • Atherosclerosis risk factors

    • Older age, family history of thrombotic stroke, diabetes mellitus, hypertension, tobacco smoking, abnormal blood cholesterol [particularly, low high-density lipoprotein (HDL) and/or high low-density lipoprotein (LDL)


  • Primary and Secondary Prevention

    • Antiplatelet Agents

      • inhibiting the formation of intraarterial platelet aggregates

      • Aspirin, clopidogrel, and the combination of aspirin plus extended-release dipyridamole

      • Aspirin dose: 50–325 mg/d

  • Anticoagulation

    • For AF patients: Warfarin


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