Seminar on… Territorial Localization and Management of Stroke - PowerPoint PPT Presentation

seminar on territorial localization and management of stroke n.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Seminar on… Territorial Localization and Management of Stroke PowerPoint Presentation
Download Presentation
Seminar on… Territorial Localization and Management of Stroke

play fullscreen
1 / 39
Seminar on… Territorial Localization and Management of Stroke
456 Views
Download Presentation
ami
Download Presentation

Seminar on… Territorial Localization and Management of Stroke

- - - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript

  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

  3. Stroke Syndromes: Classification

  4. Stroke within anterior circulation

  5. 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

  6. 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

  7. Stroke within posterior circulation

  8. 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

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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

  16. 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

  17. 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

  18. 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

  19. Significance of territorial localization ?

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

  21. Cause of Coma in Stroke

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

  23. Management of Stroke

  24. Emergency Management

  25. No

  26. 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

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

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

  29. 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

  30. 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

  31. Other measures • Polycythemia • Clotting abnormalities

  32. Surgical approaches • Internal carotid endartectomy

  33. Rehabilitation • Physiotherapy • Speech therapy

  34. 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

  35. 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

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

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

  38. Thanks