Ch 1 - Stroke: Types Flashcards
Where do most Internal carotid artery infarctions occur?
1st part of ICA immediately after carotid bifurcation
What causes occular infarction?
Embolic occlusion of retinal branch or central retinal artery
What is amaurosis fugax?
Transient monocular blindness that occurs prior to ICA occulsion in 25% of cases
Where do middle cerebral infarctions occur?
Stem of the MCA or at main divisions (superior or inferior)
of the artery in the Sylvian sulcus
What does the superior division of the MCA provide?
Rolandic and pre-Rolandic areas
What is the most common cause of occlusion of superior division of MCA?
Embolus
What is the clinical presentation of superior division MCA strokes?
Sensory and motor deficits on contralateral face and arm > leg
Eyes deviate toward lesion
What is the clinical presentation of left side (dominant) superior division MCA strokes?
Global aphasia initially and then Broca’s aphasia
What are deficits of right side (nondominant) superior division MCA strokes?
Spatial perception
Hemineglect
Constructional apraxia
Dressing apraxia
What is constructional apraxia?
Inability of patients to copy accurately drawings or 3D constructions
What does the Inferior division of the MCA supply?
Lateral temporal and inferior parietal lobes
What visual deficit is seen with Inferior division of the MCA stroke?
Superior quadrantanopia or homonymous hemianopsia
What is the clinical presentation of Left Inferior division of the MCA stroke?
Wernicke’s aphasia
What is the clinical presentation of Right Inferior division of the MCA stroke?
Left visual neglect.
What happens if there is an occlusion of the ACA proximal to the anterior communicating artery?
Well tolerated as there is blood supply from the contralateral ACA
What is the clinical presentation of an ACA stroke?
Contralateral weakness and sensory loss of foot/leg >thigh
Gait apraxia
Eyes deviate toward lesion
What are potential symptoms of an ACA stroke?
Urinary incontinence
Contralateral grasp reflex
Paratonic rigidity (Gegenhalten)
What aphasia is seen with Left ACA stroke?
Transcortical aphasia
What is seen with ACA stroke if both ACA arteries arise from one major stem?
Aphasia
Paraplegia
Incontinence
Frontal lobe dysfunction
What does the PCA supply?
Upper brain stem
Inferior temporal lobe
Medial occipital lobe
What is seen with bilateral PCA stroke?
Anton’s syndrome: denial of cortical blindness
What is the clinical presentation of PCA stroke?
Prosopagnosia Palinopsia Alexia Transcortical sensory aphasia CN3 and CN4 palsy
What is prosopagnosia?
Can’t read faces
What is Alexia?
Can’t read
What is Weber syndrome?
Oculomotor palsy with contralateral hemiplegia
What is trochlear nerve palsy?
Vertical gaze palsy
What do the vertebrobasilar arteries supply?
Midbrain Pons Medulla Cerebellum Posterior and ventral aspects of the cerebral hemispheres
Where do the vertebral arteries join and what do they form?
Form basilar artery at pontomedullary junction
What creates the posterior-inferior cerebellar (PICA)?
Vertebral arteries
What creates the anterior-inferior cerebellar (AICA)?
Superior cerebellar arteries that arise from the Basilar artery
What are symptoms of vertebrobasilar system strokes?
– Vertigo – Nystagmus – ABN of motor function, often bilaterally – Ipsilateral cranial nerve dysfunction – Crossed signs
What are crossed signs?
Motor or sensory deficit on ipsilateral side of face and contralateral side of body; ataxia, dysphagia, dysarthria
What is a characteristic of vertebrobasilar anterior circulation involvement?
Absence of cortical signs (aphasia or cognitive deficits)
Describe vertigo in vertebrobasilar insufficiency.
Usually last <30 minutes and have no hearing loss
What arteries can be involved with Wallenberg syndrome?
PICA
Vertebral arteries
Superior, middle or inferior lateral medullary artery
What is the clinical presentation of Wallenberg syndrome on the Ipsilateral side?
Horner’s syndrome
Dec pain and temp sensation of face
Ataxia/falls to lesion
What is the clinical presentation of Wallenberg syndrome on the Contralateral side?
Dec pain and temp on body Dysphagia Dysarthria Hoarseness/vocal cord paralysis Vertigo Hiccups Nystagmus, diplopia
What is not seen in Wallenberg syndrome?
Facial or extremity weakness
What structures are affected in Benedikt syndrome?
Red nucleus
Tegmentum of midbrain
What are the symptoms of medial lemniscus damage?
Ipsilateral CN3 paralysis with mydriasis
Contralateral hypesthesia
What are the symptoms of red nucleus damage?
Contralateral hyperkinesia (ataxia, tremor, chorea, athetosis)
What is the clinical presentation of Weber syndrome?
Ipsilateral CN3 palsy
Contralateral hemiplegia, Parkinson’s signs and dystaxia
What is the clinical presentation of Millard-Gubler syndrome?
Ipsilateral CN6 and 7 palsy
Contralateral hemiplegia, analgesia, hypoesthesia
What is the clinical presentation of Medial Medullary syndrome?
Ipsilateral CN12 palsy
Contralateral hemiplegia and proprioception loss
What is affected in Weber syndrome?
PCA
Base of midbrain
What is affected in Millard-Gubler syndrome?
Basilar artery
Base of pons
What is affected in Medial Medullary/Wallenberg syndrome?
Vertebral or anterior
spinal artery
What causes Locked-in syndrome?
Bilateral lesions of the ventral pons (basilar artery occlusion)
What are the Lacunar syndromes?
Pure motor hemiplegia Pure sensory stroke Dysarthria/clumsy hand syndrome Sensorimotor stroke Ataxia and leg paralysis Hemichorea-hemiballismus
What causes intracerebral hemorrhages (ICH)?
Chronic HTN and development of microaneurysms
What are common symptoms of intracerebral hemorrhages (ICH)?
Headache and/or LOC
Vomiting
Seizures
Nuchal rigidity
What is the most common location of an intracerebral hemorrhages (ICH)?
Putamen
What is seen with large putamen intracerebral hemorrhages (ICH)?
Stupor/coma
Hemiplegia
What is seen with small putamen intracerebral hemorrhages (ICH)?
Headache
Eyes deviate away from lesion
Hemiplegia
What is seen with thalamus intracerebral hemorrhages (ICH)?
Hemiplegia
Contralateral sensory deficits
Aphasia w/ dominant
Contralateral hemineglect w/ nondominant
What is seen with Pons intracerebral hemorrhages (ICH)?
Deep coma
Total paralysis
Decerebrate rigidity
What is seen with Cerebellum intracerebral hemorrhages (ICH)?
Coma/LOC Vomiting Occipital HA Vertigo Ipsilateral CN6 palsy Dsyarthria Dysphagia Cant sit, stand or walk
What is seen with Cerebral intracerebral hemorrhages (ICH)?
HA
Vomiting
Deficits based on location
What causes Subarachnoid Hemorrhages?
Typically ruptured saccular (berry) aneurysm
Where do most saccular (berry) aneurysm occur?
90% to 95% at anterior part of the Circle of Willis
When are aneurysms most likely to rupture?
Size >10 mm
During activity
5th and 6th decade
What scale is used for nontraumatic SAH?
Hunt and Hess scale
What is a Hunt and Hess scale grade 1?
Asymptomatic
Mild HA
Slight nuchal rigidity
What is a Hunt and Hess scale grade 2?
Moderate to severe HA
Nuchal rigidity
Cranial nerve palsy
What is a Hunt and Hess scale grade 3?
Drowsiness/confusion
Mild focal neurologic deficit
What is a Hunt and Hess scale grade 4?
Stupor
Moderate-severe hemiparesis
What is a Hunt and Hess scale grade 5?
Coma
Decerebrate posturing
When can CN3 be compressed with saccular aneurysms?
Posterior communicating-internal carotid junction aneurysm or posterior communicating-posterior cerebral
artery aneurysm
What is the clinical presenation of CN3 palsy?
Lateral deviation of ipsilateral eye
Ptosis
Mydriasis
Paralysis of accommodation
What are symptoms of saccular aneurysm rupture?
Sentinel HA
What is the prognosis of saccular aneurysm rupture?
25% mortality in 1st 24hr
30% rebleed in 1st mo
60% mortality from rebleed
What medications can be used for cerebral vasospasm?
Nimodipine (calcium channel blocker)
What are arteriovenous
malformations (AVM)?
Tangled mass of dilated vessels that forms communication b/w the arterial and venous systems
How do arteriovenous
malformations (AVM) cause hemorrhage?
Low pressure systems so need occlusion distally to raise luminal pressure
What is the lifetime risk of arteriovenous
malformations (AVM) causing hemorrhage?
40-50% risk
MC in smaller AVMs
MC in 20-40 yo
What is the clinical presentation of arteriovenous
malformations (AVM) rupture?
Hemorrhage
Seizures
HA
Neurologic deficit based on location