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PassPMR - 01 Stroke > Chapter 2 - Stroke Syndromes > Flashcards

Chapter 2 - Stroke Syndromes Flashcards

1. Cortical Strokes - Anterior Cerebral Artery - Middle Cerebral Artery - Posterior Cerebral Artery 2. Subcortical Strokes - Lacunar Syndromes 3. Brainstem Strokes - Midbrain Syndromes - Pontine Syndromes - Medullary Syndromes 4. Cerebellar Strokes

1
Q

How does the pattern of motor and sensory deficits differentiate cortical from subcortical involvement?

A

Cortical lesions

Often involve the face, arm, and trunk, but spare the legs, which are located in the interhemispheric fissure

Subcortical lesions

Cause a complete hemiparesis, affecting face, arm, and leg because fibers will decent from the cortex to form internal capsule and pyramidal tract.

Neurolog Secrets 6th Edition Chapter 3 pg46

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2
Q

How does the type of sensory deficit differentiate cortical from subcortical lesions by history?

A

Most of the primary sensory modalities reach “consciousness” in the thalamus and do not require the cortex for their perception.

Patient with severe cortical damage can still feel pain, touch, vibration, and position.

History of significant numbness or sensory loss, therefore, suggests a subcortical lesion.

Neurolog Secrets 6th Edition Chapter 3 pg46

For i.e. PCA stroke will involve the Thalamus, that’s why the patient will have complete sensory loss.

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3
Q

How do visual symptoms differentiate cortical from subcortical disease by history?

A

Subcortical lesions often affect the visual fibers, producing visual field cuts. Therefore, a history of visual field loss suggests a subcortical lesion.

Unless strictly cortical lesion in the occipital lobes produces visual symptoms, but it does not affect motor, sensory, or other functions.

Neurology Secrets 6th Edition Chapter 3 pg46

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4
Q

Anterior Cerebral Artery (ACA) Clinical features 🔑🔑

A
  1. Contralateral weakness/sensory loss (distal contralateral leg > upper extremity)
  2. Head and eye deviation toward the lesion (away from hemiplegic limbs)
  3. Gait apraxia
  4. Mutism (Abulia): Lack of will, drive, or initiative for action, speech and thought
  5. Urinary incontinence
  6. Contralateral grasp reflex (primitive reflexes)
  7. Paratonic rigidity
  8. Transcortical motor aphasia (on left)

Cuccurollo 4th Edition Chapter 1 Stroke pg10

Stroke Rehabilitation Clinician Handbook 2020 Model 1 pg6

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5
Q

What is abulia?

A
  1. Difficulty in initiating and sustaining purposeful movements
  2. Lack of spontaneous movement
  3. Reduced spontaneous speech
  4. Increased response-time to queries
  5. Passivity
  6. Reduced emotional responsiveness and spontaneity
  7. Reduced social interactions
  8. Reduced interest in usual pastimes

https://en.wikipedia.org/wiki/Abulia

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6
Q

Complications of Bilateral ACA infarction 🔑🔑 EXAM

A
  1. Aphasia
  2. Incontinence
  3. Paraplegia (BL Lower limbs weakness)
  4. Frontal lobe dysfunction (emotional instability, disinhibition, apathy)

Cuccurollo 4th Edition Chapter 1 Stroke pg11

  1. Appearance of primitive reflexes.
  2. Abulia

Stroke Rehabilitation Clinician Handbook 2020 Model 1 pg6

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7
Q

Superior vs Inferior vs Left vs Right MCA
List 4 features of occlusion of superior branch MCA 🔑🔑
List 4 features of Bilateral MCA complication 🔑🔑

A

Superior MCA

  • Contralateral motor deficits face and arm > leg.
  • Contralateral sensory loss face and arm > leg.
  • Head and eyes deviated toward side of infarct

Inferior MCA

  • Superior quantrantonopsia or homonymous hemianopsia (SQ or HH)
  • Left hemispheric: Wernicke’s aphasia
  • Right hemispheric: Left visual neglect

Left MCA

  • Aphasia
  • Apraxia
  • Dysphagia

Right MCA

  • Neglect
  • Anosognosia (Body part / illness)
  • Astereognosis (Objects)
  • Agraphesthesia (Number & Words)
  • Apraxia: dressing and construction

Cuccurollo 4th Edition Chapter 1 pg10

Stroke Rehabilitation Clinician Handbook 2020 Model 1 pg7

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8
Q

Gerstmann Syndrome 🔑
What is the anatomy, vascular supply, as well as signs and symptoms?

A

ANATOMY: Dominant parietal lobe (angular gyrus)

VASCULAR: MCA.

SIGN AND SYMPTOMS

  1. Agraphia (inability to write).
  2. Acalculia (inability to calculate).
  3. Right-left confusion.
  4. Finger agnosia (inability to recognize fingers).
  5. Ideomotor apraxia (may be associated).
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9
Q

Posterior cerebellar artery supply which areas in the brain? 3 marks 🔑🔑

A
  1. Upper brainstem
  2. Inferior parts of the temporal lobe
  3. Medial parts of the occipital lobe.

Cuccurollo 4th Edition Chapter 1 Stroke pg11

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10
Q

Two cranial nerves supplied by PCA 🔑🔑
Two syndromes associated with PCA 🔑🔑

A

💡 Remember it supplies upper brainstem (midbrain):

  1. Oculomotor cranial nerve (CN3) → Weber syndrome (oculomotor palsy with contralateral hemiplegia)
  2. Trochlear (CN4) nuclei and nerves → Trochlear nerve palsy (vertical gaze palsy).
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11
Q

List 4 clinical findings post PCA infarct

A

PCA INFARCTION

  1. Contralateral hemiplegia
  2. Contralateral sensory loss (Thalamus)
  3. Face Blind → Prosopagnosia (cannot read faces)
  4. Cortical blindness with bilateral involvement of the occipital lobe branches
  5. Self Blind → Visual agnosia (Can’t recognize his visual loss)
  6. Word Blind → Alexia without agraphia
  7. Contralateral homonymous hemianopsia
  8. Palinopsia (abnormal recurring visual imagery)
  9. Impaired Memory
  10. Weber syndrome (oculomotor palsy with contralateral hemiplegia)
  11. Trochlear nerve palsy (vertical gaze palsy)
  12. Topographic disorientation

Cuccurollo 4th Edition Chapter 1 Stroke pg12

https://en.wikipedia.org/wiki/Posterior_cerebral_artery_syndrome

ANTON SYNDROME

Combination of cortical blindness, denial of blindness and memory impairment

It is typically associated with bilateral posterior cerebral artery infarctions

Neurology Secrets 6th Edition Chapter 17 pg214

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12
Q

What is prosopagnosia? localize the lesion. 🔑🔑

Hint: which gyrus from the faces?

A

💡 Lesion inferior occipital region, fusiform (face forming) gyrus, and temporal cortex.

Face blindness, patient cannot recognize people’s faces.

Posterior cerebral arteries (posterior cerebral circulation) affecting inferior occipital region and temporal cortex.

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13
Q

Why lacunar stroke has better prognosis? 4 marks 🔑

A
  1. Smaller strokes (<15 mm)
  2. No cortical symptoms
  3. No LOC, coma or seizures.
  4. No sensory changes

Ref: first principles.

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14
Q

What branch do lacunar infarcts normally occur? 🔑🔑

A

Ref: Braddom pg 1185-87

Netter’s concise neuroanatomy pg 62.

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15
Q

What are the risk factors for lacunar stroke? 🔑

A

💡 Typical 50-60 yrs old patient with pure motor syndrome.

  1. Hypertension
  2. Diabetes mellitus
  3. Hyperlipidemia
  4. Smoking

https://emedicine.medscape.com/article/1163029-overview

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16
Q

List 4 Types of lacunar infarction and their location. 🔑🔑 EXAM 🟦

List 6 Types of lacunar stroke syndromes. Location, Blood supply & Presentation.

A

LACUNAR STROKE

Small (2 to 20 mm in diameter) non-cortical infarcts caused by occlusion of a single branch.

MAJOR BLOOD SUPPLY

  1. Middle Cerebral Artery (MCA): Internal Capsule (Anterior [Face] & Posterior limb [Body])
  2. Posterior Cerebral Artery (PCA): Thalamus (Sensory) & Red Nucleus (Ataxia)
  3. Basilar Artery: Cerebellar

SHORT ANSWER

  1. Pure Motor Syndrome, Internal Capsule (Posterior Limb)
  2. Pure Sensory Syndrome, Thalamus
  3. Sensorimotor Syndrome, Junction between Thalamus & Internal Capsule
  4. Dysarthria Clumsy Hand, Internal Capsule (Anterior Limb)
17
Q

Which clinical features of brain stem disease can be elicited by history?

What are the major long tracts in the brainstem?

List 8 sign and symptoms of brain stem lesions 🔑🔑

What are some common symptoms of a patient with brain stem lesion? Mention 5 🔑🔑

A

Brain stem = spinal cord (3 tracts) + cranial nerves (UMN & LMN)

Crossed symptoms = Ipsilateral C.N + contralateral body hemiparesis

Cranial nerve

  1. Motor nuclei of CNs (ipsilateral)
  2. Corticobulbar tract (contralateral)

Pyramidal (corticospinal) tract

  1. Motor Deficit

Spinothalamic tract

  1. Pain and temperature sensations up to the thalamus → Sensory Deficit

Dorsal columns

  1. Position and vibration sense up to the thalamus → Incoordination, Gait imbalance

Neurolog Secrets 6th Edition Chapter 3 pg45

18
Q

What is pseudobulbar palsy?🔑

  1. What is the localization?
  2. List 4 clinical features.
  3. List 3 causes (DDX).
A

ANATOMY:

Lesion to corticobulbar tracts

CLINICAL:

  1. Dysarthria
  2. Dysphagia
  3. Dysphonia
  4. Impairment of voluntary movements of the tongue and facial muscles
  5. Emotional lability

DDX:

  1. ALS.
  2. parkinson’s disease.
  3. multiple sclerosis.
  4. TBI
  5. Brain tumor

Ref: Wikipedia.

19
Q

67yo man with right sided third cranial nerve palsy, left hemiparesis.

Name the location of the lesion. 🔑

A

Weber syndrome = ipsilateral CN3 palsy + contralateral hemiparesis

Location: Right Midbrain (CN3-4)

20
Q

List 3 features of CN3 palsy🔑🔑

A
  1. Ptosis due to inactivation of levator palpebrae superioris muscle (upper eyelid elevation)
  2. Mydriasis (dilated pupil) and paralysis of accommodation due to interruption of parasym pathetic fibers in CN3.
  3. Downward and lateral gaze position (unopposed action of superior oblique and lateral rectus)

Cuccurollo 4th Edition Chapter 1 Stroke pg18

21
Q

Weber vs Benedikt’s 🔑
What is the anatomy, vascular supply, as well as signs and symptoms?

A

RECALL

PCA supply upper brain stem → Weber CN3 so its involved.

WEBER

Artery: PCA

Presentation

  1. Ipsilateral CN3 palsy
  2. Contralateral hemiplegia
  3. Contralateral Parkinson signs
  4. Contralateral dystaxia (mild degree of ataxia)

BENEDIKT “ATAXIX HYPER WEB”

Artery: PCA

Presentation:

  1. Ipsilateral CN3
  2. Damage to red nucleus: Contralateral hyperkinesia (ataxia, tremor, chorea, athetosis)
  3. Damage to medial lemniscus: Contralateral loss of proprioception and vibration

Cuccurollo 4th Edition Chapter 1 Stroke pg14-15

22
Q

59 YRS old patient admitted to the ER with sudden onset of quadriplegia. No history of trauma.O/E conscious, quadriplegic, not able talk, incapable of facial movement but the patient is able to blink and have vertical eye movement. Dx and Localization. 🔑🔑

A

Locked-in syndrome, Bilateral ventral pontine lesion.

23
Q

With respect to “locked in syndrome”, name the site of vascular occlusion.
Why is the patient conscious but quadriplegic? 🔑🔑
Locked in syndrome, why patient has intact consciousness and gaze 🔑🔑 EXAM

A

LESION

  • Bilateral ventral pontine infarct (Basilar artery territory)
  • Blood Supply: Basilar Artery
  • Other Causes: pontine hemorrhage, trauma, central pontine myelinolysis, tumor, and encephalitis.

PRESERVED FUNCTIONS:

  1. Supranuclear ocular pathways (located dorsally)
    1. Vertical gaze
    2. Blinking/eye opening
  2. Ascending reticular formation
    1. Consciousness/cognition

CLINICAL PRESENTATION:

  1. Bilateral corticobulbar tracts → Facial paralysis & aphonia
  2. Bilateral corticospinal tracts → Tetraplegia
  3. Bilateral CN 6 fasciculi or MLF → Horizontal eye paresis (impaired horizontal gaze)

Cuccurollo 4th Edition Chapter 1 Stroke pg16

Neurology Secrets 6th Edition Chapter 9 Brain Stem Lesion pg120

24
Q

Raymond’s vs Millard-Gubler Syndrome. Blood Supply & Presentation 🔑

A

RAYMOND

Artery: Branches of basilar artery to pons

Presentation

  1. Abducens nerve palsy
  2. Pyramidal Tract → Contralateral hemiparesis

MILLARD-GUBLER

Artery: Branches of basilar artery to pons

Presentation:

  1. Ipsilateral abducens (CN6) and facial (CN7) palsies
    • Ipsilateral facial plasy & lateral rectus plasy
  2. Contralateral hemiplegia
  3. Contralateral analgesia, hypoesthesia
25
Q

Lateral Medullary Syndrome 🔑🔑

Blood Supply & Mention 8 possible signs and symptoms

A

BLOOD SUPPLY

  1. Vertebral arteries (involved in eight out of 10 cases)
  2. PICA
  3. Lateral medullary artery (superior - middle - infecrior)

IPSILATERAL

  1. Horner’s syndrome
  2. Decrease pain and temperature on the ipsilateral face (CN 5)
  3. Loss of taste (CN 7)
  4. Limb and gait ataxia (cerebral peduncle)

CONTRALATERAL

  1. Decreased pain and temperature on contralateral body
  2. Dysphagia
  3. Dysarthria, hoarseness of voice, paralysis of vocal cord
  4. Diplopia
  5. Nystagmus
  6. Vertigo
  7. Nausea and vomiting
  8. Hiccups

Cuccurollo 4th Edition Chapter 1 Stroke pg15

Stroke Rehabilitation Clinician Handbook 2020 Model 1 pg20

26
Q

Medial Medullary Syndrome.

Blood Supply & List 3 symptoms 🔑🔑

A

BLOOD

  1. Vertebral arteries (upper medulla)
  2. Anterior spinal artery

PRESENTATION

  1. CN12 → Ipsilateral hypoglossal palsy (with deviation toward the side of the lesion)
  2. Pyramidal Tract → Contralateral hemiparesis
  3. Medial Lemniscus → Contralateral sensory loss of proprioception and vibration

Cuccurollo 4th Edition Chapter 1 Stroke pg15

Stroke Rehabilitation Clinician Handbook 2020 Model 1 pg20

27
Q

Deference between dysdiadochokinesis and dysmetria 🔑🔑

A

Dysdiadochokinesis

Difficulty with rapid alternating movements

Dysmetria

Difficulty with placement of body part during active movement resulting in undershooting (HYPOMETRIA) or overshooting (HYPERMETRIA) of the target.

Braddom pg 1184

28
Q

What are the 3 vessels to the cerebellum?

PassPMR - 01 Stroke (6 decks)

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