Stroke

Question 1

what is a cerebrovascular accident (CVA) (stroke)?

Answer 1

Neurological signs and symptoms, usually focal and acute, that result from disease involving cerebral blood vessels

Question 2

what is an ischaemic stroke?

Answer 2

when the blood supply to an area of brain tissue is reduced, resulting in tissue hypoperfusion

Question 3

what causes an ischaemic stroke?

Answer 3

embolism
systemic hyoperfusion
cerebral vinous sinus thrombosis

Question 4

pathophys of embolism causing ischaemic stroke?

Answer 4

an embolus originating somewhere else in the body (e.g. the heart) causes obstruction of a cerebral vessel, resulting in hypoperfusion to the area of the brain the vessel supplies.

Question 5

pathophys of thrombosis causing ischaemic stroke?

Answer 5

a blood clot forms locally within a cerebral vessel (e.g. due to atherosclerotic plaque rupture).

Question 6

pathophys of systemic hypoperfusion causing ischaemic stroke?

Answer 6

blood supply to the entire brain is reduced secondary to systemic hypotension (e.g. cardiac arrest).

Question 7

pathophys of cerebral venous sinus thrombosis causing ischaemic stroke?

Answer 7

blood clots form in the veins that drain the brain, resulting in venous congestion and tissue hypoxia.

Question 8

what is a haemorrhagic stroke?

Answer 8

secondary to rupture of a blood vessel or abnormal vascular structure within the brain

Question 9

what are the sub-types of a haemorrhagic stroke?

Answer 9

Intracerebral haemorrhage

Subarachnoid haemorrhage

Question 10

what is an intracerebral haemorrhage?

Answer 10

bleeding within the brain secondary to a ruptured blood vessel.

Can be intraparenchymal (within the brain tissue) and/or intraventricular (within the ventricles).

Question 11

what is a subarachnoid haemorrhage?

Answer 11

A type of stroke caused by bleeding outside of the brain tissue, between the pia mater and arachnoid mater.

Question 12

what are the risk factors for a stroke?

Answer 12

hypertension
diabetes mellitus
heart disease (AF, CCF)
heredity
blood lipids, cholesterol, smoking

Question 13

the anterior cerebral arteries supply…

Answer 13

the anteromedial area of the cerebrum

Question 14

the posterior cerebral arteries supply…

Answer 14

a mixture of the medial and lateral areas of the posterior cerebrum

Question 15

the middle cerebral arteries supply…

Answer 15

the majority of the lateral cerebrum

Question 16

what is a total anterior circulation stroke (TACS)?

Answer 16

large cortical stroke affecting the areas of the brain supplied by both the middle and anterior cerebral arteries

Question 17

how do you diagnose a TACS?

Answer 17

all of the following 3 present:
1. unilateral weakness (and/or sensory deficit) of the face, arm and leg
2. homonymous hemianopia
3. higher cerebral dysfunction (dysphasia, visuospatial disorder)

Question 18

what is a partial anterior circulation stroke (PACS)?

Answer 18

less severe than TACS
- part of the anterior circulation has been compromised

Question 19

how do you diagnose a PACS?

Answer 19

2 of the following:
1. unilateral weakness (and/or sensory deficit) of the face, arm and leg
2. homonymous hemianopia
3. higher cerebral dysfunction (dysphasia, visuospatial disorder)

Question 20

what is posterior circulation syndrome (POCS)?

Answer 20

damage to the area of the brain supplied by the posterior circulation (eg. cerebellum and brainstem) and (occipital lobe, thalamus, medial temporal lobe)

Question 21

how do you diagnose a POCS?

Answer 21

1 of the following is present:
1. cranial nerve palsy and a contralateral motor/sensory deficit
2. bilateral motor/sensory deficit
3. conjugate eye movement disorder (eg. horizontal gaze palsy)
4. cerebella dysfunction (eg. vertigo, nystagmus, ataxia)
5. isolated homonymous hemianopia

Question 22

what is a lacunar stroke (LACS)?

Answer 22

subcortical stroke that occurs secondary to small vessel disease. No loss of higher cerebral functions.

Question 23

how do you diagnose a LACS?

Answer 23

1 of the following needs to be present:
1. pure sensory stroke
2. pure motor stroke
3. sensori-motor stroke
4. ataxic hemiparesis
5. clumsy hand-dysarthria

Question 24

what is a transient ischemic attack (TIA)?

Answer 24

blood supply to the brain is temporarily blocked

signs are the same as for a stroke but for a shorter duration of time

Question 25

what is important to note with a TIA?

Answer 25

can be a warning that you may have a stroke and an opportunity to prevent this from happening

Question 26

what is a middle cerebral artery (MCA) stroke?

Answer 26

ischemic stroke that occurs in the MCA
- can involve the frontal, temporal and parietal lobes

Question 27

what are the features of a MCA?

Answer 27

deficits in movement and sensation of the legs, arms & lower 2/3 of the face

difficulty swallowing (dysphagia)

impaired speech ability with left MCA

impaired vision and partial contralateral blindness

headaches

hemineglect (right MCA)

UL more affected than LL

impulsiveness

Question 28

symptoms of a MCA in the left hemisphere

Answer 28

• Right hemiparesis - Variable involvement of face and upper and lower extremity
• Right-sided sensory loss in a pattern similar to that of the motor deficit - Usually involves all modalities, decreased stereognosis, and agraphesthesia, left-right confusion
• Right homonymous hemianopia
• Dysarthria
• Aphasia, fluent and nonfluent
• Alexia, Agraphia, Acalculia, Apraxia

Question 29

symptoms of a MCA in the right hemisphere

Answer 29

• Left hemiparesis - Same pattern as on right
• Left-sided sensory loss - Similar pattern that of the motor deficit
• Left homonymous hemianopia - Same pattern as on right
• Dysarthria
• Neglect of the left side of environment
• Anosognosia
• Asomatognosia
• Loss of prosody of speech
• Flat affect

Question 30

what is a posterior cerebral artery (PCA) storke?

Answer 30

involvement of the occipital lobe, the medial lobe, the medial temporal lobe or the thalamus

Question 31

what symptoms does a PCA stroke of the occipital lobe cause?

Answer 31

contralateral homonymous hemianopia

cortical blindeness (bilateral lesions)

Question 32

what symptoms does a PCA stroke of the medial temporal lobe cause?

Answer 32

*Deficits in long-term and short-term memory
*Behaviour alteration (agitation, anger, paranoia)

Question 33

what symptoms does a PCA stroke of the thalamus infarct cause?

Answer 33

–Contralateral sensory loss
–Aphasia (if dominant side involvement)
–Executive dysfunction
–Decreased level of consciousness
–Memory impairment

Question 34

what are the clinical features of a brainstem stroke?

Answer 34

–Crossed sensory findings (e.g. ipsilateral face and contralateral body numbness)
–Crossed motor findings (ipsilateral face, contralateral body)
–Gaze-evoked nystagmus
–Ataxia and vertigo, limb dysmetria
–Diplopia and eye movement abnormalities
–Dysarthria, dysphagia
–Tongue deviation
–Deafness (very rare)
–Locked-in syndrome (can’t move any limb, can’t speak, can sometimes blink)

Question 35

what are the clinical features of a midbrain stroke?

Answer 35

• Ipsilateral 3rd nerve palsy
• Contralateral hemiparesis of the arm and leg, sometimes with hemiplegia of the face
• Contralateral hemiataxia

Question 36

clinical features of pontine stroke:

Answer 36

*Ipsilateral signs:
*Horner’s syndrome
*6th or 7th nerve palsy (diplopia, whole side of face is weak)
*Hearing loss (rare)
*Loss of pain and temperature sense
*Contralateral signs:
*Weakness in leg and arm
*Loss of sensation in arm and leg
*Nystagmus, nausea

Question 37

clinical features of a medullary stroke:

Answer 37

*Ipsilateral signs:
*Tongue weakness
*Sensory loss in face
*Horner’s syndrome
*Ataxia
*Palate weakness (dysphagia)
*Contralateral signs:
*Weakness, sensory loss in arm and leg
*Nausea, nystagmus, dysphagia, dysarthria

Question 38

clinical features of a cerebellar stroke:

Answer 38

*Ischemia involving:
*Superior cerebellar artery (SCA)
*Anterior or posterior inferior cerebellar artery (AICA or PICA)
*Ataxia, vertigo, nausea, vomiting, dysarthria
*Often headache and nystagmus
*Can also have rapid deterioration in level of consciousness

Question 39

clinical features of a cerebellar infarction

Answer 39

*Infarction causes edema resulting in mass effect, herniation and compression of the fourth ventricle
*This can lead to rapid deterioration in level of consciousness
*Surgical decompression is often necessary in these circumstances

Question 40

manifestation of cerebellum infarct

Answer 40

DANISH
Dysdiadochokinesia: the lack of ability to perform rapidly alternating movements.
Ask the patient to quickly supinate and pronate both forearms simultaneously. Movements will be slow and incomplete on the side of the cerebellar lesion.
Ataxia: voluntary movement disturbance involves tremor with fine movements eg writing or buttoning the clothes.
UL: Finger to nose test- testing tip of the nose with the index finger test the movements are not properly coordinated.
LL: ask patient to place the heel of one foot against the shin of the opposite leg.
Nystagmus: Ataxia of ocular muscles, a rhythmical oscillation of the eyes.
To provoke nystagmus, the patient should rotate eyes horizontally
Intention tremor
Dysarthria/Scanning speech:ataxia of the larynx muscles, speech is slurred and syllables are separated from one another.
Hypotonia: the muscles lose resistance to palpation. The patient walks with a broad-based gait and leans toward the affected side.

Rebound phenomenon- Rebound phenomenon is a reflex that occurs whena patient attempts to move a limb against resistance that has been suddenly removed

Pendular knee jerk- the leg continues to move several times after the initial reflex

Question 41

what is a lacunar stroke?

Answer 41

occlusion of the penetrating branches of the circle of Wills, middle cerebral stem, and vertebral and basilar arteries, affecting the deep grey and white matter of the cerebrum and brainstem

Question 42

difference between pure motor and pure sensory stroke

Answer 42

Pure motor stroke usually arises from infarction in the posterior limb of the internal capsule; course is often stuttering over hours to days.

Pure sensory stroke usually arises from thalamic infarction

Question 43

symptoms of a lacunar stroke:

Answer 43

weakness and sensory loss with no visual field deficit, aphasia, neglect, ataxic hemiparesis (often arises in the corona radiata), clumsy hand-dysarthria (caused by infarction in the pons)

Question 44

signs and symptoms of intracerebral haemorrhage

Answer 44

 Deep location: usually due to rupture of small, deep perforating artery; often associated with hypertension.
 Superficial/lobar location: cerebral amyloid angiopathy often the cause; older patients.
 Other common causes: arteriovenous malformation/cavernoma; ruptured saccular aneurysm; coagulopathy

Question 45

signs and symptoms of subarachnoid haemorrhage:

Answer 45

thunderclap headache eg “worst headache of my life.” A headache often is associated with nausea, vomiting, and diplopia.

Often signs of meningismus, neck stiffness

Cranial nerve deficits

Often in a state of coma and unconscious

Question 46

what is lock in syndrome?

Answer 46

Basilar artery thrombosis and bilateral infarction of the ventral pons

Question 47

what are the clinical features of lock in syndrome?

Answer 47

Sudden onset
Patients develop acute hemiparesis rapidly progressing to
quadriplegia and lower bulbar paralysis. Initially the patient is dysarthric and dysphonic but rapidly progresses to mutism (anarthria).
Consciousness and sensation is preserved.
The patient cannot move or speak but remains alert and oriented.
Mortality rates are high (59%), and survivors are left with severe impairments associated with brainstem injury

Question 48

clinical features of wernicke’s aphasia

Answer 48

deficit in comprehension and severe difficulty in reading and writing. Lesions causing this problem are usually in the dominant temporal lobe.

Question 49

clinical features of broca’s aphasia

Answer 49

comprehension is usually preserved but language expression is affected. Lesions are usually in the dominant frontal lobe. Broca’s aphasia, also called ‘expressive’ or ‘non-fluent aphasia’, may result in almost complete loss of language expression to a slowed, deliberate speech utilizing only key words and simple grammatical structure.

Question 50

what is receptive aphasia?

Answer 50

the problem of understanding language, fluent

Question 51

what is expressive aphasia

Answer 51

the problem of producing the correct word or sequence of words, non-fluent.

Question 52

what causes aphasia?

Answer 52

damage to the regions of the left cerebral cortex

Question 53

what is dysphagia?

Answer 53

difficulty swallowing

can lead to aspiration of saliva, food or liquids

Question 54

what is silent aspiration?

Answer 54

when you accidentally inhale food, liquid or other material into your trachea (windpipe or airway) and you don’t know it.

Question 55

what is pusher syndrome?

Answer 55

patients actively push away from the nonhemiparetic side, leading to a loss of postural balance

The perception of body posture in relation to gravity is altered. The patients experience their body as oriented “upright” when the body actually is tilted to the side of the brain lesion (to the ipsilesional side).