Stroke Flashcards
A 69-year-old lady was slurring her words at a coffee morning. At the same time her right arm began to feel heavy and weak. 24 hours later all her symptoms had resolved. Which of these is the likely cause?
Transient ischaemic attack
A 42 year old woman suffers a violent headache followed by sudden collapse. You notice that her left pupil is fixed and dilated and her left eye is deviated laterally and downwards.
Which artery is likely to have been affected?
Posterior communicating artery
Damage to posterior communicating artery
caused an ipsilateral third nerve palsy causing her pupil to dilate and the eye to deviate laterally and downwards.
Paralysis of the third cranial nerve affects the medial, superior, and inferior recti, and inferior oblique muscles.
The eye is incapable of movement upwards, downwards or inwards, and at rest the eye looks laterally and downwards owing to the overriding influence of the lateral rectus and superior oblique muscles respectively.
A 53-year-old man with hypertension is admitted following a sudden collapse and is unable to move any part of his body except for eye movements, he appears to understand your questions, but is unable to answer.
Where is the likely lesion?
Brainstem
Brainstem lesions
locked-in syndrome.
• Patients cannot move or communicate verbally due to paralysis of nearly all voluntary muscles.
• Blinking and vertical gaze may be preserved depending on the extent and level of the lesion within the brainstem
• They are conscious and aware.
• Complete recovery is rare.
You are taking a history from an elderly gentleman who has had a stroke; he keeps trying to take his gown off and some of his responses are inappropriate and occasionally rude.
Where is the likely lesion?
Frontal lobe
Frontal lobe lesions
• Decreased lack of spontaneous activity - no desire to do anything and is unable to plan activities.
• Loss of attention - lack of interest and is easily distracted.
• Memory is normal but the patient cannot be bothered to remember.
• Loss of abstract thought - eg, cannot understand proverbs.
• Perseveration - a tendency to continue with one form of behaviour when a situation requires it to change.
• Change of affect - the patient either becomes apathetic and ‘flat’ or becomes over-exuberant and childish or uninhibited with possibly inappropriate sexual behaviour.
As part of a neurological examination, you ask the patient to walk a few steps. When they do so they walk with a wide unsteady gait and appear uncoordinated. Their speech is slurred.
Where is the likely lesion?
Cerebellum
Cerebellar lesions
Patients have a wide unsteady gait
Impaired coordination
Uncontrolled repetitive eye movements
Difficulty with fine motor tasks
Intentional Tremor
Slurred speech
Whilst examining an elderly lady on the stroke ward, it becomes apparent that she can only see one half of your face.
Where is the likely lesion?
Occipital lobe
Occipital lesions
Typically cause visual disturbances and depends on where the lesion is
These can include visual illusions and hallucinations
Trouble recognising objects or facial blindness
Being able to write but not read
When a lesion affects most of the occipital lobe on one side it can cause an homonymous hemianopia which means the patient is unable to see the visual field on the opposite side of the lesion
A 30-year-old pregnant lady complains to the GP of progressive hand weakness. She is unable to open jars and even grip her tea cup. The GP noticed that the muscles around her thumb were wasting.
Peripheral nerve
Carpal tunnel syndrome
This due to compression of the median nerve in the carpal tunnel.
• Wasting of the abductor pollicis brevis can develop with the following distribution of numbness and pain.
An elderly patient has a stiff flexed arm, and a stiff extended leg (both on the left) which they find difficult to bend.
Where is the cause most likely to be located?
Upper motor neurone
Upper motor neurone lesions : bulk of muscles
No wasting
Upper motor neurone lesions : tone of muscles
Tone increases = hypertonia
Upper motor neurone lesions : power of muscles
Paralysis affects movements of group of muscles
Spastic/clasp knife
Upper motor neurone lesions : reflexes
Exaggerated = hyperreflexia
Upper motor neurone lesions : fasciculation
Absent
Upper motor neurone lesions : babinski sign
Present
Upper motor neurone lesions : clasp-knife reaction
Present
Lower motor neurone lesions : bulk of muscles
Wasting of the affected muscles = atrophy
Lower motor neurone lesions : tone of muscles
Tone decreases = hypotonia
Lower motor neurone lesions : power of muscles
Individual muscles paralysed
Flaccid
Lower motor neurone lesions : reflexes
Diminished or absent = hyporeflexia
Lower motor neurone lesions : fasciculation
Present
Lower motor neurone lesions : babinski sign
Absent
Lower motor neurone lesions : clasp-knife reaction
Absent
Bell’s palsy
form of facial paralysis resulting fromfacial nerve (VII) dysfunction. The facial nerve is responsible for controlling muscles of facial expression, controlling hearing via the stapedius muscleand providing taste sensation to the anterior two-thirdsof the tongue.
Lesionsof the facial nerve can result in paralysis of facial muscles, increased hearing volume (hyperacusis) andloss of taste. The symptoms of a facial nerve lesion appear on the side of the head the nerve supplies (e.g. left facial nerve lesion will cause left facial paralysis).
Babinski reflex
occurs after the sole of the foot has been firmly stroked. The big toe then moves upward or toward the top surface of the foot. The other toes fan out. Babinski reflex is one of the normal reflexes in infants and in children up to 2 years old. It disappears as the child gets older.
An 89-year-old man presents with acute onset of weakness and numbness of his left lower leg and foot is unusually agitated and in an aggressive mood.
Which artery is likely to have been affected?
Anterior cerebral artery
Anterior cerebral artery damage
Supplies the anteromedial surface of the cerebral hemisphere.
• Paraplegia usually affects the lower limbs sparing the upper limbs and face.
• They may be incontinent.
• They may display frontal lobe symptoms e.g. personality changes
A 51-year-old man has a 2-month history of weakness in both of his hands, he is now unable to open jars. His hands show wasting of the thenar eminence. He has recently developed slurred speech and difficulty swallowing. His tongue appears spastic, and he is unable to protrude it.
Which of these is the likely cause?
Motor neurone disease
Motor neurone disease
Progressive disorder of unknown aetiology
Onset usually after age 50. Males more likely to be affected.
Present with combination of both UMN and LMN signs without sensory involvement.
Symptoms include – limb weakness, cramps, disturbance of speech or swallowing.
Signs – wasting and fasciculation of muscles, pyramidal tract involvement causing spasticity and exaggerated tendon reflexes
Symptoms can start focally but become widespread with time
A 40-year-old woman felt immediate back pain and a popping sensation after lifting a heavy box. The next day she noticed she was tripping over her right foot as it was dragging along the floor. Where is the cause most likely to be located?
Nerve root
Foot drop
caused by paralysis of the muscles that lift the foot
Given the history the most likely cause of damage is compression of the nerve root by a prolapsed vertebral disc.
30-year-old woman noticed both her eye lids becoming progressively droopier with time (ptosis). Weeks later she began to experience double vision and found it progressively more tiring and difficult to chew while eating. Which of these is the likely cause?
Myasthenia gravis
Myasthenia gravis
Condition of the neuromuscular junction
• Acetylcholine receptors are blocked by an auto immune reaction between the receptor protein and anti-acetylcholine receptor antibody.
• Women more affected than men. Presents between 15 to 50 years.
• Main symptom is abnormal fatigable weakness of muscles.
• First symptoms are usually ptosis or diplopia.
• Weakness of chewing, swallowing, speaking or limb movement can occur.
The circle of Willis is an essential part of the blood supply to the brain.
Which of these supplies the circle of Willis?
Internal carotid artery
Anterior cerebral artery supplies
medial aspects of the frontal and parietal lobes; strip of cortex on superior aspect - includes motor and somatosensory cortex responsible for lower limbs; some anterior structures of Diencephalon.
Middle cerebral artery supplies
majority of lateral aspects and deep parts of hemispheres-includes motor and somatosensory cortices responsible for face, arm and trunk; internal capsule; some structures of the Diencephalon
Posterior cerebral artery supplies
mainly the occipital lobe; small portion of inferior temporal lobe
Common causes of UMN weakness
Multiple sclerosis
Tumours
Spinal cord injury/lesion
Brain injury and trauma
Capsular stroke
Cerebral palsy
Dementia
Common causes of LMN weakness
Peripheral trauma
Guillain-Barré syndrome
Botulism
Nonclassical polio
Cauda equina syndrome
Amyotrophic lateral sclerosis
Motor neurone disease
Common causes of neuromuscular junction weakness
Autoimmune disorders such as myasthenia gravis (autoimmune destruction of nicotinic ACh receptors)
Congenital disorders
Toxins
Drug-induced disorders
Common causes of muscle weakness
Muscular dystrophy (X-linked genetic disorders resulting in malformed dystrophin- loss of cell membrane cytoskeletal connections, unregulated influxes of calcium to sarcolemma)
Forehead sparing
UMN lesion as still have contra lateral supply
• facial nerve palsy - no movement as left nuclei
Left-sided strokes most commonly cause
aphasia, which is the inability to express or understand speech
Strokes affecting one side of the motor or sensory cortex will result in a
Contra-lateral neurological deficit
Stroke definition
hypoperfusion of the brain tissue resulting in cell death
What percentage of left handlers of RH dominant for speech and language
15%
Stroke affecting the internal capsule
Haemorrhagic of lenticulostriate artery
Occipital lobe stroke
Contralateral homonymous hemianopia
Which will produce a greater neurological deficit:
- stroke of motor cortex
- stroke of internal capsule
Internal capsule
