Stroke Localization Practice - Reynolds Flashcards
69 y/o WM with a h/o HTN, DM and CAD presented with sudden difficulty speaking while watching the Kansas-Oregon game. He got up from his recliner and fell down due to R-sided weakness. His son took him to the ED where he was noted to have an expressive aphasia, R homonymous hemianopsia (optic radiations), R facial droop, his R arm was plegic and his R leg was severely weak at 2/5 strength. He had reduced sensation on the right.
- Where would you localize their lesion?
- Brain (left cortex, left MCA).
What would be the weakness pattern in a left ACA stroke?
left leg weakness (and some left arm weakness).
Would there be homonymous hemianopsie?
No,
In a complete ___ lesion, you’d expect all ACA and MCA territory to be gone. Arms and legs would be plegic
ICA
- 57 y/o patient with HTN and DM was playing golf and fell down due to right leg weakness. He was also c/o double vision. His buddies take him to the ED.
- He is awake and alert. Speech is dysarthric, language function is intact. On cranial nerve testing he has small but reactive pupils. On right lateral gaze, his eyes will not move past midline. When attempting to look to the left, the right eye will not adduct past midline, the left eye moves all the way to the left but develops prominent nystagmus. He can look up and down, he has a right lower motor neuron facial weakness (entire face and forehead is involved), his left palate does not elevate well and his tongue deviates to the left when protruding, he has left sided weakness at about 3/5 throughout, he has some sensory loss on the left, left side is hyperreflexic and left toe goes up
Where would you localize this lesion?
Brainstem - right medial pons - basilar paramedian -
- 29 year old presents to the clinic after returning from a hiking trip to the Grand Canyon due to pain and weakness in his right arm
- He reports that he noticed difficulty getting his backpack off and on the last couple of days on the hike and his right shoulder was hurting.
- He denies headache or neck pain or injuring his shoulder or neck. He did not fall. He has no radiating pain or paresthesias from his neck into his arm.
- He has no bowel or bladder complaints
- Healthy young man with completely normal exam except for his right arm:
- 4/5 strength in the right deltoid, right biceps and 4-/5 strength in the right supra and infraspinatus. Brachioradialis, triceps and distal arm muscles are normal.
- Mildly decreased pinprick sensation over the right deltoid.
- Reflexes are 2+ and symmetric throughout except for 1+ at the right biceps
- Toes are downgoing
When do you localize this?
Plexopathy
73 y/o woman develops sudden onset of slurred speech and left-sided weakness. On exam she is awake and alert but severely dysarthric almost to the point of being unintelligible. She is able to follow commands and can write sentences without errors. On cranial nerve testing she has a prominent left facial weakness that spares the forehead, but otherwise cranial nerves are intact. On motor testing she has severe weakness of the left arm and leg with barely a trace of movement in the left hand and left hip flexors. There is NO sensory loss. Reflexes are 1+ symmetrically and toes go down.
Where is the stroke?
right internal capsule - small lacunar infarct due to occlusion of the deep penetrating artery
- Right small artery lacunar infarct due to occlusion of a deep penetrating artery
- Pure motor lacunar syndrome
- Lesion will be internal capsule or possibly ventral pons
- Why can this NOT be an MCA occlusion?
–> because no sensory loss
- 79 y/o woman was found by her granddaughter lying on the floor. She denied anything being wrong but could not stand due to left-sided weakness. Upon arrival in the ED she did not know why her granddaughter brought her to the ED.
- She is awake and alert. Speech is slurred but she is not aphasic, she has a R gaze preference but with maximal encouragement, you can get her to briefly move her eyes past midline to the left. She has a L homonymous hemianopsia on visual field testing. She has a left facial droop that spares the forehead. She has complete L hemiplegia and she denies that her left arm is actually her arm. She is unaware of you touching the left side of her body.
Brain - right cortex - right MCA
- 34 year old healthy firefighter develops neck pain and dizziness in the middle of a Crossfit workout when he is rolling a giant tire around the gym floor. He sits down due to the dizziness and his firefighter buddies notice that his voice is hoarse and they take him to the ED. On arrival to the ED he is alert but very dizzy and nauseated.
- He is vertiginous and nauseated. He is hiccuping incessantly. His speech is hoarse.
- CS: BP 149/66 P 69 RR 14 T 99.0
- General exam: healthy appearing, complaining of neck pain
- General exam is unremarkable.
- Visual fields are intact
- R pupil is 4mm, L pupil is 2mm. Both are reactive.
- EOM intact but there is prominent nystagmus on lateral gaze, more prominent to the right. There is mild left-sided ptosis
- CN 5: Left facial sensory loss to PP, LT and temp
- CN 7 and 8 are intact
- CN 9 & 10: Left side of palate elevates poorly.
- CN 11 & 12 are intact
- Motor strength is 5/5 (normal)
- DTRs are 1+ and symmetric throughout
- Toes are downgoing
- Sensory: decreased to LT, PP, temp on the right arm and leg
- Coordination: Normal on the right. Clumsy rapid alternating movements on the left and ataxic finger to nose and heel to shin on the left
- Gait: off balance, falls to the left
Left Medulla - PICA - Wallenberg syndrome from left vertebral dissection
- 49 year old woman with DM, HTN, HLD, smoking presents with sudden onset of numbness and tingling on the right side and trouble walking.
- On exam she is awake and alert. Speech and language are normal. There is no facial droop or motor weakness. EOM are intact without nystagmus. There is decreased sensation on the right side of the face. There is severe sensory loss to temperature, pinprick, light touch and proprioception on the entire right side of her body.
- She is ataxic on finger to nose and heel to shin on the right side.
- Reflexes are 1+ and symmetric in the upper extremities and the knees and absent at the ankles bilaterally
- Toes are downgoing bilaterally.
- She cannot walk without assistance.
•Left brain penetrating artery subcortical stroke
(she has sensory ataxia because of a lack of proprioception)
•17 year old has a motorcycle crash. On exam in the ED he is paraplegic and cannot feel anything below the nipple line. He is awake and alert and moves his arms normally. He has no cranial nerve abnormality. Reflexes are normal in his arms and absent in the legs. Babinski signs are not present.
Spinal cord lesion (t4)
Why is he not hyperrefleixc? Spinal shock
- 66 year old man with h/o HTN and HLD has sudden onset of left sided weakness and trouble with his right eye. His son takes him to the ED
- On exam he is awake and alert. He has near complete ptosis of the right eye. When you lift up the right eyelid, you see that the right pupil is 6mm and non-reactive compared to 3mm and reactive in the left eye. The right eye is deviated out and down. It will not move past midline to the left and will not look up. He has a left facial droop that spares the forehead.
- On motor exam he has severe weakness on the left side where the arm and leg are barely antigravity.
- There is no sensory change.
- Reflexes are symmetric. Toes are downgoing
superior midbrain - webers? paramedian branches of basilar. right midbrain
- 49 year old healthy man presents to the ED with 1 week of gradually progressing leg weakness and difficulty walking and some paresthesias in his feet. He was treated with antibiotics for a “walking pneumonia” a couple of weeks ago. He has had no injuries. He denies neck pain and has had no bowel or bladder dysfunction.
- Vitals and general exam are unremarkable.
- On cranial nerve testing you note mild, bifacial weakness but no other abnormality
- Motor exam shows severe weakness in the lower extremities at barely 2/5 in the hip flexors and his feet are plegic. In the arms he has mild weakness in the hands but 5/5 strength proximally in the arms.
- There is no sensory loss on objective exam
- Reflexes are absent throughout. Toes downgoing.
- Nerve
- Distal > proximal weakness
- No sensory level
- Facial nerves are involved so can’t be in the C-spine anyway
- What is wrong with him?
- AIDP
- The police find a homeless man unresponsive on the street downtown and call paramedics who intubate him on the scene and transfer to NCBH
- Arrival vital signs: BP 240/130 HR 148 and irregular RR: ventilated T 99
- Patient is unresponsive on the ventilator
- Pupils are pinpoint and minimally reactive.
- On eye movement testing, the eyes will occasionally spontaneously deflect down but they do not move horizontally.
- With cold caloric testing, the eyes do not move to either side and remain midline.
- He will grimace slightly to facial pressure
- On motor testing he makes no spontaneous movement
- To stimulation centrally or in the limbs he will extensor (decerebrate) posture.
- Reflexes are brisk throughout with bilateral upgoing toes.
Brainstem - pons
