Stroke syndromes Flashcards
Cerebral vasculature
a) Branches off vertebral arteries
b) Branches off basilar artery
c) Brainstem vascular supply
a) PICA
b) AICA, pontine arteries, SCA, PCA
c) - Midbrain - PCA
- Pons - SCA, pontine arteries, AICA
- Medulla - PICA, vertebral arteries
Brainstem structures:
a) Medial (4Ms) and lateral (5 Ss) medullary structures
b) Cranial nerve nuclei
Medial:
- Motor pathway
- Medial lemniscus
- MLF
- Motor nerves - CN 3, 4, 6 and 12
Lateral:
- Spinothalamic
- Spinocerebellar
- Sympathetic
- Sensation for the face
- Speech/swallow nuclei - CNs IX and X (causes hoarse voice/dysphagia)
Note - signs of medial and lateral medullary signs probably indicates basilar artery pathology
Brainstem syndrome*
a) Lateral medullary syndrome
b) Medial medullary syndrome
c) Pontine syndromes
d) Midbrain syndrome
- note - cranial nerve palsies generally ipsilateral to brainstem lesion
a) Wallenberg: occlusion of PICA, clinical features = DANVAH
- Dysphagia (PICA-chew)
- Ataxia (ipsilateral)
- Nystagmus
- Vertigo
- Anaesthesia (ipsilateral CN V palsy, contralateral pain + temp loss)
- Horner’s (ipsilateral)
b) - Contralateral limb weakness
- Ipsilateral tongue weakness/wasting and deviation to ipsilateral side (lick the lesion)
- Contralateral MEDIAL lemniscus loss (vibration, light touch, proprioception)
c) Millard-Gubler syndrome:
(paramedian artery infarct)
- Contralateral hemiparesis, ipsilateral abducens, and facial nerve palsy
- May also have dysphagia, dysarthria, conjugate gaze palsy
Locked in syndrome:
(mid-basilar* artery stroke - causing bilateral pontine infarcts)
- Corticospinal damage - quadriplegia
- Corticobulbar tract - anarthria
- Nucleus abducens - horizontal gaze palsy, but vertical gaze remains intact (as CN III/IV in the midbrain). If unilateral, could have one-and-a-half syndrome
*More distal basilar infarcts lead to subcortical/cerebellar signs but not locked in syndrome
Pontine haemorrhage will cause the above plus:
- Headache
- Pinpoint pupils
- Dolls eye reflex (nuclear gaze palsy)
- 80% die within 48 hours
d) Weber’s: - “Web in my eye”
(Paramedian branches of PCA)
- Contralateral weakness
- Ipsilateral oculomotor nerve palsy
- May have contralateral Parkinsonism if substantia nigra affected
What are ‘crossed’ signs
Brainstem lesions that cause ipsilateral features in the face (CNs) and contralateral features in the limbs
Moya moya syndrome
- what is it?
- who it affects?
- angiogram appearance
- Vasculopathy affecting the basal ganglia, that presents with recurrent TIAs, headaches and seizures
- Affects children 5-10 years and adults 30-50
- Angiogram appearance - “puff of smoke”
Subclavian steal syndrome
a) what is it?
b) how does it present?
c) management
a) Stenosis of the subclavian arteries (usually due to atherosclerosis). Leads to reduction in blood flow to upper limbs, and resultant collateral supply from vertebral arteries, causing cerebral ischaemia when using arms
b) Pain/numbness in upper limbs with stroke like symptoms on using the arms (e.g. painting, dusting high surfaces, etc.)
c) antiplatelets, statins, +/- surgery
Carotid endarterectomy indications
> 50% on symptomatic side (acute non-disabling stroke or TIA)
or >80% in absence of symptoms
Thrombectomy
a) Indications (2, 6, 6, 24)
b) Who should undergo CT angiography?
c) Should they be thrombolysed as well?
a) Indications (2, 6, 6, 24):
Acute ischaemic stroke with…
Pre-stroke functional status 2 or less on the modified Rankin scale*, and
NIHSS score 6+, and
Presenting within:
- 6 hours, and confirmed large vessel occlusion** by CTA or MRA, or
- 24 hours, and confirmed large vessel occlusion demonstrated by CTA or MRA… only if there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume
*Slight disability, but independent in ADLs (do not require carers)
** LVO:
• Carotid T occlusion (internal carotid bifurcation occlusion)
• M1 (trunk of the MCA) or M2 (MCA branch in Sylvian fissure) occlusion
• Vertebro-basilar occlusion
b) Patients who fulfil the initial mRS and NIHSS criteria with likely large vessel occlusion
c) Yes, thrombolysis should be given as well unless contraindicated
Thrombolysis
a) indications
b) contraindications (mnemonic: ABCDEFG)
a) - Age >18
- Acute ischaemic stroke
- Presenting within 4.5 hours of symptom onset
b) A - AV malformation, aneurysm (or any neoplasm)
B - BP >185/110
C - CNS procedure/recent head trauma/recent stroke last 3/12
D - diathesis - active bleeding, PLT <100, INR >1.7, APTT raised on DOACs
E - endocarditis
F - former history of ICH at any time
G - glucose (hypoglycaemia)
Cerebellar stroke
a) Proportion of cerebellar infarcts that present with isolated vertigo
- artery affected
b) Differentiating from vestibular neuritis
c) Proportion of vertigo patients who have cerebellar stroke
a) 10% (and cerebellar infarcts make up 3% of all strokes)
- medial branch of the PICA
b) HINTS exam:
a) HI - catch up saccade when moving towards the affected ear (opposite to nystagmus direction) .
NT - unidirectional horizontal in VN (direction away from affected ear, worse when looking to away from affected ear). Bidirectional in CVA
Skew - vertical movement
- Vertigo caused by cerebellar infarction tends to cause objective ataxia, whereas vestibular neuritis patients often can walk unaided
- Vascular risk factors - previous stroke/TIA, HTN, AF, carotid stenosis
- Focal neurology, cerebellar/brainstem signs
- Total ipsilateral hearing loss - may indicate brainstem stroke/SOL
c) 3%
Timing of starting/restarting anticoagulation after acute ischaemic stroke
4 to 14 days post-stroke
Risk of haemorrhagic transformation highest in first 72 hours
TACS, PACS, PoCS and LACS
TACS (ACA + MCA): all 3 out of…
- Unilateral weakness/sensory deficit
- Homonymous hemianopia
- Higher cortical dysfunction
PACS: 2 out of 3 of the above
POCS: one out of…
- Palsy of ipsilateral CN, AND contralateral limb weakness, OR conjugate gaze palsy (brainstem)
- Only homonymous hemianopia (occipital)
- Cerebellar dysfunction - vertigo, nystagmus, ataxia
- Symmetrical deficit - bilateral sensory or motor deficit (brainstem)
- Reduced consciousness
LACS: one of the following…
- Pure motor stroke - unilateral weakness of face and/or arm and/or leg
- Pure sensory stroke
- Sensorimotor stroke
- Ataxic hemiparesis (combination of unilateral weakness and ataxia +/- other cerebellar signs)
- Dysarthria-clumsy hand syndrome
(note: there is no loss of higher cortical function as lacunar strokes are SUBcortical)
Parietal lobe syndromes
a) Dominant
b) Non-dominant
c) Bilateral occipito-parietal syndrome
a) Dominant = Gerstmann syndrome:
- Dysgraphia/agraphia: deficiency in the ability to write
- Dyscalculia/acalculia: difficulty in learning or comprehending mathematics
- Finger agnosia: inability to distinguish the fingers on the hand
- Left-right disorientation
https://www.youtube.com/watch?v=GLJdcmSIoNQ
b) - Hemineglect
- Spatial disorientation
- Can’t copy clock face
- Dressing apraxia
- Constructional apraxia
c) Balint syndrome:
- Optic ataxia (mis-reaching)
- Simultagnosia
- Oculomotor apraxia (can’t follow with eyes, has to turn head)
Barthel index
a) What does it assess?
b) 10 areas
c) Grading
a) Functional dependence post-stroke
b) Feeding, washing, grooming, dressing, bladder, bowels, toileting, transfers, walking on flat, stairs
c) 0-19 = totally dependent
20-39 = very dependent
40-59 = partially dependent
60-79 = minimally dependent
80+ = totally independent
Cortical blindness
a) Cause
b) Features o/e (including reflexes)
c) What is Anton-Babinski syndrome?
a) Cortical blindness is caused by bilateral occipital lobe damage (e.g. bilateral PCA infarct or basilar infarct)
b) - Total loss of visual acuity
- Normal eye movements if instructed where to look
- Normal pupillary and corneal reflexes
- Normal fundoscopy
- May be able to follow a moving object (Riddoch phenomenon) but usually not
Anton-Babinski syndrome:
- No insight into the blindness, complete denial
- Visual confabulation - will often describe in great detail what something looks like but this will be entirely fabricated
- May have visual hallucinations
