Stroke Syndromes

Question 1

Unilateral face and arm weakness, mild dysarthria; no sensory, visual, cortical dysfunction

Answer 1

Lacunar infant in posterior Internal Capsule: Pure Motor Hemiparesis (sometimes has leg too).

Question 2

Unilateral numbness, paresthesias, and hemisensory deficit involving face, arm, trunk, and leg.

Answer 2

Pure Sensory Stroke: Lacunar infarct in the ventroposteriolateral nucleus of the thalamus.

Question 3

Weakness that is more prominent in the lower extremity, along with ipsilateral arm and leg incoordination.

Answer 3

Ataxic-hemiparesis: Lacunar infarction at the anterior limb of the internal capsule.

Question 4

Hand Weakness, mild motor aphasia, NO sensory abnormalities

Answer 4

Dysarthria-clumsy hand syndrome: Lacunar stroke at the basis pontis.

Question 5

What is the principal cause of a lacunar stroke?

Answer 5

Hypertension

Question 6

Patient with h/o HTN presents with 3 hours of severe occipital headache, neck stiffness, ataxia, and nystagmus. He also has unilateral dysmetria. Diagnosis?

Answer 6

Cerebellar Hemorrhage; usually no hemiparesis.

Question 7

Patient presents in a coma by ambulance after feeling weak at home and rapidly progressing to his current state. He has pinpoint pupils and decerebrate rigidity. Dx?

Answer 7

Pontine Hemorrhage.

Question 8

Patient with h/o HTN presents with acute onset left sided hemiparesis, hemisensory loss and homonymous hemianopsia with eyes deviated to the right. dx?

Answer 8

Hypertensive hemorrhage of the Putamen and affecting the Internal Capsule.

Question 9

TPA Exclusion Criteria?

Answer 9

• Hemorrhage involving >33% cerebral hemisphere on CT.
• Stroke/trauma to head in past 3 months.
• H/o ICH, neoplasm, or AVM
• Recent head/spine surgery.
• Active bleeding or arterial puncture in 7 days.
• BP >185/110
• Platelets 1.7, PT >15).
  OTHER:
• MI in 3 months
• Pregnancy
• Major surgery/trauma w/in 14days.
• rapidly improving.

Question 10

What happens when a stroke affects the Right parietal lobe?

Answer 10

Neglect, ataxia, anosagnosia (denial of any deficit). Will likely be related issues with movement.

Question 11

What happens when a stroke affects the left parietal lobe?

Answer 11

Gerstmann Syndrome: finger agnosia, agraphia, acalculia, L/R disorientation.

Question 12

Flaccid face and arm paralysis (minimal leg involvement), Broca’s aphasia and homonymous inferior quadrantanopia. Where is the lesion?

Answer 12

Quadrantanopia suggests parietal/frontal lobe, broca’s suggests frontal lobe, face and arm suggest cortex; This is the Superior division of the MCA on the opposite side of the arm/face lesions.

Question 13

Mild Arm and face weakness, homonymous superior quadrantanopia, contralateral neglect, wernicke’s aphasia. Where is the lesion?

Answer 13

Wernicke’s suggests temporal lobe, superior quadrantanopia is optic radiation involvement (also temporal); suggests lesion is in inferior division of the MCA on the opposite side of the face/arm weakness.

Question 14

Ocular apraxia (difficulty fixating the eyes), inability to integrate a visual scene, optic ataxia.

Answer 14

Balint’s syndrome: bilateral parietal lobe strokes (watershed?).

Question 15

Patient presents with a migraine, confusion, homonymous hemianopsia with macular sparing, color anomia, agnosia, spatial disorientation; stroke type?

Answer 15

PCA Stroke. Rare - eye findings push you towards the back given macular sparing. Macula is lateral geniculate nucleus (MCA), not occipital (PCA).

Question 16

Flaccid right leg weakness, urinary incontinence, apathy, perseveration. Stroke?

Answer 16

Left ACA. Urinary incontinence should lead you hear, as should mood/personality changes.

Question 17

Patient with language issues: preserved comprehension, but difficulty with fluency, repetition, and naming. Aphasia Syndrome?

Answer 17

Broca’s.

Question 18

Patient with language issues: preserved fluency, but difficulty with comprehension, repetition, and naming. Aphasia Syndrome?

Answer 18

Wernicke’s.

Question 19

Patient with language issues: preserved comprehension and fluency, but difficulty with repetition and naming. Aphasia Syndrome?

Answer 19

Conduction; arcuate fasiculus is blocked.

Question 20

Patient with language issues: preserved repetition and fluency, but difficulty with comprehension and naming. Aphasia Syndrome?

Answer 20

Transcortical sensory.

Question 21

Patient with language issues: Preserved repetition and comprehension, but difficulty with naming and fluency. Aphasia Syndrome?

Answer 21

Transcortical Motor.

Question 22

Patient with language issues: difficulty with repetition, fluency, comprehension, and naming. Aphasia Syndrome?

Answer 22

Global aphasia.

Question 23

Patient with a right sided CNIII deficit and left sided hemiparesis. Stroke syndrome and location?

Answer 23

R sided Weber Paralysis: Midbrain stroke catching Ipsilateral CN3; Cerebral peduncle gets hit, catching contralateral motor fibers.

Question 24

Patient with left sided CNIII deficit, ataxia, and tremor. Stroke syndrome and location?

Answer 24

Left sided claude Paralysis: Midbrain stroke catching the ipsilateral CN3, and the red nucleus.

Question 25

Bendiki Paralysis; what all is involved?

Answer 25

Red Nucleus = ataxia and tremor
CN3 (ipsilateral)
Cerebral peduncle = contralateral hemiparesis.

Question 26

Patient comes in with right sided hemiparesis and loss of tactile and vibration sense as well as inability to look completely medially with nystagmus on exam. What artery is likely involved?

Answer 26

Basilar artery. This is a Medial Pontine Syndrome.
Corticospinal Tract = contralateral hemiparesis
Medial Lemniscus = contralateral loss of vibration/tactile sense
MLF = inability to look medial on affected side with gaze palsy/nystagmus
If abducens n (CN VI) is involved, there will be an ipsilateral lateral rectus paralysis, which indicates an inferior pontine lesion.

Question 27

Patient comes in with vertigo, nausea, and vomiting, and hearing loss. On exam, patient has right sided limp/gait ataxia, loss of left sided pain and temperature sensation, and decreased right sided facial lacrimation, salivation, pain, and temperature. What artery is likely involved?

Answer 27

AICA (right): This is lateral pontine syndrome.
Lateral spinothalamic tract: Contralateral pain and temp of body.
CN VII: LMN lesion of ipsilateral face, decreased lacrimation and salivation.
Spinal Trigeminal Tract: Loss of Ipsilateral face pain/temp sensation.
Vestibular nucleus: Vertigo, nystagmus, N/V
Cochlear nucleus: Hearing loss.
Middle/Inf. Peduncle: Ipsilateral limp/gait ataxia.
Descending Sympathetics are affected (Horners syndrome).

Question 28

Patient with a left sided ptosis, miosis, and anhydrosis with no ability to feel pain or temperature on his entire left side (face included) comes in complaining of nausea and vomiting. What is the syndrome and what is the artery involved?

Answer 28

Lateral Medullary Syndrome, aka Wallenberg syndrome. Its the PICA or Vertebral artery.