TRANS 065: STROKE SYNDROMES Flashcards
Most common of the Types of stroke, some textbooks says 85-87% of stroke.
ischemic
Although the Intracerebral and subarrachnoid have lower prevalence than Ischemic stroke, they have higher mortality rate. T or F?
T
TOAST Criteria?
- Large artery atherosclerosis
- Cardioembolism
- Small vessel occlusion (lacune)
- Stroke of other determined etiology
- Stroke of undetermined etiology
The Internal Carotid artery bifurcates into
ACA and MCA
The Vertebral artery merges to form the
Basilar Artery
In the top of Basilar artery we have 2 pairs.
Superior Cerebellar artery and Posterior Cerebellar Artery”
From the origin to the bottom of Sylvian Fissure is what segemetn of MCA?
M1
• Right sided weakness, face, arm>leg, sometimes hemisensory deficit
• Conjugate eye deviation to left (cortical sign towards the lesion)
• Expressive aphasia
Most of us the dominant brain is the left resulting to Broca’s area on the left. The Broca’s area is affected. Broca’s area is for speech expression becoming nonfluent aphasia. This patient have normally intact comprehension but unable to express themselves very well.”
what vessel?
LEFT MCA STROKE ANTERIOR (SUPERIOR) DIVISION
what vessel
Signs & Symptoms: • Left sided weakness: face, arm > leg • May have hemisonsory deficit • Eyes deviate to right • Neglect Neglect different from deficit. Deficit means you loss it, Neglect meaning you don't have it and you cannot pay attendtion to that. In testing the patient's arms separately, they can feel it, but when tested simultaneously the patient neglect left side of the body (extinction)." • Aprosody No emotional part of speech, the way they talk differ from their emotion. They cannot show the anger or happiness in their speech"
RIGHT MCA STROKE ANTERIOR (SUPERIOR) DIVISION
what vessek?
Signs & Symptoms:
• Right hemiparesis: mild/transient
• Right Homonymous hemianopia: Upper quadrantanopia
Optic radiation is involved. If the stroke is smaller, patient can have only quadrantanopia”
• Comprehensive aphasia (Wernicke’s aphasia/fluent/receptive aphasia)
These people are very happy and just say whatever comes to their mind spontaneously.”
LEFT MCA STROKE POSTERIOR (INFERIOR) DIVISION
what vessel?
Signs & Symptoms:
• Left hemiparesis: mild/transient
• Left homonymous hemianopia: Upper quadrantanopia
• Hemi-neglect
90% of attention comes from the right side of the brain. If you have a right posterior stroke they then to have neglect or extinction”
• Apraxia
• Delayed depression
40-50% of patient develops some sort of depression”
RIGHT MCA STROKE POSTERIOR (INFERIOR) DIVISION
Signs & Symptoms:
• Motor deficit
o Contralateral leg, distal > proximal weakenss
o Mostly spare arm and face
o Both ACAs: Paraparesis/plegia
• Sensory:
o Mild: in the affected leg
• May have other symptoms
o Mutism (patient don’t want to move or do anything)
o Akinetic mutism or aboulia
• Decreased spontaneous activity and speech
• Prolonged latency in responding to questions/directions
• Restlessness
o Hyperactivity
o Agitation
ACA
Medial temporal lobe and Occipital lobe is supplied by
PCA
Signs & Symptoms: • Contralateral Visual Field Deficits: Homonymous hemianopia or Quadrantonopia • Visual agnosia • Visual hallucination • Headache/Dizziness/Confusion
PCA
Signs & Symptoms: • Dizziness: 75% • Nausea or vomit: 50% • Ataxia, dysarthria, nystagmus: 90% • Headache (more in PICA stroke) • Incoordination/balance issue
cerebellar artery
most common cause of cardioembolims?
Afib/aflutter
they say that this is one of the most severe or most grave stroke; we can’t do anything, patient can be locked-in, meaning they block everything from the neck down.
deep basilar artery
is a rare neurological disorder in which there is complete paralysis of all voluntary muscles except for the ones that control the movements of the eyes.
locked in syndrome
waht tx? up to 4.5 hours from onset or last known well
IV Alteplase
“ when you have a large vessel stroke, IV-tPA can act very poorly; they can open the blood vessel to about maximum _____%
30%
this is a microinvasive procedure where you insert the catheter inside the artery and remove the thrombus with the device; we pull the thrombus outside the body.
Mechanical thrombectomy
for prevention of intracranial atheroscleoitc dse (stenosis)
o ASA + Plavix for 3 months then monotherapy
o Statin therapy
“ Ex. Lipitor (Athorvastatin) - continued for life unless contraindication develops
o Risk factors modification, routine exercise, healthy diet and lifestyles
prevention of embolic
Telemetry, TTE/TEE (Transthoracic Echocardiogram/Transesophageal Echocardiogram)
o Long term cardiac monitor: 30-day Holter, Loop recorder
“ or 30-day cardiac event monitor
“ loop recorder can be longer
“ loop recorders are like small microchip the size of a pinky finger implanted under the skin in the chest; it can stay there for 2-3 years and we can capture atrial fibrillation for longer time.
o Anticoagulant
“ like warfarin
Lenticulostriate arteries are from waht artery?
Lenticulostriate arteries are from the middle cerebral artery
these causes Lacunar strokes
PENETRATING ARTERIES: FROM BASILAR ARTERY & PCA
pure motor stroke?
• Common Locations o Internal Capsule o Corona radiata “ periventricular white matter o Basis pontis
Symptoms of a pure motor stroke?
• Symptoms
o Contralateral hemiplegia/paresis
o Face, arm and leg
“ face arm and leg can be equally affected compared to large vessel stroke
“ because these areas are very tight and they squeeze for example in the internal capsule, corona radiata or the pons
o Dysarthria
“ this is a long localizing sign; many diseases can cause dysarthria
o Dysphagia
“ no aphasia because it is a cortical sign
pure sensory stroke?
Thalamus
symptoms of pure sensory stroke?
• Symptoms: o Contralateral numbness, tingling o Thalamic pain syndrome “ pain that you cannot really describe and very difficult to treat o Loss of sensation o Unpleasant sensation
mixed sensorimotor stroke?
• Location: Thalamus and Internal Capsule
symptoms of mixed sensorimotor stroke?
• Symptoms:
o Contralateral hemiplegia/paresis
o Contralateral sensory loss
DYSARTHRIA-CLUMSY HAND location?
• Location:
o Upper pons
o Internal capsule
o corona radiata
DYSARTHRIA-CLUMSY HAND symptoms?
o Facial weakness o Mild weakness of hand o Hand clumsiness “ cannot do fine motor skill, very poor o Severe dysarthria
ATAXIC HEMIPARESIS
• Location:
o Internal capsule
o Basis pontis
o Corona radiata
ataxic hemiparesis symptoms?
o Ipsilateral ataxia/paresis
o Contralateral weakness and ataxia: leg more than arm
wallenburg syndrome location?
Lateral part of the medulla
wallenburg syndrome smptoms
• Symptoms: o Dysphagia o Dysarthria o Diplopia o Dizziness o Nystagmus o Nausea and vomit o Ataxia o Impaired gait
“ some of the patients have pseudobulbar palsy; they are emotionally labile; they can burst out laughing or crying for no reason
- Ipsilateral decreased pain and temperature on face
- Contralateral decreased pain and temperature sensation from body (limbs and torso))
- Ipsilateral Horner’s Syndrome (ptosis)
- Uncontrolled hiccups
\hwat vessel
Left Lateral Medullary Stroke
what syndrome
• Ipsilateral CN III palsy o Diplopia o Ptosis o Afferent papillary defect • Contralateral hemiplegia and paresis o Corticospinal o Corticobulbar
webers syndrome
Causes of lacunar stroke?
• Lipohyalinosis of small arteries
“ destructive lesion to the blood vessel wall
o Stenosis
o Occlusion
• Micro-atheroma formation at the origins of small arteries
o Stenosis or occlusion of the origins
“ sometimes the big arteries has atherosclerotic disease and the plaque already formed at the small branches; and when the plaque is big enough it occludes the origin of this artery and no more blood flow into the small arteries causing lacunar stroke
RF for lacunar stroke?
o HTN, DM, HLD (Hyperlipidemia)
Smoking
o Others: age, obesity
Tx for lacunar stroke?
• Acute Treatment:
o IV-Alteplase up to 4.5 hours from onset or last known well
“ Unlike Large Vessel Stroke Treatment, patients of Lacunar Strokes do not need Thrombectomy; it is too small to get the clot
prevention lacunar stroke?
• Prevention o ASA and Plavix for 3 weeks then daily monotherapy o Statin o Risk factors control ▪ BP <140/90 ▪ HbA1c <6.5 ▪ CHOL <200 ▪ LDL <70 o Healthy diet, lifestyle “ low salt, more vegetable, no smoking nor alcohol o Routine exercise “ current American Heart Association recommends at least 40 mins moderate intensity exercise for most days of the week; good exercises are those that make you sweat
if Px is on warfarin, give
“ if Px is on warfarin, give FFP and Vitamin K
“ if Px is on heparin, give
if Px is on heparin, give Protamine
“ if Px is on Factor Xa inhibitor or direct thrombin inhibitor like serato or eloquist, give
“ if Px is on Factor Xa inhibitor or direct thrombin inhibitor like serato or eloquist, give reversion like Centra
acute treatment for subcortical hemorrhage for BP?
• Acute Treatment
o sBP control: BP <160 x 24 hrs
acute tx for cortical or lobar hemorrhage?
• Acute Treatment
o sBP <160 x 24 hrs then <140/90
o Reverse coagulopathy
o Surgical intervention
CORTICAL/LOBAR HEMORRHAGE causes?
o Cerebral Amyloid Angiopathy
o Mass
o Vascular malformations: AVM (Arteriovenous Malformation), AVF (Arteriovenous Fistula)
prevention of CORTICAL/LOBAR HEMORRHAGE
“ depends on the causes above
“ for Cerebral Amyloid Angiopathy unfortunately we don’t have a cure, so we do supportive care and control BP; if there is recurrent bleed, controlling BP can minimize the extension (of the bleed)
“ for tumor, we have to treat
“ for AVM and AVF, we have to embolize it by surgery or by occluding it by endovascular therapy
Acute tx for subarachnoid hemm?
• Acute Treatment
o sBP <160
o Reverse coagulopathy
o Look for causes
▪ Aneurysm rupture
“ do CT angiogram or DSA (Digital Subtraction Angiography)
o Coiling embolization
“ we use catheter and pack with wire or any thin metal
“ first endovascular approach to consider
o Clipping
