Clinical Presentation of Stroke Syndromes

Report
By Ken HuiYee for PBL group 7
Case 24

Causes:
 Thrombosis & Embolism (65% of strokes)
▪ Artery-to-artery
▪ Cardioembolic
▪ Thrombosis in-situ
 Small vessel (lacunar) strokes (20% of strokes)
▪ atherothrombotic or lipohyalinotic occlusion of a small
intracranial artery
▪ Often symptomless
 Thrombus formation on atherosclerotic plaques
embolize to intracranial arteries
▪ Carotid bifurcation
▪ most common site (10% of ischaemic strokes)
 Diseased vessel may acutely thrombose
▪ Including aortic arch, common carotid, internal carotid,
vertebral, and basilar a.

Arrhythmias
 AF



Mural thrombus
DCM
Valvular lesions
 Mitral stenosis, Endocarditis, Rheumatic fever

Paradoxical embolus
 Atrial septal defect, Patent foramen ovale, Atrial
septal aneurysm

Venous sinus thrombosis
 Complication of:
▪ OCP
▪ Pregnancy & the postpartum period
▪ Inflammatory bowel disease
▪ Intracranial infections (meningitis)
▪ Dehydration


Less common (only 15% of all strokes)
Higher mortality rate than Ischaemic

Causes:
 Head trauma
▪ Most common cause of SAH
 Hypertensive haemorrhage
 Aneurysm
Spontaneous rupture
of small penetrating
artery
 Common sites:

 Basal ganglia (especially
the putamen), thalamus,
cerebellum, and pons.
 SAH from berry aneurysm
▪ AcomA, PcomA, MCA (locations from most common to
less common)
 Mycotic aneurysm
▪ Eg. Endocarditis
 Amyloid angiopathy
▪ Degen of intracranial vessels
▪ Rare in <60
 Tumour
 Drugs (eg. Cocaine)
▪ Young pts

Can’t be distinguished on basis of the history
or clinical examination

Ischaemic stroke tends to be painless
 However h/a may still occur

Haemorrhagic stroke causes h/a esp. If ICP is
raised

Investigations:
 Determine between ischaemic and haemorrhagic
 CT
 MRI
 CSF
Acute
Stuttering
Sudden onset
More likely to be
thrombotic and lacunar
onset
Neurological deficits
wax and wane
Proceeds towards
complete neurological
deficits
Abrupt neurological
deficit
 HOPC:
▪ Pt describes a shade or curtain being pulled over the
front of the eye (right)
▪ Vision in right eye is lost only for a short time (seconds
to minutes)
▪ On examination patient has carotid bruits
▪ Painless

Ddx:
 Amaurosis Fugax
▪ Central retinal artery occlusion
 Retinal migraine
▪ Develops more slowly (15 to 20mins)
 Rise in ICP
▪ Can compromise optic disc perfusion
 HOPC:
▪ Sudden onset of headache with aura
▪ Nausea and vomiting
▪ Tingling, numbness and vague weakness on the right
side of the body
▪ Patient prefers a dark room
▪ Patient reports that the aura has persisted for more than
a week.
 IX:
▪ CT and MRI show focal ischaemia

Rare complication of migraines

Definition:
 Aura and a migraine headache, with the aura
symptom persisting > 7/7
 + neuroimaging  focal ischaemia
Complete
Incomplete
Total area of the brain
supplied by an occluded
vessel is damaged
Further prophylaxis Rx
is pointless
some cellular damage
Additional tissue in the
affected vascular
distribution is at risk
Prophylaxis Rx is useful
Not that practical as distinction based on clinical
findings can be impossible

HOPC:
 A 62-year-old woman was admitted to MMC with
acute onset of left-sided hemiparesis. On
admission, she had left-sided hemiplegia and
facial palsy with minor dysarthria

IX:
 CT
▪ right MCA mainstem occlusion but no early ischemic
changes

Thrombolysis commenced  pt improved
initially but then developed sudden decline of
consciousness

Repeat CT
 Ruled out ICH

MRI
 New occlusion in Left MCA discovered

Underlying cause was due to cardioembolic
ischaemic stroke due to AF

HOPC:
 Pt presents to ED with global aphasia
 Pt’s partner reports that pt is right handed

HOPC:
 Pt presents to ED with right leg and foot paralysis
 Sensory impairment (pain, temperature) over
right lower limb
 Examination of upper limb = normal
 Impairment of gait

HOPC:
 Pt presents with homonymous hemianopia
 Has a failure to see to-and-fro movements,
inability to perceive objects not centrally located

HOPC:
 Pt presents with homonymous hemianopia
 Has a failure to see to-and-fro movements,
inability to perceive objects not centrally located
 Reports peduncular hallucinosis

Midbrain – Subthalamic -Thalamic
 Weber Syndrome
▪ Contralateral hemiplegia
 Thalamic Dejerine-Roussy
▪ Contralateral hemisensory loss
 Claude’s Syndrome
▪ Third nerve palsy Contralateral ataxia

Anton's syndrome
 Bilateral infarction in the distal PCAs producing
cortical blindness
 Pt maybe unaware of blindness and may deny it

Balint’s syndrome
 Watershed infarction between PCA and MCA
 Disorder of the orderly visual scanning of the
environment

Hypotension due to eg. AMI  low perfusion
in borderzones/junctional territories of the
cerebral end arteries

Clinical Presentation:
 “Man-in-the-barrel” clinical presentation
 Optic ataxia
 Cortical blindness
 Difficulty in judging size, distance, and movement
 Memory loss
 Dysgraphia


81 yr old man with HT and AF on
anticoagulants, right-handed
HOPC:
 h/a, diaphoresis, dizziness, diplopia
 Sudden onset of R arm tingling, numbness and
weakness
 Progressive slurred speech

Signs & Symptoms continued:
 Horizontal eye movements/conjugated gaze
restricted
 Jaw deviation to the right
 Bilateral facial weakness
▪ Difficulty wrinkling forehead or close eyes




Dysphagia
Balance issues
Cheyne-Stokes breathing
Dry oral pharynx

IX:
 CT - progressive hemorrhagic stroke intrinsic to
the pontine tegmentum of the brain stem, with
rupture into the fourth ventricle
Clinical Feature
Hemiparesis
Sensory loss
Diplopia
Facial numbness
Facial weakness
Nystagmus & vertigo
Dysphagia & dysarthria
Structure Involved
Clinical Feature
Structure Involved
Hemiparesis
Corticospinal tracts
Medial midpontine syndrome,
Medial inferior pontine syndrome
Sensory loss
Medial lemniscus and
spinothalamic tracts
Lateral midpontine syndrome
Diplopia
Oculomotor/Adducens
Medial inferior pontine syndrome
Facial numbness
Trigeminal
Lateral midpontine syndrome,
Lateral inferior pontine syndrome
Facial weakness
Facial
Lateral inferior pontine syndrome
Nystagmus & vertigo
Vestibular
Medial inferior pontine syndrome
Dysphagia &
dysarthria
Glossopharyngeal &
vagus
Medullary Syndrome
Occluded Blood Vessel
Clinical Manifestations
ICA
Ipsilateral blindness (variable)
MCA syndrome
MCA
Contralateral hemiparesis, sensory loss (arm, face worst)
Expressive aphasia (dominant) or anosognosia and spatial
disorientation (nondominant)
Contralateral inferior quadrantanopsia
ACA
Contralateral hemiparesis, sensory loss (worst in leg)
PCA
Contralateral homonymous hemianopia or superior
quadrantanopia
Memory impairment
Basilar apex
Bilateral blindness
Amnesia
Basilar artery
Contralateral hemiparesis, sensory loss Ipsilateral bulbar
or cerebellar signs
Vertebral artery or PICA
Ipsilateral loss of facial sensation, ataxia, contralateral
hemiparesis, sensory loss
Superior cerebellar artery
Gait ataxia, nausea, dizziness, headache progressing to
ipsilateral hemiataxia, dysarthria, gaze paresis,
contralateral hemiparesis, somnolence

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