1. Dr. Meg-angela Christi Amores
Stroke Syndromes
Dr. Meg-angela Christi Amores

2. Stroke Cerebrovascular disease Stroke
ischemic stroke, hemorrhagic stroke, and cerebrovascular anomalies such as intracranial aneurysms and arteriovenous malformations (AVMs)
Stroke
abrupt onset of a neurologic deficit that is attributable to a focal vascular cause
Ischemic or hemorrhagic

3. Stroke Ischemic Stroke
Acute occlusion of an intracranial vessel causes reduction in blood flow to the brain region it supplies
A fall in cerebral blood flow to zero causes death of brain tissue within 4–10 min
values <16–18 mL/100 g tissue per min cause infarction within an hour
values <20 mL/100 g tissue per min cause ischemia without infarction unless prolonged for several hours or days

4. Ischemic stroke Ischemic penumbra
Tissue surrounding the core region of infarction that is ischemic but reversibly dysfunctional
will eventually infarct if no change in flow occurs
Fever dramatically worsens ischemia, as does hyperglycemia[glucose > 11.1 mmol/L (200 mg/dL)], so it is reasonable to suppress fever and prevent hyperglycemia as much as possible

5. Ischemic Stroke Pathophysiology
1) occlusion of an intracranial vessel by an embolus that arises at a distant site
(2) in situ thrombosis of an intracranial vessel, typically affecting the small penetrating arteries that arise from the major intracranial arteries
(3) hypoperfusion caused by flow-limiting stenosis of a major extracranial

6. Stroke Syndromes
Patient presentation can localized area of the brain affected/ blood vessel occluded
Divided into:
(1) large-vessel stroke within the anterior circulation
(2) large-vessel stroke within the posterior circulation
(3) small-vessel disease of either vascular bed

7. Stroke within the Anterior Circulation

8. Middle Cerebral Artery

9. Middle Cerebral Artery
If occluded at its origin:
contralateral hemiplegia
Hemianesthesia
homonymous hemianopia
gaze preference to the ipsilateral side
If dominant hemisphere: global aphasia
If non-dominant hemisphere: anosognosia, constructional apraxia, and neglect

10. Middle Cerebral Artery
Somatic motor area for face and arm and the fibers descending from the leg area to enter the corona radiata and corresponding somatic sensory system
Paralysis of the contralateral face, arm, and leg;
sensory impairment over the same area (pinprick, cotton touch, vibration, position, two-point discrimination, stereognosis, tactile localization, barognosis, cutaneographia)

11. Middle Cerebral Artery

12. Middle Cerebral Artery
Motor aphasia: Motor speech area of the dominant hemisphere
Central aphasia, word deafness, anomia, jargon speech, sensory agraphia, acalculia, alexia, finger agnosia, right-left confusion (the last four comprise the Gerstmann syndrome): Central, suprasylvian speech area and parietooccipital cortex of the dominant hemisphere
Conduction aphasia: Central speech area (parietal operculum)

13. Middle Cerebral Artery
Homonymous hemianopia (often homonymous inferior quadrantanopia): Optic radiation deep to second temporal convolution
Paralysis of conjugate gaze to the opposite side: Frontal contraversive eye field or projecting fibers

14. Anterior Cerebral Artery

15. Anterior Cerebral Artery

16. Anterior Cerebral Artery
anterior limb of the internal capsule, the anterior perforate substance, amygdala, anterior hypothalamus, and the inferior part of the head of the caudate nucleus
Occlusion of the proximal ACA is usually well tolerated because of collateral flow through the anterior communicating artery and collaterals through the MCA and PCA

17. Anterior Cerebral Artery
Paralysis of opposite foot and leg: Motor leg area
A lesser degree of paresis of opposite arm: Arm area of cortex or fibers descending to corona radiata
Cortical sensory loss over toes, foot, and leg: Sensory area for foot and leg
Urinary incontinence: Sensorimotor area in paracentral lobule

18. Anterior Cerebral Artery

19. Anterior Cerebral Artery
Abulia (akinetic mutism), slowness, delay, intermittent interruption, lack of spontaneity, whispering, reflex distraction to sights and sounds: Uncertain localization—probably cingulate gyrus and medial inferior portion of frontal, parietal, and temporal lobes
Impairment of gait and stance (gait apraxia): Frontal cortex near leg motor area
Dyspraxia of left limbs, tactile aphasia in left limbs: Corpus callosum

20. Stroke within the Posterior Circulation
Posterior Cerebral Artery
result from atheroma formation or emboli that lodge at the top of the basilar artery

21. Posterior Cerebral Artery
P1 Syndromes
third nerve palsy with contralateral ataxia (Claude's syndrome) or with contralateral hemiplegia (Weber's syndrome)
contralateral hemiballismus (if subthalamic n)
thalamic Déjerine-Roussy syndrome - contralateral hemisensory loss followed later by an agonizing, searing or burning pain in the affected areas

22. Posterior Cerebral Artery
P2 Syndromes
infarction of the medial temporal and occipital lobes
Contralateral homonymous hemianopia with macula sparing
acute disturbance in memory (hippocampus)
peduncular hallucinosis - visual hallucinations of brightly colored scenes and objects
infarction in the distal PCAs produces cortical blindness
Anton's syndrome – unaware of blindness and in denial

23. Basilar Artery Complete basilar occlusion :
a constellation of bilateral long tract signs (sensory and motor) with signs of cranial nerve and cerebellar dysfunction
“locked-in" state of preserved consciousness with quadriplegia and cranial nerve signs suggests complete pontine and lower midbrain infarction

24. Imaging
CT Scan
identify or exclude hemorrhage as the cause of stroke
the infarct may not be seen reliably for 24–48 h
may fail to show small ischemic strokes in the posterior fossa
MRI
reliably documents the extent and location of infarction in all areas of the brain
less sensitive than CT for detecting acute blood

25. Imaging Cerebral Angiography
"gold standard" for identifying and quantifying atherosclerotic stenoses of the cerebral arteries
used to deploy stents within delicate intracranial vessels
intraarterial delivery of thrombolytic agents

26. Primary and Secondary Prevention
General Principles
medical and surgical interventions
lifestyle modifications
Evaluation of a patient's clinical risk profile
Atherosclerosis risk factors
Older age, family history of thrombotic stroke, diabetes mellitus, hypertension, tobacco smoking, abnormal blood cholesterol [particularly, low high-density lipoprotein (HDL) and/or high low-density lipoprotein (LDL)

27. Primary and Secondary Prevention
Antiplatelet Agents
inhibiting the formation of intraarterial platelet aggregates
Aspirin, clopidogrel, and the combination of aspirin plus extended-release dipyridamole
Aspirin dose: 50–325 mg/d
Anticoagulation
For AF patients: Warfarin