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.

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Arrhythmias
 AF
Mural thrombus
DCM
Valvular lesions
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 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

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Less common (only 15% of all strokes)
Higher mortality rate than Ischaemic

 Causes:
 Head trauma
▪ Most common cause of SAH
 Hypertensive haemorrhage
 Aneurysm

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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
 Sudden onset
 Abrupt neurological deficit
Stuttering
 More likely to be thrombotic and lacunar onset
 Neurological deficits wax and wane
 Proceeds towards complete neurological deficits

 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:
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Aura and a migraine headache, with the aura symptom persisting > 7/7
+ neuroimaging  focal ischaemia

Complete
 Total area of the brain supplied by an occluded vessel is damaged
 Further prophylaxis Rx is pointless
Incomplete
 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

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IX:
 CT
▪ right MCA mainstem occlusion but no early ischemic changes
Thrombolysis commenced  pt improved initially but then developed sudden decline of consciousness

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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

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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

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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
Hemiparesis
Sensory loss
Diplopia
Facial numbness
Structure Involved
Corticospinal tracts Medial midpontine syndrome,
Medial inferior pontine syndrome
Lateral midpontine syndrome Medial lemniscus and spinothalamic tracts
Oculomotor/Adducens Medial inferior pontine syndrome
Trigeminal Lateral midpontine syndrome,
Lateral inferior pontine syndrome
Facial weakness Facial
Nystagmus & vertigo Vestibular
Dysphagia & dysarthria
Glossopharyngeal & vagus
Lateral inferior pontine syndrome
Medial inferior pontine syndrome
Medullary Syndrome

Occluded Blood Vessel
ICA
MCA
ACA
PCA
Basilar apex
Basilar artery
Vertebral artery or PICA
Superior cerebellar artery
Clinical Manifestations
Ipsilateral blindness (variable)
MCA syndrome
Contralateral hemiparesis, sensory loss (arm, face worst)
Expressive aphasia (dominant) or anosognosia and spatial disorientation (nondominant)
Contralateral inferior quadrantanopsia
Contralateral hemiparesis, sensory loss (worst in leg)
Contralateral homonymous hemianopia or superior quadrantanopia
Memory impairment
Bilateral blindness
Amnesia
Contralateral hemiparesis, sensory loss Ipsilateral bulbar or cerebellar signs
Ipsilateral loss of facial sensation, ataxia, contralateral hemiparesis, sensory loss
Gait ataxia, nausea, dizziness, headache progressing to ipsilateral hemiataxia, dysarthria, gaze paresis, contralateral hemiparesis, somnolence