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Seminar on clinical aspects of stroke
- 1. CLINICAL APPROACH TO ISCHEMIC STROKE AND RELATED ANATOMY GUIDE: Dr.Priyanka kukrele Assistant professor Dept of medicine NSCB MCH Jabalpur PRESENTED BY : Dr. Brijraj Shukla RMO in Dept. of medicine NSCB MCH Jabalpur
- 3. Cerebral ischemic stroke Definition: acute focal neurological dysfunction caused by focal infarction at single or multiple sites of the brain or retina. Evidence of acute infarction may come either from:- a) symptom duration lasting more than 24 hours b) neuroimaging or other technique in the clinically relevant area of the brain. According to WHO ICD-11
- 4. TRANSIENT ISCHEMIC ATTACK Old definition – (clinically based) Brief episodes of neurologic dysfunction <24 hours resulting from focal temporary central ischemia New definition – (tissue based) Transient episode of neurologic dysfunction caused by focal brain, spinal cord or retinal ischemia without acute infarction. According to WHO ICD-11
- 5. PROGRESSIVE STROKE •A stroke in which the focal neurological deficits worsen with time •Also called stroke in evolution COMPLETED STROKE •A stroke in which the focal neurological deficits persist and do not worsen with time. According to HARRISON
- 7. • Atrial fibrillation(17%), • Carotid disease(4%), • Others(64%) ISCHEMIC STROKE • INTRACEREBRAL ,4% • SUBARACHNOID,7% • OTHER,4% HEMORRHAGIC STROKE
- 8. EPIDEMIOLOGY Stroke is the second leading cause of death worldwide. Most common cause of severe physical disability. Stroke causing 6.2 million death in 2011. Prevalence of stroke in India is about 44.29 to 559 per 100,000. Death rate is about 1.92 per 1000. Annual incidence rate of stroke in india is 105 to 152 per 100,000 population. WHO estimates suggest that by 2050 ,80% stroke cases would occur in low and middle income countries mainly India and China.
- 10. ISCHEMIC STROKE
- 14. ARTERIAL SUPPLY OF BRAIN CIRCLE OF WILLIS Anterior Circulation Posterior Circulation
- 16. AREAS OF BRAIN SUPPLIED BY DIFFERENT ARTERIES ANTERIOR • Anterior cerebral artery • Anterior communicating artery • Anterior choroidal artery • Middle cerebral artery • Internal carotid artery • Common carotid artery POSTERIOR • Posterior cerebral artery • Vertebral artery • Posterior inferior cerebral artery • Basilar artery
- 17. Differentiating features between - anterior and posterior circulation stroke CLINICAL FEATURES ANTERIOR CIRCULATION POSTERIOR CIRCULATION A.HISTORY 1. Vertigo ABSENT PRESENT 2. Unsteadiness ABSENT PRESENT B.SIGNS 1. Crossed hemiplegia ABSENT PRESENT 2.Bilateral deficits ABSENT PRESENT 3.Cerebellar signs ABSENT PRESENT 4.Ocular findings(LMN/INO/Gaze deviation to paralysed side) ABSENT PRESENT 5.Dissociated sensory loss ABSENT PRESENT 6.Sensory loss over V1 and V2 ABSENT PRESENT 7.Horners syndrome ABSENT PRESENT
- 19. Anterior cerebral artery occlusion Clinical features 1.Contralateral a.paralysis of leg and foot with paresis of arm b.cortical sensory loss over leg and foot c.presence of primitive reflexes 2.Urinary incontinence 3.Gait apraxia 4.Mutism, delay and lack of spontaneity of motor acts 5.Apraxia of left sided limbs(with left sided lesion and corpus callosum involvement) RT RT LT LT LT RT
- 20. Internal carotid artery infarction Clinical features Variable - based on the collaterals and mechanism of stroke (embolism, extension of thrombus , low flow) 1. Amaurosis fugax 2. Watershed infarctions 3. MCA/ACA- either alone or in combinations
- 22. BLOOD SUPPLY
- 23. Middle cerebral artery occlusion - superior branch Clinical features 1.Contralateral hemiplegia – face and upper limb more involved than lower limb. 2. Contralateral hemisensory loss. 3.Conjugate gaze paresis(patient looks towards the side of lesion. 4.Broca’s dysphasia (if left sided) LT LT LT RT RT RT RT LT
- 24. Middle cerebral artery occlusion - Inferior branch Clinical features 1.Contralateral hemianopia. 2.Wernicke’s dysphasia ( if left sided ) 3.Left spatial neglect ( if right sided ) LT LT RT RT EYE FIELD
- 25. Middle cerebral artery occlusion – stem occlusion(M1) Clinical features 1.Contralateral hemiplegia 2. Contralateral hemisensory loss 3. Contralateral gaze palsy 4. Contralateral hemianopia 5.Global dysphasia (Left sided lesion) 6.Anosognosia and amorphosynthesis (Right sided lesion) 7.Altered sensorium (due to edema) RT RT LT LT
- 26. Middle cerebral artery occlusion - Lenticular striate artery occlusion Clinical features 1.Contralateral hemiparesis 2.Contralateral sensory loss 3.Transcortical motor / sensory aphasia (left sided lesion) (left sided lesion) RT LT
- 30. Lateral medullary syndrome A. IPSILATERAL 1.Xth cranial nerve palsy 2.Cerebellar signs 3.Horner’s syndrome 4.Impaired pain, temperature and touch on the upper half of face B. CONTRA LATERAL 1.Impaired pain and temperature over the body LT LT RT RT
- 31. Medial medullary syndrome A.IPSILATERAL 1.XIIth nerve palsy B.CONTRALATERAL 1.Hemiplegia – sparing the face 2.Hemianaesthesia sparing the face. RT RT LT LT
- 32. Medial pontine syndrome – occlusion of paramedian branch of basilar artery A.IPSILATERAL 1.Gaze paresis 2.Cerebellar signs B.CONTRALATERAL 1.Hemiparesis 2.Hemianaesthesia RT RT RT LT LT LT
- 33. Lateral pontine syndrome -occlusion of anterior inferior cerebellar artery A.IPSILATERAL 1.LMN VIIth nerve palsy 2.Gaze palsy 3.Deafness,tinnitus 4.Cerebellar signs B.CONTRALATERAL 1.Impairment of pain and temperature on the body LT LT LTRT RT RT
- 34. MID BRAIN
- 35. Weber syndrome-occlusion of perforating branch of posterior cerebral artery Clinical features 1.Ipsilateral a.3rd nerve palsy 2.Contralateral a.hemiplegia RT RT LT LT RT LT
- 36. Claude syndrome-occlusion of perforating branch of posterior cerebral Clinical features 1.Ipsilateral a.3rd nerve palsy 2.Contralateral a.cerebellar ataxia LT LT RTRT
- 37. Thalamus-occlusion of thalamo geniculate branches of posterior cerebral artery Contralateral 1.Sensory loss 2.Spontaneous pain 3.Choreo athetosis 4.Ataxic tremor 5.Mild hemiparesis
- 38. Occipital lobe-occlusion of left calcarine artery Clinical features 1.Right Hemianopia
- 39. Occipital lobe-occlusion of both calcarine arteries Clinical features 1.Bilateral hemianopia cortical blindness (light reflex preserved)
- 40. Basilar artery occlusion Clinical features 1.Paralysis of all four limbs 2.Bulbar paralysis 3.Eye movements abnormalities 4.Nystagmus 5.Coma Note: The neurological deficit is variable depending upon the ischemia – modifying factors
- 45. Limitations of clinical localisation of stroke syndromes 1. A single syndrome may occur due to lesion at different sites Eg. Pure motor hemiplegia 2.A vascular occlusion at a specific site can produce varying clinical manifestations. 3.Clinical examination may not detect very small or multiple infarctions(as in SBE). Note:Imaging is very useful in the above situations.
- 46. SUMMARY VASCULAR TERRITORY SYMPTOMS INTERNAL CAROTID ARTERY Hemiparesis, aphasia, hemianopsia ANTERIOR CEREBRAL ARTERY Hemiparesis,especially in lower limbs MIDDLE CEREBRAL ARTERY Upper limd hemiparesis, hemianopsia, aphasia POSTERIOR CEREBRAL ARTERY Hemiparesis, hemianopsia, ataxia, dizziness MCA/ACA- either alone or in combinations
- 48. TAKE HOME MESSAGE Importance of clinical localisation of stroke 1. Careful clinical evaluation in combination with imaging helps to find out the etiology of stroke and plan the appropriate treatment. 2. Clinical observations in correlation with imaging helps to understand neurology / neurophysiology better. Note:Neurological examination must be tailored according to the clinical scenario .
- 49. THANK YOU
Hinweis der Redaktion
- hello
- First is ischemic heart disease Combine 1+2 causes 15 million death in 2015 acc to WHO
- Brodmann area presentation…
- BILATERAL DEFICIT - difference in maximal or near maximal force generating capacity of muscles when they are contracting alone or in combination with contralateral muscles. Dissociatiated sensory loss-selective loss of fine touch and proprioception without loss of pain and tempreture or vice veirsa
- Apraxia- difficulty with motor planning to perform tasks..,,abulia-akinetic mutism/lack of will.
- Amorosis fugax- it is painless temparery loss of vision of both eyes….ophthelmic artary /ica
- 1- DUE TO MOTOR AREA INVOLVMENT OF FACE AND UPPER LIMB,,FIBRES FROM LEG CORTEX TO CORONA RADIATA. 3- FRONTAL CONTRAVERSIVE EYE FIELD 4. NONFLUENT APHASIA.
- anosognosia- deficit of self existence.. Amorphosynthesis- unaware of sometic sansations of half of body
- Lacunar infarct- deep infarcts,as a result of atherothrombotic or lipohyalinotic occlusion of perforating or penitraing arterieslacuna size is 3 mm to 2 cm. it may be present as(INTERNAL CAPSULE SYNDROMES)-1- pure motor, 2- pure sensory,3- atexic hemiparasis, 4-clumsy hand-dysarthria syndrome,.. Psuedobulbar palsy may occur after multiple lacunar infarcts…
- Balient syndrome-bilateral visual association area lesion………causes-palinopsia and asimultanagnosia,,,,,,,,,,,,anton’s syndrome—b/l distal PCA infaction causes cortical blindness(preserved pupillry reflex)
- WALLANBERG SYNDROM……. Horner syndrome also due to sympathetic tract involvement
- Contraletral- pyramidal tract and medial lemniscus
- Paresis due to lesion of corticobulbar and corticospinal tracts.
- Red nucleus involvement,,,,claude syndrome+W=B,………4. northningar 5. perinaud-dorsal midbrain
- Subthalamic nucleus involve- hemiballismus,……. Thalamic dejerine-roussy syndrome- contraleteral hemisensory loss followed later by an agonizing, searing or burning pain..relieved byanticonvulsents or TCA.