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Home , Abulia, Aphasia

Stroke Syndromes

 Anterior circulation

 Lacunar syndromes

 Posterior circulation

Patricia Daly ANP Stroke NGH 9th November 2018 [email protected]

Central Nervous System Peripheral Nervous System Clinical anatomy of the allows connection between internal/external stimuli to CNS Cerebrum

 Frontal Cranial nerves & Brain Spinal cord Peripheral nerves  Temporal (heart, visceral organs, skin & limbs)  Parietal

 Occipital lobes Cerebrum Autonomic Somatic Nervous Cerebellum Grey matter: deep Nervous System System in brain: Voluntary actions Cerebellum myelinated involuntary actions fibres from •- converge •Movement Brainstem •-relays  •Midbrain sensory processes Coordinates • to cerebral cortex Sympathetic &  Pons Parasympathetic voluntary physical •Medulla •Hypothalamus- action & some homeostasis & Nervous Systems  temp regulation reflexes

Principal Motor Pathways Three major sensory tracts Corticospinal tract: Basal ganglia system: Voluntary movement and maintenance of muscle  The posterior column tract – fine touch fine/delicate movement tone , controlling propioception ,vibration. movement Primary sensory cortex on side opposite stimulus Motor commands are  delivered by: Somatic The spinothalamic tract ( lateral and anterior) pain, temperature, crude touch and pressure nervous system – directs Cerebellar system: sensations contraction of skeletal coordinates motor Primary sensory cortex on side opposite stimulus muscles. Autonomic activity  The spinocerebellar tract ( anterior and posterior) nervous system -directs the activity of glands ,smooth Cerebellar cortex primarily on side of stimulus muscle and cardiac muscle

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Type Area involved Clinical picture Broca’s Frontal lobe Non fluent speech. ( expressive) *Majority of Right Cannot repeat or write. handed Can understand well Speech produced in left frontal lobe Wernike’s Temporal / Fluent speech but aphasia(receptive) nonsensical. Cannot repeat, write or understand Frontal/temporal/parietal Non fluent speech lobes Cannot write, repeat/understand

CT Brain – Ischaemic Changes and dominance

 Right handed - dominant left cerebral hemisphere(>90%) Dominant hemisphere control language & mathematical functions

 Left handed- 50/50 dominant right/left hemisphere

Haemorrhagic Stroke Brain vasculature

2 Cerebral artery stroke syndromes Anterior circulation

Artery Area affected ACA Medial frontal.medial Contralateral weakness( parietal hip and leg) Incontinence MCA Frontal, parietal, Aphasia ,gaze deviation temporal hemiplegia ( face/arm), Sensory loss, neglect, visual field deficits PCA Medical , Memory loss confusion , much of homomonous heminiapia the thalmus

MCA Dominant MCA  Occlusion of the MCA +/- ICA can result in ischaemia  If dominant left - in both MCA and ACA territories.  Right  Right sensory loss  Approx 2/3 Ischaemic stroke occur in mca territory  Stereognosis, agraphesthesia,left right disorientation  Right HH  MCA can involve the frontal, temporal and parietal  lobes… can also include the basal ganglia  Global aphasia  Alexia, , acalulia,

Apraxia

 normal strength and sensation but unable to produce a motor pattern correctly .. Including oral apraxia

 Can occur with damage to either frontal lobe

 Prefrontal cortex- MCA territory

3 Cranial Nerve II Neurological Motor exam

 Systematically examine all of the major muscle groups  CNII- Optic carries visual impulses from the eye to the optical cortex via  Note the appearance i.e. wasted, highly developed, the optic tracts. normal  Examine eye and surrounds  Feel the tone of the muscle i.e.flaccid, clonic, normal  Acuity  Test the strength  Visual field Testing by confrontation.  Note body positioning  Near response -Pupillary constriction, convergence & accommodation of the lens (CN II & III)  Note involuntary movements  Fundoscopy

Cranial Nerves III,IV,VI

 CNIII, CN IV,CN VI- Extraocular movements in the 6 cardinal directions of gaze.  Observe for loss of conjugate movements, nystagmus, & diplopia

(monocular/binocular) CN III – pulls the eye in toward the nose and up towards the forehead and constricts the pupil ( ptsosis..drooping eye lid) large poorly reactive pupil that cannot pull in toward the nose or look up, double vision

Motor & Sensory cortex Cranial nerve VII

 CN VII Facial nerve supplies motor branches to the muscles of facial expression.  Upper and lower CNVIIth  Frown  Open eyes wide  Smile  Puff out cheeks

4 Cranial Nerve V Sensory System  CN V-Trigeminal nerve  Motor testing – temporal & sensory supply to the face and Masseter muscles motor supply to the muscles of  Clench teeth  Pain & Temp ( spinothalmic tracts) mastication.3 sensory branches  Move jaw from side to side  Position & vibration ( Posterior columns) of the trigeminal nerve: ophthalmic, maxillary and  note feeling & bulk of  Light touch ( both of the above) mandibular. muscles

 Discriminative Sensations ( depend on touch &  Test sensory branches by lightly touching the face with a piece of  Corneal reflex- not usually position) cotton wool followed by a blunt carried out  Point Localization pin in three places on each side  Two point discrimination of the face:  Recognition of size, weight, shapes and form of objects (stereognosis).  around the jawline,  Graphaesthesia  on the cheek and,  Extinction phenomenon  on the forehead.

ACA stroke syndrome Non Dominant MCA Syndrome  If R Dominant:  Contralateral leg > arm  Left hemiparesis & sensory loss paresis  L HH  Or bilateral leg weakness if both ACAs  Dysarthria are involved  Neglect  Abulia, disinhibition,  Spatial disorientation exceutive dysfunction  Apraxia

PCA stroke syndromes  Mainly involves the occipital, medical temporal lobe of thalamus

 Occipital lobe: Contralateral HH, ( bilateral lesions)

 Medical temporal lobe: deficits in long and short term memory, behaviour alteration ( anger, agitation, paranoia)

5 Posterior circulation syndromes Cerebellar stroke  Vascular territory: Superior cerebellar artery,Anterior Posterior Occipital lobe, cerebral artery thalmus,medial posterior inferior cerebellar artery temporal lobe  Ataxia, vertigo, nausea, vomiting & dysarthria  Dysdiadokinesia & . Brainstem Midbrain,Pons,  Gait disturbance and balance issues Medulla  Often & nystagmus  Can also have rapid deterioration in level of Cerebellum consciousness

Brainstem stroke syndromes sensory deficits affecting the trunk &extremities on the  Many Lateral opposite side of the infarction and medullary  Some clinical findings … crossed sensory findings ie syndrome sensory deficits affecting the face and cranial nerves on ipislateral face and contra lateral body numbness the same side with the infarct.

 Crossed motor findings ( ipislateral face , contralateral loss of pain and temperature sensation on the contralateral side of the body and ipsilateral (same) body) side of the face.  Gaze evoked nystagmus Clinical symptoms include  Ataxia and vertigo, limb dysmetria, or , dysarthria, ataxia, facial pain, vertigo nystagmus Horner's syndrome & hiccups  Diplopia and eye movement abnormalities  Dysarthria and dysphagia, tongue deviation, deafness( rare) locked in syndrome

6 Horner's syndrome

 Partial ptosis (upper eyelid drooping).

 Miosis (pupillary constriction) leading to anisocoria (difference in size of the pupils).

 Hemifacial anhidrosis (absence of sweating).

Common Lacunar Syndromes Lacunar Syndromes

 Pure Motor stroke- most common type 30-35% contralateral weakness /power loss  Symptoms may occur suddenly, progressively, or typically affects the face, arm, or leg of the side of the body opposite the location of the infarct. Dyarthria, dysphagia and transient sensory symptoms can also be present fluctuating.

 Pure Sensory stroke loss of sensation on one side of the body- can later develop  Unusually results from small vessel disease tingling, pain, burning  Deep white matter. Basal ganglia/pons  Sensiomotor stroke hemiparesis or hemiplegia with sensory impairment on the same side  Not benign

 Ataxic hemiparesis combination of cerebellar & motor symptoms, including  but true cortical signs (aphasia, visuospatial neglect, weakness and clumsiness, on the ipsilateral side of the body.[] It usually affects the leg more than it does the arm;. symptoms are often over hours or days. gaze deviation, and visual field defects) are always

 Clumsy hand, dysarthria absent in lacunar  Cause likely hypertension/diabetes but not always

Area function Clinical findings Frontal lobe Higher cortical function Contralateral weakness Tone, reflexes, plantars

Parietal lobe Prim somatosensory Sensory cortex. Spatial awareness loss,neglect,visiual field loss,wernickes aphasia Temporal lobe Medial-memory,emotions Memory impairment Lateral- hearing,vison Hearing and visual loss Occipital lobe Primary visual H Hemianopia,Visual cortex,visual spatial hallucinations, alexia awareness, colour, without agraphia perception Cerebellum Coordination of smooth Ataxia, vertigo, nausea, muscle movements vomiting * risk of obstructive hydrocephaleus in acute setting

7 brainstem Relays info from peripheries to higher centres Receives direct input from cranial nerves midbrain Nucleus of CNIII & CNIV .Top of reticular activating system ( mediates wakefulness) Motor sensory and coordination tracts Largely poorly reactive pupil that cannot pull in toward the nose or look up, double vision

Pons Contra lateral weakness and sensation issues Thank You CN VI lesion ( diplopia , cannot adduct eye) CN VII facial weakness

Medulla characterized by sensory deficits affecting the trunk Lateral medullary &extremities on the opposite side of the infarction and sensory [email protected] syndrome ( stroke) deficits affecting the face and cranial nerves on the same side with the infarct. loss of pain and temperature sensation on the contralateral side of the body and ipsilateral (same) side of the face. Clinical symptoms include or dysphagia, dysarthria, ataxia, facial pain, vertigo nystagmus Horner's syndrome & hiccups

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