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Definition of Stroke/Brain Attack

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Definition of Stroke/Brain Attack Definition of Stroke/Brain Attack Stroke II: • A syndrome caused by disruption in the flow of Diagnosis, Evaluation, and Prevention blood to part of the brain due to either: – occlusion of a blood vessel • ischemic stroke Lenore N. Joseph, MD – rupture of a blood vessel Neurology Service Chief, McGuire VAMC • hemorrhagic stroke Assistant Professor of Neurology • The interruption in blood flow deprives the brain VCU Health System of nutrients and oxygen resulting in injury to cells Medical College of Virginia in the affected vascular territory of the brain 1 2 Stroke: The Problem Stroke: The Problem • Third leading cause of death in US • Among 6 month or longer survivors: – after heart disease and cancer – 48% have a hemiparesis • 740,000 new strokes each year – 22% cannot walk • 4.5 million stroke survivors – 24-53% report complete or partial • Leading cause of disability in adults in US dependence for activities • $45.5 billion per year in the USA – 12-18% are aphasic • 1 of 6 Americans will be affected – 32% are clinically depressed – only 10% fully recover 3 4 Symptoms of Brain Attack: Symptoms of Brain Attack: Teach your patients! Teach your patients! • Sudden weakness, paralysis, or numbness of: • Sudden unexplained dizziness –face – especially when associated with other – arm and the leg on one or both sides of the neurologic symptoms body – unsteadiness • Sudden loss of speech, or difficulty speaking or – sudden falls understanding speech • Sudden severe headache and/or loss of • Sudden dimness or loss of vision consciousness – particularly in only one eye 5 6 1 Ischemic Stroke Risk Factors: Ischemic Stroke Nonmodifiable • Most common stroke type • Older age – 85% of all strokes • Male sex • 65% of 1st time strokes •Race • Genetic factors 7 8 Ischemic Stroke Risk Factors: Ischemic Stroke Risk Factors: Modifiable Modifiable • Hypertension • Cigarette smoking – increases risk 6-8 times above baseline – RR =1.5 population • Asymptomatic carotid artery stenosis – even “borderline” HTN is associated with • Physical inactivity increased risk of stroke • Diabetes mellitus • Controlling HTN is the single most important – RR+1.5 - 3 measure to be taken in decreasing the risk of stroke • Elevated cholesterol • Prior TIA • Cardiac risk factors – Afib, etc. 9 10 Ischemic Stroke Risk Factors: Modifiable/Putative • Elevated • Infection Is it a stroke? homocysteine – chlamydia • Migraine – pneumonia • Oral contraceptives • Hypercoagulable states • Obesity • Systemic inflammation/ • Alcohol abuse connective tissue •Stress disorders • Sleep apnea • Sympathomimetic • Illegal drug use medications 11 12 2 Stroke Syndromes by Location: NINDS Classification: Ischemic Strokes Middle Cerebral Artery (MCA) • Clinical • Arterial territory – atherothrombotic – internal carotid – cardioembolic – middle cerebral – lacunar – anterior cerebral – vertebral • Mechanism – basilar – thrombotic – posterior cerebral – embolic – hemodynamic 13 14 Stroke Syndromes by Vascular Territory: MCA Stroke Syndromes by Location: MCA • Complete • Contralateral face=arm>leg paralysis • Superior division • Contralateral cortical and primary sensory • Inferior division impairment • Gerstman Syndrome –face – agraphia - inability to write – arm – acalculia - inability to calculate –leg – right-left confusion – finger agnosia - inability to recognize fingers • ideomotor apraxia may be associated • Ataxic hemiparesis 15 16 Stroke Syndromes by Location: MCA Stroke Syndromes by Location: MCA • Language disorders: • Anosognosia - ignorance of deficit – aphasia – unilateral neglect – alexia – constructional apraxia – agraphia – abnormal spatial localization • cortical signs c/w dominant hemisphere • cortical signs c/w nondominant hemisphere involvement involvement 17 18 3 Stroke Syndromes by Vascular Territory: Large Vessel Ischemic Stroke Anterior Cerebral Artery (ACA) • MCA territory distribution stroke due to critical stenosis of the right internal carotid artery 19 20 Stroke Syndromes by Location: Stroke Syndromes by Location: ACA Posterior Circulation • Contralateral foot and leg paralysis • Contralateral “cortical sensory” impairment of the lower extremity • Extreme apathy (abulia) especially in bilateral lesions • Gait apraxia or “cerebral paraplegia” in bilateral lesions with injury to the corpus callosum 21 22 Stroke Syndromes by Location: Stroke Syndromes by Vascular Territory: Posterior Cerebral Artery (PCA) PCA • Homonymous hemianopsia • Balint Syndrome – due to ischemia of the calcarine cortex – loss of voluntary but not reflex eye movements – usually with macular or the optic radiation – optic ataxia • Cortical blindness – asimultagnosia – bilateral homonymous hemianopsia • unable to understand visual objects as a whole – may see Anton’s syndrome: visual confabulation • Alexia without agraphia • Thalamic syndromes • Weber Syndrome (Midbrain) – sensory loss or spontaneous pain/dysaesthesias – weakness contralateral upper and lower extremity or movement disorders – ipsilateral gaze palsy (CN3) • chorea/tremor 23 24 4 Stroke Syndromes by Vascular Territory: Stroke Syndromes by Location: PCA Posterior Circulation Patient with alexia w/o agraphia 25 26 Stroke Syndromes by Vascular Territory: Stroke Syndromes by Vascular Territory: Posterior Circulation Basilar Branch • Hallmarks of brainstem/cerebellum involvement: • Anterior Inferior Cerebellar Artery – diplopia • Lateral pontine syndrome - Marie-Foix Syndrome – Ipsilateral cerebellar ataxia due to involvement of – vertigo cerebellar tracts (middle cerebellar peduncle) – ataxia – Contralateral hemiparesis due to corticospinal tract – nystagmus involvement – Variable contralateral hemihypesthesia for pain and temperature due to spinothalamic tract involvement • Posterior inferior cerebellar artery • Lateral medullary syndrome - of Wallenberg – ipsi pain and numbness, esp on the face – ipsilateral limb ataxia, vertigo, nausea, nystagmus, 27 dysphagia, Horner syndrome 28 Stroke Syndromes by Vascular Territory: Stroke Syndromes by Vascular Territory: Basilar Branch/Penetrators Vertebral Artery • Locked-in Syndrome • Lateral Medullary syndrome - of Wallenburg • Lateral pontine syndrome - Marie-Foix Syndrome • Medial medullary syndrome - Dejerine Syndrome • Ventral pontine syndrome - Raymond Syndrome • May also be seen with anterior spinal artery involvement • Ventral pontine syndrome - Millard-Gubler – rare stroke syndrome (<1% of vertebrobasilar strokes, Syndrome Bassetti et al., 1994) – medial medullary infarct is associated with clinical • Inferior medial pontine syndrome - Foville Syndrome triad of ipsilateral hypoglossal palsy, contralateral • Ataxic Hemiparesis hemiparesis, and contralateral lemniscal sensory loss • Cortical blindness - Anton Syndrome – variable manifestations may include isolated • Medial medullary syndrome hemiparesis, tetraparesis, ipsilateral hemiparesis, I or C facial palsy, ataxia, vertigo, nystagmus, dysphagia • See www.strokecenter.org for details – palatal and pharyngeal weakness rare in pure MMI, 29 common in lateral medullary infarct 30 5 NINDS Classification: Ischemic Strokes Large Vessel Ischemic Stroke • Clinical • Arterial territory • The large extracranial and intracranial arteries – atherothrombotic/ – internal carotid are predisposed to atherosclerotic large vessel ischemia – middle cerebral narrowing/occlusion – cardioembolic – anterior cerebral • Bifurcations are common sites: – lacunar – vertebral – internal carotid artery at the bulb – basilar – vertebral and basilar arteries • Mechanism – posterior cerebral – middle cerebral arteries – thrombotic – embolic – hemodynamic 31 32 Large Vessel Ischemic Stroke: Large Vessel Ischemic Stroke: Mechanisms Mechanisms • Artery to artery embolism • Normal carotid – plaque/thrombus from a proximal artery becomes bifurcation dislodged, travels distally, and obstructs a • Stenosis of the ICA smaller segment or branch of the artery will usually produce • Thrombosis stroke syndromes – propagation of thrombus along arterial wall until referable to the the vessel is occluded or critically stenosed middle cerebral • Hypoperfusion artery territory – through a critical arteriosclerotic stenosis affecting the territory of that artery 33 34 Large Vessel Ischemic Stroke Large Vessel Ischemic Stroke • MCA territory distribution stroke due to critical stenosis of the right internal carotid artery Doppler study of the right internal carotid artery showing 80% stenosis near the origin (in the bulb) 35 36 6 Cardiac Embolism Cardiogenic Embolism • Among the most devastating of the stroke types • Atrial Fibrillation • Least likely to present with prior transient • Acute Myocardial ischemic attacks Infarction • Most likely to recur if patient is not adequately • Valvular disease prophylaxed for subsequent events – mitral and aortic valves • Cortical, rather than deep white matter, strokes • Dilated cardiomyopathy predominate • Intracardiac tumors – atrial myxoma • Intracardiac defects 37 38 Atrial Fibrillation (AF) Incidence of Stroke • Most common cardiac arrhythmia and affecting • Incidence of stroke associated with AF 1% of the population increases with age • Prevalence increases with increasing age Stroke Rate Age Group • Relatively infrequent in those under 40 years old (percent per year) (years) • occurs in upwards of 5% of those over 80 years 1.3 50-59 of age 2.2 60-69 4.2 70-79 5.1 80-89 Circulation 2002;106:14; Arch Intern Med 1987;147:1561 39 Wolf et.al, Stroke 1991;22:983 40 Risk of Stroke in AF: Other Studies Cardiogenic Embolism • Once you
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