12/12/2019

Unusual Syndromes

December 13, 2019 Navin K. Varma, MD

Objectives

 Brief review of common stroke syndromes

 Survery of unusual stroke syndromes

 Etiology  Presentation  Localization

Common causes

 Hypertension  Tobacco use

 Carotid Stenosis  Obesity

 Coronary artery  Obstructive sleep disease apnea

 Peripheral artery  Sedantary lifestyle disease  Alcohol  A fib  Anticoagulants/

 Dyslipidemia  Antithrombotics

 Age, race, gender  Trauma

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Less well known causes I

 Drugs  Arteritis/vasculitis

 Estrogens,  Giant cell, Lupus, testosterone, , Takayasu, pseudophed, cocaine, antiphospholipid meth, radiation syndrome, polyarteritis nodosa,  Trauma rheumatoid, Bechet's,  Lay Scleroderma, primary

 Massage, yoga, hair, angiitis of CNS, strangulation lymphatoid  Medical granulamatosis  Chiropractic

Less well known causes II

 Genetic/congential  Sarcoid

 Fibromuscular dysplasia,  Buerger's (smoking) Ehlers-Danlos, Marfan's, AVM, MELAS, CADASIL,  DIC (myomas),  Snake bite, NMS Neurofibromatosis pseudoxanthoma  Polycythemia elasticum, Moya-Moya,  Thrombocythemia antithrombin III deficiency, Protein C/S  Leukemia  Amyloid, hemophilia, heriditary hemorrhagic  TTP telangiectasia  Sickle Cell

Less well known causes III

 LV thrombus  Sneddon syndrome (livedo reticularis plus  ASD v PFO stroke)  Fat emboli  Binzwanger's  Infections leucoaraiosis (ETOH)  Marantic emboli, meningitis, pharyngitis

 Paraneoplastic  No cause,  Paraproteinemia, Others, cryptogenic: 13-40% treatment/radiation

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Presentation

 Common time course  Amaurosis

 Sudden,  Headache

 Evolving over a week  TA,  Posterior,

 Stuttering  Dissection

 Progressive  SAH, SDH

  Multifocal Seizure

 Focal stenosis

Common Stroke Localization

 Anterior Circulation

 Middle cerebral artery  Anterior cerebral artery

 Posterior Circulation

 Posterior cerebral artery  Superior cellebellar artery  Inferior cellebellar artery  Basilar artery

Uncommon Stroke Localization I

 Medullary  Basilar

 Wallenberg:  Weber: Pure motor, INO

 ipslateral Horner's,  Locked In contralateral sensation to limbs, ipslateral  Tip of the Basilar

sensation to face,  Variable pupillary vertigo, nausea, response, supernuclear nystagmus, ipsilateral paresis of vertical gaze, limb ataxia ptosis or lid retraction (III), arousal disorder,  ipsilateral lower , hallucinations, hemiballisums/,  Middle medulla: , amnesia  vertigo, headache, ataxia, nystagmus

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Uncommon Stroke Localization II

 AICA: ,  SCA

Pons  Proximal: ipsilateral Horner's, ipsilateral limb  Tinnitus, N/V, ispsilateral ataxia and tremor, Horner's, ipsilateral limb contralateral body sensory, ataxia, ispsilateral VII, contralateral UMN VII'th and ispsilateral sensory face, IV'th. contralateral body sensory, deafness  Distal: headache, ataxia, dysarthria, dizzinesss, N/V

Uncommon Stroke Localization III

 PCA  Thalamic

 Cortical Blindness subthalamic:

 Positive like  posteromedial : phenomenon (TIA)  Unilatral: depression of  Visual Perseveration consciousness, (Palinopsia) neuropsychological changes, impaired  Alexia without agraphia upgaze.

 Visuospatial dysfunction  Bilateral: Above plus

 Mood disturbance (bulbar), impaired attention, , amnesia

Uncommon Stroke Localization IV

 Thalamus  Thalamogeniculate:

 Polar:  Dejerine-Roussy: mild contralateral  Left: non-fluent dysphasia, normal hemiparesis, receptive/arcuate hemianesthesia, contralateral hemiataxia,  Right: hemineglect ,

 Bilateral: acute amensia hyperaesthesia, choreoathetoid  Posterior thalamus movements

 Visual fields

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Uncommon Stroke Localization V

 Ataxic Hemiparesis  (25)

 Dysarthria-clumsy hand  Limb dyskinesia (21)  Homolateral ataxia, crural  Indifference (7) paresis  Depression (3)

(12)

 Forced laughter/crying (5)

 Alien hand, hypoalgesia, visual field loss (2 each)

Int J Clin Exp Pathol 2014;7(8):5160-5164 www.ijcep.com /ISSN:1936- 2625/IJCEP0001014

Uncommon Stroke Localization VI

 Caudate (31) 

with psychic akinesia  Tremor, Chorea, (48%) (lateral syndromes Blephrospasm,Tic, RLS more so)  Behavior (globus pallidus)  Frontal system  Cognitive and abnormalities (26%) (Putamen)  Speech (left) (23%)  Hemparesis without chorea,  Neglect (right) (10%) sensory changes, aphasia,

downloaded from HTTP://ahajournal.org December 2019 Acute hemineglect Caudate Vascular Lesions Emre Kumral, MD, PhD; Dilek Evyapan, MD, PhD; Kaan Balkir, MD

Objectives

 Brief review of common stroke syndromes

 Survery of unusual stroke syndromes

 Etiology  Presentation  Localization

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