12/12/2019
Unusual Stroke 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, triptans, Takayasu, pseudophed, cocaine, antiphospholipid meth, radiation antibody 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 Tuberous Sclerosis (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 cranial nerves, hallucinations, hemiballisums/chorea, Middle medulla: cortical blindness, amnesia vertigo, headache, ataxia, nystagmus
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Uncommon Stroke Localization II
AICA: Cerebellum, 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 Migraine like posteromedial thalamus: phenomenon (TIA) Unilatral: depression of Visual Perseveration consciousness, (Palinopsia) neuropsychological changes, impaired Alexia without agraphia upgaze.
Visuospatial dysfunction Bilateral: Above plus akinetic mutism
Mood disturbance (bulbar), impaired attention, apathy, 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 astereognosis,
Bilateral: acute amensia hyperaesthesia, choreoathetoid Posterior thalamus movements
Visual fields
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Uncommon Stroke Localization V
Ataxic Hemiparesis Corpus Callosum (25)
Dysarthria-clumsy hand Limb dyskinesia (21) Homolateral ataxia, crural Indifference (7) paresis Depression (3)
Aphasia (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) Basal ganglia
Abulia with psychic akinesia Tremor, Chorea, (48%) (lateral syndromes Blephrospasm,Tic, RLS more so) Behavior (globus pallidus) Frontal system Cognitive and dystonia 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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