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 1 12/12/2019 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 2 12/12/2019 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 3 12/12/2019 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 4 12/12/2019 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 5.