ACUTE LEFT MIDDLE CEREBRAL ARTERY (MCA) STROKE WITH RIGHT HEMIPLEGIA BUT PRESERVED LANGUAGE. CT perfusion mean-transit time map showing delayed perfusion of the left MCA distribution (blue) Predicted region of infarct (red) and penumbra (green) based on CT perfusion data Conventional angiogram showing occlusion of the left internal carotid- MCA bifurcation (left panel), and revascularisation of the vessels following succesful thrombectomy 8 hours after stroke symptom onset(right panel) The clot removed with a thrombectomy device CT scan of the brain 2 days later,note the infarction in the region predicted in B but presevation of the penumbral region by successfl revascularization.
MRI OF ACUTE STROKE
My patient named Gopal, 59 years old, hailingfrom Kavoor carpenter by occupation came toGWH hospital with chief complaint of weaknessof the right side of the body since 20 days.
History of presenting illnessPatient was apparently normal 20 days back when he developedweakness over right side of the body, when he was about to goto bathroom at 7 30 am, where he suddenly felt weak and couldnot move his right side. It was sudden in onset and evolution ofparalysis was complete within 6 hours. Patient complained ofdeviation of angle of the mouth to left side during eating orspeaking and slurring of speech.No history of loss of consciousness,No history of seizures, headache or vomiting.No history of previous neurodeficit which recover completely.No history of loss of bowel and bladder control.No history difficulty in swallowing and nasal regurgitation.No history of vertigo or diplopiaNo history of fever, breathlessness, chest pain and palpitation.
Past historyNo history of DM, hypertension or seizures.No history contact with tuberculosis.Family historyNo significant family history.Personal historyPatient consume mixed diet.Sleep and Appetite normal.Normal bowel and bladder habits.History of intake of 180 ml of alcohol per for 25 years.No history of any other addictions
General physical examinationPatient is conscious , cooperative, oriented with time, place andperson.Afebrile at time of examination.No pallor, icterus, cyanosis, clubbing, lymphadenopathy andpedal edema.VitalsPR: 70/min, normal rhythm, good volume, normal character, novessel wall thickening, no radio-radial or radio-femoral delay. Allperipheral pulses felt.RR: 17/min abdomino-thoracic.BP:130/84 mmHg, right arm supine position.JVP is not raised.
Central Nervous System Examination:Higher mental function test1-Education: Patient is right handed, uneducated.2-Language: Good comprehension but slurring ofspeech is present. Able to name, repeat, read and write.3-Speech: Slurred speech4-Memory: All remote, intermediate and recent memoryare intact.5-No delusion, hallucination and illusion.
Cranial nerve examination Right LeftOlfactory nerve normal normalOptic nerve•Visual acuity Finger counting at 6m. Finger counting at 6m.•Visual field Normal Normal•Colour vision normal NormalOcculomotor, trochlear andabducens nerve•Movement of eyeball Normal Normal•Pupil-shape Normal Normal-position Central Central•Light reflex-direct Normal Normal-consensual Normal Normal•Accommodation reflex Normal NormalTrigeminal nerve•Sensory Normal Normal•Motor Normal Normal-clenching of teeth-jaw against resistance Normal Normal•Reflex-corneal reflex -jaw jerk
Cranial nerve examination Right LeftFacial nerve•No loss of nasolabial fold• Deviation angle of mouth toleft side•Orbicularis oculi•Buccinator•Frontalis Normal Normal•Taste sensation of ant. 2/3 oftongue –Vestibulocochlear nerve•Rinne’s test AC > BC AC > BC•Weber’s test Lateralized equally both sidesGlossopharyngeal and vagusnerve•Movement of uvula Central•Palatal movement Normal•Gag reflex NormalSpinal accesory nerve•shrugging of shoulder Normal Normal•Movement of neck Normal Normal
Cranial nerve examination Right LeftHypoglossal nerve•No wasting and fasciculationof tongue•No deviation of tongue
Motor system Right LeftNutrition (bulk) No wasting No wastingTone•Upper limb Hypertonic Normal•Lower limb Hypertonic NormalPower•Upper limb 2/5 5/5•Lower limb 2/5 5/5•Grip test Weak NormalCoordination Could not be tested Normal
Sensory system Right • Left• Superficial-pain-touch Normal Normal-temperature• Deep-crude touch-fine touch Normal Normal-vibration-joint sense-tactile localisation-tactile discrimination Normal Normal-position sense
Gait : Not assessedInvoluntary movement :AbsentSkull and spine :NormalMeningeal sign :No neck stiffness, Kernig’s and Brudzinki’s sign negative.Cerebellar function :Within normal limitOther system:•Respiratory system: normal vesicular breath sound, no added sound•Cardiovascular system: S1 S2 heard, no murmur•Abdominal: soft, non-tender, no organomegalyProvisional Diagnosis: Right sided hemiplegia due tocerebrovasular accident most likely of the thrombotictype, with the lesion in the left internal capsule involvingthe left middle cerebral artery.
IMAGING STUDIES• CT SCANS – identify or exclude hemorrage – Imaging modality of choice in acute stroke- because of its speed and wide availability – Identify other conditions: • Extraparenchymal hemorrages • Neoplasm • abscesses
– Ct scans obtained in the first several hours after an infarction generally shows no abnormality– Contrast enhanced CT scans : • showing contrast enhancement of subacute infarct • Allow visualisation of venous structures– CT angiography (CTA) may visualised : • Cervical and intracranial arteries • Intracranial veins • Aortic arch • Coronary arteries • Intracranial aneurysm
• MRI – Documents the extent and location of infarction – Less sensitive than CT for detecting acute blood – MR perfusion studies (gadolinium contrast iv) – MR angiography is sensitive for stenosis of extracranial internal carotid arteries and of large intracranial vessels
• Cerebral angiography – X ray cerebral angiography is the gold standard for • identifying and quantifying artherosclerotic stenoses of the cerebral arteries • Characterising aneurysm,vasospasm,intraluminal thrombi, fibromuscular dysplasia,arteriovenous fistula, vasculitis – Endovascular technique • To deploy stents within delicate intracranial vessels • To perform balloon angioplasty of stenotic lesions • To treat intracranial aneurysm by embolisation • To open occluded vessels in acute stroke with mechanical thrombotic devices
• Ultrasound – Duplex ultrasound (combination of B-mode ultrasound image with a doppler ultrasound assestment of flow velocity) • Can identified stenosis at the origin of internal carotid artery – Transcranial doppler (TCD) • Can detect stenotic lesion in the large intracranial arteries • Assist thrombolysis • Improve large artery recanalisation following rtPA administration
• Perfusion techniques – Both xenon techniques (principally xenon CT) and PET can quantify cerebral blood flow. – CT perfusion • Increase sensitivity for detecting ischemia • Can measure the ischemic penumbra – MR diffusion & MR perfusion combination • Identify the ischemic penumbra
Intravenous Recombinant Tissue Plasminogen Activator (rtPA) Indications: Contraindications- Clinical diagnosis of stroke. - Sustained BP >185/110 mmHg- Onset of symptoms to time of despite treatment. administration ≤ 3 hours. - Platelets <100,000 ; HCT <25% ;- CT scan showing no h’hage or glucose <50 or > 400 mg/dl. edema of >1/3 of the MCA - Used of heparin within 48 hrs territory. and prolonged PTT or elevated- Age ≥ 18 years. INR.- Consent by patient or surrogate. - Rapidly improving symptoms. - Prior stroke or head injury within 3 mnths ; prior intracranial h’hage. - Major Sx in preceding 14days. - Minor stroke symptoms. - GI bleeding in preceding 21 days. - Recent MI - Coma or stupor.