The document discusses stroke, including its types, risk factors, pathophysiology, and clinical manifestations based on the artery affected. Ischemic stroke is more common than hemorrhagic and results from blockage of an artery depriving the brain of blood flow. Clinical features vary depending on the specific artery involved, such as contralateral weakness with middle cerebral artery stroke or visual field defects with posterior cerebral artery stroke. Complications can include altered consciousness, speech/language issues, and emotional or cognitive changes.

1. STROKE
SAYALI GUJJEWAR
MPT II

2. QUESTIONS
 PAPER VI
1. Clinical features of middle cerebral artery stroke. (8M)
2. Transient Ischaemic Attack. (8M)
3. Describe the blood supply of the brain and explain the investigations done for stroke. (20M)
4. Describe the clinical effects of anterior cerebral artery insufficiency. Add a note on manifestations of higher
functions. (20M)
5. List the clinical manifestations of Haemorrhagic stroke, mentioning the structures involved, resultant signs
and symptoms. Add a note on Diagnostic procedures for the same. (20M)
6. Elaborate the clinical manifestations of posterior cerebral artery infarction. Relate them to the structures
involved. (20M)
7. List the clinical manifestations of infarction of middle cerebral artery mentioning the structures involved and
resultant signs & symptoms. Add a note on diagnostic procedures for the same. (20M)
8. Discuss acute medical management of cerebro vascular accidents. (8M)

3. DEFINITION
 Stroke (cerebrovascular accident [CVA]) is the sudden loss of
neurological function caused by an interruption of the blood flow to
the brain.
REFERENCE: Physical rehabilitation / [edited by] Susan B. O’Sullivan, homas J. Schmitz, George D. Fulk. — 6th ed.

4. TYPES
 Ischemic stroke is the most common type, affecting about 80% of
individuals with stroke, and results when a clot blocks or impairs
blood flow, depriving the brain of essential oxygen and nutrients.
 Hemorrhagic stroke occurs when blood vessels rupture, causing
leakage of blood in or around the brain.
REFERENCE: Physical rehabilitation / [edited by] Susan B. O’Sullivan, homas J. Schmitz, George D. Fulk. — 6th ed.

5. EPIDEMIOLOGY
 Stroke is the second leading cause of death worldwide.
 The incidence of stroke ranged from 105 to 152/100,000 persons per
year, in India.
 Prevalence of stroke ranged from 44.29 to 559/100,000 persons in
different parts of the country during the past decade.
 These values are higher than those of high-income countries.
REFERENCE: Incidence & prevalence of stroke in India: A systematic review Sureshkumar Kamalakannan,Aashrai S. V.
Gudlavalleti, Venkata S. Murthy Gudlavalleti, Shifalika Goenka and Hannah Kuper. Indian J Med Res. 2017 Aug; 146(2): 175–185.

6. ETIOLOGY
ATHEROSCLEROSIS
 major contributory factor in cerebrovascular disease.
 characterized by plaque formation with an accumulation of lipids,
fibrin, complex carbohydrates, and calcium deposits on arterial walls
that leads to progressive narrowing of blood vessels.
 Interruption of blood flow by atherosclerotic plaques occurs at certain
sites of predilection, these generally include bifurcations,
constrictions, dilations, or angulations of arteries.
 most common sites for lesions to occur are at the origin of the
common carotid artery or at its transition into the middle cerebral
artery, at the main bifurcation of the middle cerebral artery, and at
the junction of the vertebral arteries with the basilar artery.

7. CEREBRAL THROMBOSIS
 refers to the formation or development of a blood clot within the cerebral
arteries or their branches.
 Thrombi lead to ischemia, or occlusion of an artery with resulting cerebral
infarction or tissue death.
 Thrombi can also become dislodged and travel to a more distal site in the
form of an intra-artery embolus.
CEREBRAL EMBOLUS
 composed of bits of matter (blood clot, plaque) formed elsewhere and
released into the bloodstream, traveling to the cerebral arteries where they
lodge in a vessel, producing occlusion and infarction.
 The most common source of CE is disease of the cardiovascular system.
 Occasionally systemic disorders may produce septic, fat, or air emboli that
affect the cerebral circulation.
Ischemic strokes may also result from LOW SYSTEMIC PERFUSION, the result of
CARDIAC FAILURE or SIGNIFICANT BLOOD LOSS WITH RESULTING SYSTEMIC
HYPOTENSION.

8. HEMORRHAGE
 Hemorrhagic strokes, with abnormal bleeding into the extravascular areas of the brain, are the result of
rupture of a cerebral vessel or trauma.
 Hemorrhage results in increased intracranial pressures with injury to brain tissues and restriction of distal
blood flow.
 Intracerebral hemorrhage (IH) is caused by rupture of a cerebral vessel with subsequent bleeding into the
brain.
 Primary cerebral hemorrhage (nontraumatic spontaneous hemorrhage) typically occurs in small blood
vessels weakened by atherosclerosis producing an aneurysm.
 Subarachnoid hemorrhage (SH) occurs from bleeding into the subarachnoid space typically from a saccular
or berry aneurysm affecting primarily large blood vessels.
ARTERIOVENOUS MALFORMATION (AVM)
 congenital defect that can result in stroke.
 AVM is characterized by a tortuous tangle of arteries and veins with agenesis of an interposing capillary
system.
 The abnormal vessels undergo progressive dilation with age and eventually bleed in about 50% of cases.
 Sudden and severe cerebral bleeding can result in death within hours, because intracranial pressures rise
rapidly and adjacent cortical tissues are compressed or displaced as in brainstem herniation.

9. RISK FACTORS
 Hypertension
 Heart Disease (HD)
 Disorders Of Heart Rhythm
 Diabetes Mellitus (DM)
 Elevated Total Blood Cholesterol
(Hypercholesterolemia)
 Elevated Low-density Lipoprotein (LDL
[“Bad”]) Cholesterol
 Low Levels Of High-density Lipoprotein
(HDL [“Good”]) Cholesterol
 Elevated Fasting Triglyceride Level
 Marked Elevations Of Hematocrit
 Family History, Age, Gender, And Race
(African American)
 Atrial fibrillation
 End-stage Renal Disease And Chronic Kidney
Disease
 Sleep Apnea
 Women With Early Menopause (Before 42
Years Of Age)
 Pregnancy, Birth, And The First 6 Weeks
Postpartum In Older Women And African
Americans
 Preeclampsia
 cigarette smoking
 Physical inactivity
 Obesity
 Diet
 Cardiac Disorders Such As Rheumatic Heart
Valvular Disease, Endocarditis, Or Cardiac
Surgery

10. PATHOPHYSIOLOGY
Sudden
cessation of
cerebral blood
flow
Oxygen glucose
deprivation
Neuronal death
Neuronal
activity
cessation
Infarct expands

11. release of excess
neurotransmitters
progressive
disturbance of energy
metabolism and
anoxic depolarization.
inability of brain cells
to produce energy,
particularly (ATP)
excess influx of
calcium ions
1. failure of the
neuronal membrane
2. stimulates the
release of nitric oxide
and cytokines
damage brain cells
ISCHEMIC CASCADE

12. Ischemic
strokes
cerebral
edema
elevate
intracranial
pressure
intracranial
hypertension
and neurological
deterioration

13. Vascular Syndromes
 Anterior Cerebral Artery Syndrome
 Middle Cerebral Artery Syndrome
 Internal Carotid Artery Syndrome
 Posterior Cerebral Artery Syndrome
 Lacunar Strokes
 Vertebrobasilar Artery Syndrome

14. Anterior Cerebral Artery Syndrome
 Because the anterior communicating artery
allows perfusion of the proximal ACA from
either side, occlusion proximal to this point
results in minimal deficit.
 More distal lesions produce more significant
deficits.

16. Middle Cerebral Artery Syndrome
 Occlusion of the proximal MCA
produces extensive
neurological damage with
significant cerebral edema.
 Increased intracranial
pressures typically lead to
loss of consciousness, brain
herniation, and possibly
death.

17.  The most common characteristics of MCA
syndrome are contralateral spastic hemiparesis
and sensory loss of the face, UE, and LE, with
the face and UE more involved than the LE.
 Lesions of the parieto-occipital cortex of the
dominant hemisphere (usually the left
hemisphere) typically produce aphasia.
 Lesions of the right parietal lobe of the
nondominant hemisphere (usually the right
hemisphere) typically produce perceptual
deficits (e.g., unilateral neglect, anosognosia,
apraxia, and spatial disorganization).

18. Posterior Cerebral Artery Syndrome
 Occlusion proximal to the posterior
communicating artery typically results in
minimal deficits owing to the collateral
blood supply from the posterior
communicating artery.

19.  Occlusion of thalamic branches
may produce hemianesthesia
(contralateral sensory loss) or
central post-stroke (thalamic)
pain.
 Occipital infarction produces
homonymous hemianopsia,
visual agnosia, prosopagnosia,
or, if bilateral, cortical
blindness.
 Temporal lobe ischemia results
in amnesia (memory loss).
 Contralateral hemiplegia occurs
with involvement of the
cerebral peduncle.

20. Internal Carotid Artery Syndrome
 Occlusion of the internal carotid artery (ICA) typically
produces massive infarction in the region of the brain
supplied by the middle cerebral artery.
 The ICA supplies both the MCA and the ACA.
 If collateral circulation to the ACA from the circle of
Willis is absent, extensive cerebral infarction in the areas
of both the ACA and MCA can occur.
 Significant edema is common with possible uncal
herniation, coma, and death (mass effect).

21. Lacunar Strokes
 Lacunar strokes are caused by small vessel disease deep in the
cerebral white matter (penetrating artery disease).
 They are strongly associated with hypertensive hemorrhage
and diabetic microvascular disease.
 Lacunar syndromes are consistent with specific anatomical
sites.
 Pure motor lacunar stroke is associated with involvement of
the posterior limb of the internal capsule, pons, and pyramids.
 Pure sensory lacunar stroke is associated with involvement of
the ventrolateral thalamus or thalamocortical projections.

22.  Dysarthria/clumsy hand syndrome (involving the base of the pons,
genu of anterior limb, or the internal capsule)
 Ataxic hemiparesis (involving the pons, genu of internal capsule,
corona radiata, or cerebellum)
 Sensory/motor stroke (involving the junction of the internal capsule
and thalamus), or
 Dystonia/involuntary movements (choreoathetosis with lacunar
infarction of the putamen or globus pallidus; hemiballismus with
involvement of thesubthalamic nucleus).
 Deficits in consciousness, language, or visual fields are not seen in
lacunar strokes because the higher cortical areas are preserved.

23. Vertebrobasilar Artery Syndrome
 Medial Medullary Syndrome
Occlusion of vertebral artery, medullary branch

24.  Lateral Medullary (Wallenburg’s) Syndrome
Occlusion of posterior inferior cerebellar artery or vertebral artery

26.  Complete basilar artery syndrome (locked-in syndrome)
Occlusion of Basilar artery, ventral pons

27.  Medial inferior pontine syndrome
Occlusion of paramedian branch of basilar artery

28.  Lateral inferior pontine syndrome
Occlusion of anterior inferior cerebellar artery, a branch of the basilar
artery

29.  Medial midpontine syndrome
Occlusion of paramedian branch of the mid-basilar artery
 Lateral midpontine syndrome
Occlusion of short circumferential artery

30.  Medial superior pontine syndrome
Occlusion of paramedian branches of upper basilar artery
 Lateral superior pontine syndrome
occlusion of superior cerebellar artery

31. NEUROLOGICAL COMPLICATIONS AND
ASSOCIATED CONDITIONS
 Altered Consciousness
 Disorders of Speech and
Language
 Dysphagia
 Cognitive Dysfunction
 Altered Emotional Status
 Hemispheric Behavioral
Differences
 Perceptual Dysfunction
 Seizures
 Bladder and Bowel
Dysfunction
 Cardiovascular and Pulmonary
Dysfunction
 Deep Venous hrombosis and
Pulmonary Embolus
 Osteoporosis and Fracture
Risk

32.  ALTERED CONSCIOUSNESS
 DISORDERS OF SPEECH AND LANGUAGE
o lesions involving the cortex of the dominant hemisphere (typically the left
hemisphere) demonstrate speech and language impairments.
o Aphasia is the general term used to describe an acquired communication
disorder caused by brain damage and is characterized by an impairment of
language comprehension, formulation, and use.

33. FLUENT APHASIA

34. NONFLUENT APHASIA

35. GLOBAL APHASIA

36. o Dysarthria refers to a category of motor speech disorders caused by
lesions in parts of the central or peripheral nervous system that
mediate speech production.