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stroke or cerebrovascular accident
- 1. STROKE SQN LDR DR AAMIR HUSSAIN ASSTT PROF AND MEDICAL SPECIALIST
- 2. INTRODUCTION SUDDEN WEAKNESS OF ARM,LEG OR FACE NUMBNESS CONFUSION DIFFICULTY IN SPEAKING OR UNDERSTANDING VISUAL PROBLEM DIZZINESS VOMITING HEADACHE
- 3. DEFINITION STROKE SUDDEN ONSET OF FOCAL NEUROLOGICAL DEFICIT THAT PERSISTS FOR MORE THAN 24 HOURS TRANSIENT ISCHEMIC STROKE SUDDEN ONSET OF FOCAL NEUROLOGICAL DEFICIT THAT RESOLVES WITHIN 24 HOURS
- 4. DEFINITION STROKE IN EVOLUTION FOCAL NEUROLOGICAL DEFICIT WORSENS WITH TIME COMPLETED STROKE FOCAL NEUROLOGICAL DEFICIT PERSISTS AND DO NOT WORSEN WITH TIME REVERSIBLE ISCHEMIC NEUROLOGICAL DEFICIT FOCAL NEUROLOGICAL DEFICIT FROM WHICH THE PATIENT RECOVERS WITHIN A FEW DAYS TO A WEEK
- 5. EPIDEMIOLOGY THIRD MOST COMMON CAUSE OF DEATH MOST COMMON CAUSE OF DISABILITY IN ADULTS NINETY-FIVE 95 % OF ALL STROKES OCCUR IN PEOPLE AGED OVER 65 YEARS MALES ARE MORE AT RISK OF STROKE THAN FEMALES ACCORDING TO WHO, 15 MILLION PEOPLE WORLDWIDE SUFFER A STROKE EACH YEAR 5 MILLION ARE LEFT PERMANENTLY DISABLED AND NEARLY 5 MILLION DIE
- 6. TYPES ISCHEMIC STROKE 80% THROMBUS EMBOLUS HAEMORRHAGIC STROKE 20% ANEURYSMS AV MALFORMATION INTRACEREBRAL OR SUBARACHNOID
- 7. RISK FACTORS INCREASING AGE SMOKING HYPERTENSION DIABETES MELLITUS HYPERLIPIDEMIA ALCOHOL ATRIAL FIBRILLATION HYPERCOAGULABLE STATES
- 8. ANATOMY ANTERIOR CIRCULATION STROKE(80%) OPHTHALMIC ARTERY ANTERIOR CEREBRAL ARTERY MIDDLE CEREBRAL ARTERY POSTERIOR COMMUNICATING ARTERY POSTERIOR CIRCULATION STROKE(20%) VERTEBRAL ARTERY FROM SUBCLAVIAN ARTERY PICA BASILAR ARTERY POSTERIOR CEREBRAL ARTERY
- 16. HISTORY ONSET PROGRESSION RECOVERY TIA AND RISK FACTORS LEVEL OF CONSCIOUSNESS PARALYSIS SPEECH BOWEL CONTROL BLADDER CONTROL FITS ASPIRATION MEDICATIONS
- 17. EXAMINATION NEUROLOGICAL HIGHER MENTAL FUNCTION SPEECH CRANIAL NERVES MOTOR SYSTEM SENSORY SYSTEM AUTONOMIC CARDIOVASCULAR CARDIAC CAROTIDS
- 18. PYRAMIDAL PARALYSIS/HEMIPLEGIA DYSPHSIA HEMISENSORY LOSS HEMIANOPIA CN PALSIES INCREASED REFLEXES PLANTARS ARE EXTENSORS SPASTICITY AND DRAGGING GAIT SEIZURES
- 19. FEATURES OF CEREBELLAR LESION ATAXIA NYSTAGMUS DYSARTHRIA INTENSION TREMOR PAST POINTING HYPOTONIA DYSDIADOKOKINESIA WIDE BASED GAIT PLANATRS ARE FLEXORS PARALYSIS LESS LIKELY
- 20. EXTRA PYRAMIDAL BRADYKINESIA FESTINANT GAIT RESTING TREMORS RIGIDITY PARALYSIS LESS LIKELY PLANTARS ARE FLEXORS INVOLUNTARY MOVEMENT
- 23. TIPS SPINOTHALMIC TRACTS CROSS THE MIDLINE SOON AFTER ENTERING THE SPINAL CORD DORSAL COLUMN TRACTS DO NOT CROSS IN SPINAL CORD.THEY INSTEAD CROSS IN MEDULLA OBLONGA PYRAMIDAL TRACTS CROSS IN THE MEDULLA OBLONGATA BRAIN STEM LESIONS PRODUCE CROSSED HEMIPLEGIA CEREBELLAR LESIONS PRODUCE IPSILATERAL HEMIPLEGIA CRANIAL NERVES LESIONS ARE MOSTLY IPSILATERAL CORTICAL LESIONS PRODUCE CONTRALATERAL HEMIPLEGIA
- 24. LACUNAR INFARCTION SMALL LESIONS USUALLY LESS THAN 5 MM INVOLVES ARTERIOLES IN THE BASAL GANGLIA PONS CEREBELUM INTERNAL CAPSULE THALAMUS DEFICIT PROGRESSES OVER HOURS BEFORE STABILIZING PROGNOSIS IS GOOD PARTIAL OR COMPLETE RESOLUTION OVER WEEKS
- 25. CEREBRAL INFARCTION THROMBOTIC OR EMBOLIC OCCLUSION OF MAJOR ARTERY MCA INFARCT ACA INFARCT PCA INFARCT PICA
- 26. EXAMINATION FOCUS CONSCIOUSNESS SPEECH FLUENT WITHOUT COMPREHENSION(SENSELESS) NONFLUENT WITH BROKEN SENTENCE(TELEGRAPHIC) SWALLOW CRANIAL NERVES POWER/TONE REFLEXES AND PLANTARS PRONATOR DRIFT COORDINATION GAIT
- 27. MIDDLE CEREBRAL ARTERY INFARCT HEMIPLEGIA, ON OPPOSITE SIDE/CONTRALATERAL HEMISENSORY LOSS HOMONYMOUS HEMIANOPIA EYES DEVIATION,TO THE SIDE OF LESION APHASIA/DYSPHASIA GLOBAL MOTOR/EXPRESSIVE SENSORY/RECEPTIVE
- 28. CASE SCENARIO :EXPRESSIVE APHASIA A 60-YEAR-OLD MALE IS BROUGHT TO EMERGENCY DEPARTMENT WITH SUDDEN WEAKNESS OF RIGHT SIDE OF THE BODY AND DIFFICULTY IN SPEECH.ON EXAMINATION OF RIGHT LIMBS,THE MUSCLE POWER IS REDUCED (3/5),TONE IS INCREASED,AND REFLEXES ARE BRISK WITH UPGOING PLANTAR. HE UNDERSTANDS AND OBEY THE COMMAND,BUT HE FINDS DIFFICULTY IN SPEAKING.HIS SPEECH IS HALTING AND EFFORTFUL AND INCLUDE IMPORTANT CONTENTS OF WORDS WITH OUT GRAMMAR.HE FELT DEPRESSED WITH IMPAIRED SPEECH. WHAT IS THE LIKELY PROBLEM… WHERE IS THE LESION…. WHAT IS THE LESION WHICH CIRCULATION OR ARTERY IS INVOLVED…
- 29. CASE SCENARIO: RECEPTIVE APHASIA A 60-YEAR-OLD MALE IS BROUGHT TO EMERGENCY DEPARTMENT WITH SUDDEN WEAKNESS OF RIGHT SIDE OF THE BODY AND APPARENTLY CONFUSED STATES.ON EXAMINATION OF RIGHT LIMBS,THE MUSCLE POWER IS REDUCED (3/5),TONE IS INCREASED,AND REFLEXES ARE BRISK WITH UPGOING PLANTAR. HE APPEARED TALKATIVE BUT FAILED TO UNDERSTAND AND MISINTERPRET THE COMMAND.SPEECH CONTENT LOOKED GRAMMATICAL BUT LACK SENSE AND SOME TIME USE NEW WORDS.HE APPEARED UNAWARE OF HIS SPEECH PROBLEM. WHAT IS THE LIKELY PROBLEM… WHERE IS THE LESION…. WHAT IS THE LESION WHICH CIRCULATION OR ARTERY IS INVOLVED…
- 30. ANTERIOR CEREBRAL ARTERY LIMITED WEAKNESS,MONOPLEGIA CORTICAL SENSORY LOSS Stereognosis, graphesthesia, position sense CONFUSION/MEMORY DISTURBANCE REEMERGENCE OF PRIMITIVE REFLEXES Palmomental reflex, grasp reflex URINARY INCONTINENCE
- 31. POSTERIOR CEREBRAL ARTERY HEMISENSORY DISTURBANCE THALMIC PAIN HEMIPARESIS
- 32. WEBER’S SYNDROME: MIDBRAIN STROKE A 60-YEAR-OLD FEMALE IS PRESENTED TO EMERGENCY DEPARTMENT WITH WEAKNESS OF LEFT SIDE OF BODY ,DIPLOPIA AND DROPPING OF RIGHT EYE. ON EXAMINATION OF LEFT LIMBS,THE MUSCLE POWER IS REDUCED (3/5),TONE IS INCREASED,AND REFLEXES ARE BRISK WITH UPGOING PLANTAR. THE RIGHT EYE HAS A COMPLETE PTOSIS.THE EYE BALL IS DOWN AND OUT.THE PUPIL IS FULLY DILATED AND NON REACTIVE TO LIGHT OR ACCOMODATION. WHAT IS THE LIKELY PROBLEM… WHERE IS THE LESION…. WHAT IS THE LESION WHICH CIRCULATION OR ARTERY IS INVOLVED…
- 33. PICA /LAT MED SYNDROME /WALLENBERG IPSILATERAL SPINOTHALAMIC SENSORY LOSS FACE V CN X CN IPSILATERAL LIMB ATAXIA IPSILATERAL HORNER SYNDROME CONTRALATERAL SPINOTHALAMIC SENSORY LOSS OF LIMBS
- 34. WALLENBERG’S SYNDROME: LATERAL MEDULLARY SYNDROME A 65-YEAR-OLD MALE IS PRESENTED TO EMERGENCY DEPARTMENT WITH ACUTE ONSET OF VOMITING,VERTIGO AND UNSTEADINESS WITH TENDENCY TO FALL ON RIGHT SIDE.HE ALSO COMPLAINTS OF DIPLOPIA ,DYSPHAGIA AND DYSARTHRIA. ON EXAMINATION,HIS MUSCLE POWER IS ALMOST NORMAL WITH NORMAL REFLEXES AND EQUIVOCAL PLANTARS,BUT HAS ATAXIA ON RIGHT SIDE. HE HAS PARTIAL PTOSIS AND A CONSTRICTED PUPIL OF RIGHT EYE.NYSTAGMUS IS NOTED IN BOTH EYES HE HAS LOSS OF PAIN AND TEMPERATURE SENSATION OVER RIGHT FACE AND LEFT SIDE OF BODY. AAH TEST AND GAG REFLEX WERE ABSENT.
- 35. BASILAR ARTERY OR BOTH VERTEBRAL ARTERIES COMA WITH PINPOINT PUPIL FLACCID QUADRIPLEGIA LOCKED-IN SYNDROME SENSORY LOSS VARIABLE CN PALSIES
- 36. CEREBELLAR ARTERIES VERTIGO NAUSEA VOMITING NYSTAGMUS IPSILATERAL LIMB ATAXIA CONTRALATERAL SPINOTHALAMIC SENSORY LOSS
- 37. ANTERIOR VS POSTERIOR CIRCULATION STROKE CLINICAL FEATURES POSTERIOR CIRCULATION (VA,BA,PCA) ANTERIOR CIRCULATION (MCA,ACA) VERTIGO AND UNSTEADINESS YES NO VOMITING YES NO CROSSED HEMIPLEGIA YES NO BILATERAL DEFICIT YES NO CEREBELLAR SIGNS YES NO HORNER’S SYNDROME YES NO DISSOCIATED/ CROSSED SENSORY LOSS YES NO DIPLOPIA/ III CN PALSY YES NO APHASIA NO YES
- 38. SIMPLIFIED CLASSIFICATION OF STROKE OXFORD CLASSIFICATION OR BAMFORD CLASSIFICATION THREE IMPORTANT FEATURES IN ANTERIOR CIRCULATION 1. HEMIPLEGIA 2. HEMIANOPIA 3. APHASIA IMPORTANT FEATURES IN POSTERIOR CIRCULATION 1. CEREBELLAR 2. BRAINSTEM( CRANIAL NERVE PALSY) 3. VERTIGO/VOMITING 4. HORNER’S SYNDROME
- 43. INVESTIGATIONS 1. NON CONTRAST CT SCAN BRAIN TO R/O HAEMORRHAGE MRI BRAIN WITH DIFFUSION WEIGHTED SEQUENCE FOR DISTRIBUTION AND EXTENT OF INFARCT OR TO R/O OTHER CAUSES CT ANGIOGRAPHY HEAD AND NECK MR ANGIOGRAPHY CAROTID DUPLEX ULTRASONOGRAPHY TRANSCRANIAL DOPPLER ULTRASONOGRAPHY CONVENTIONAL CATHETER ANGIOGRAPHY ECHOCARDIOGRAPHY TRANSTHORACIC TRANSOESOPHAGEAL ECG CXR
- 44. CASE SCENARIO A 30-YEAR-OLD MALE IS BROUGHT TO EMERGENCY DEPARTMENT WITH SUDDEN SEIZURE AND LOSS OF CONSCIOUSNESS. HIS FRIENDS INFORMED ABOUT SUDDEN SEVERE HEADACHE AND VOMITING BEFORE HE LOST HIS CONCIOUSNESS. ON EXAMINATION, HE IS HYPERTENSIVE WITH BP 220/140 HIS NECK IS STIFF AND DEMONTRATED POSITIVE KERNIG’S SIGN. HIS LEFT PUPIL IS FULLY DILATED PLANTARS ARE UPGOING PATIENT DIED AFTER 2 HOURS.
- 50. INVESTIGATIONS 2. BLOOD CP AND PLAT BLOOD SUGAR LIPID PROFILE PT/INR PTTK(APTT) THROMBIN TIME
- 51. HYPERCOAGULABLE STUDIES 3. PROTEIN C PROTEIN S ANTITHROMBIN III LUPUS ANTICOAGULANT ANTICARDIOLIPIN ANTIBODIES FACTOR V LEIDEN HOMOCYSTEINE
- 52. STROKE MIMICS SEIZURES POSTICTAL TODD’S PARESIS ASSOCIATION HYPOGLYCEMIA SYNCOPE MIGRAINE FUNCTIONAL/CONVERSION DISORDER NO DEFINITE PATTERN ANXIETY/DEPRESSION/PANIC HOOVER’ TEST BRAIN TUMOURS METABOLIC ENCEPHALOPATHY
- 53. THANKS