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- 1. Stroke Syndromes of theForebrain (SSoF) Hartmut Uschmann, MD Neurologist
- 2. SSoF What is astroke? How do strokes happen? Is stroke a common disorder? SSoF I
- 3. What is astroke? Any acute CNS injury that has a vascular cause. Ergo: stroke is not a disease, but a collection of disorders with a common cause. Stroke = I don’t know what happened to you.
- 4. How do strokeshappen? cardioembolic hypertensive ICH atheroembolic amyloid angiopathy primary ICH small vessel disease thrombophilia ISCHEMIC AVM non atherosclerotic vasculopathy intra-axial after ischemic stroke watershed infarction STROKE tumor secondary ICH coagulopathy trauma HEMORRHAGIC traumatic SAH aneurysmal EDH extra-axial SDH spontaneous traumatic
- 5. Is stroke acommon disease? USA > 700,000 new and recurrent strokes annually (500,000 new, 200,000 recurrent) 160,000 death annually Mortality declining Leading cause of disability Preventable disease !
- 6. Is stroke acommon disease? Aftermath: Leading cause for long-term disability In 1999 >1.1 million stroke survivors report difficulties with ADL’s secondary to stroke Annual recurrence rate 14% (after stroke or TIA) 22% of men and 25% of women dye w/i the first year after stroke 50-70% of stroke survivors regain functional independence 20% require institutional care at 3 month post stroke
- 7. The Burden ofStroke Exact incidence in Mississippi unknown-no stroke registry Estimate: 5000 new and 2000 recurrent strokes/year Approximately 1/3 die and 1/3 survive severely disabled Stroke: the leading cause of long-term disability
- 8. The Burden ofStroke Aftermath: Leading cause of long-term disability In 1999 >1.1 million stroke survivors nationally report difficulties with ADL’s secondary to stroke Annual recurrence rate 14% (after stroke or TIA) 22% of men and 25% of women die w/i the first year after stroke 50-70% of stroke survivors regain functional independence 20% require institutional care at 3 months post stroke
- 9. The Burden ofStroke Financial Burden: 2004: 53.6 Billion on direct and indirect cost Mean lifetime cost per patient with ischemic stroke is estimated 140,048 (in 1999 $)
- 10. SSoF I Stroke syndromes Large vessel Anterior circulation Posterior circulation Lacunar W/o localizing value With localizing value
- 11. SSoF I Predominance of lesionssites Vascular abnormailities Racial and gender related factors
- 12. SSoF I Carotid arteryand branches TMD= transient monocular blindness (disturbance) Is the only distinguishing clue between carotid vs. MCA disease May signify carotid dz. vs. aortic or trunk dz. Ischemia (A. fugax,...) Optic disc elevation, ischemia Optic nerve ischemia (meningioma…) Mechanical effects (retina…)
- 13. SSoF I Ischemic retinaldisease secondary to:
- 14. SSoF I Ischemic retinaldisease secondary to:
- 15. SSoF I Ischemic retinaldisease secondary to:
- 16. SSoF I Ischemic retinaldisease secondary to:
- 17. SSoF I Case: Patient comes in c/o R hemiparesis of sudden onset, that was associated with a brief LOC Exam findings: 2/5 R UE weakness, 3/5 R LE strength, dense, but somewhat incongruent R hemianopsia, dense R hemisensory disturbance, all modalities, patient is still somnolent
- 18. SSoF I Carotid arteryand branches Ant. choroidal artery Contralateral hemiplegia, hemisensory loss and hemianopsia (PLIC, optic tract or LGN) Field cut not typically congruent Resulting optic disc atrophy with chronic lesion Varying thalamic involvement Bilateral infarction: acute pseudobulbar state Neglect/language impairment sometimes present
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- 20. SSoF I Carotid arteryand branches ACA Rare, most often seen in vasospasm/SAH Heubner’s artery (medial lenticulostriate aa.): caudate head & ALIC infarction Abulia, acinetic mutism and other language dysfunction
- 21. SSoF I Carotid arteryand branches ACA Proximal occlusion: Leg weakness>arm weakness, but not always present (Man - in - the - barrel) Gait abnormalities (independent of weakness) Medial frontal lobe damage with behavioral changes (agitation, anxiety, memory dysfunction) Disconnect syndromes Alien hand, apraxias, anomias, grasp reflex…
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- 24. Stroke Syndromes of theForebrain (SSoF) II Hartmut Uschmann, MD Neurologist
- 25. Clinical syndromes: AIS Carotid artery and branches ICA Ophthalmic artery Anterior choroidal artery ACA Aa. of Heubner Cortical branches of ACA
- 26. Clinical syndromes: AIS Carotid artery and branches MCA Most commonly affected end-vessel “hemispheric stroke” Diversity of symptoms, depending on lesion site
- 27. Clinical syndromes: AIS Diversityof symptoms, depending on lesion site Contralateral hemiparesis Arm>Face>Leg Language dysfunction with dominant hemisphere involvement Neglect with non-dominant hemisphere involvement Apraxia syndromes
- 28. Clinical syndromes: AIS Carotid artery and branches MCA anatomy Main trunk (M1) Lateral lenticulostriate aa. (5-17) Divisions (M2) Branches (M3)
- 29. Clinical syndromes: AIS Carotidartery and branches MCA TRUNK 3mm on average, 18-26mm in length “Perforators” (lat. lenticulo-striate aa.) Supply N. lentiforme, N. caudatus, C. interna Larger perforators usually more lateral Endarteries
- 30. Clinical syndromes: AIS Carotid artery and branches MCA DIVISIONS Superior and inferior division Trifurcation Continuous vessel with consecutive branching
- 31. Clinical syndromes: AIS Sup.Division Always gives of orbitofrontal and prefrontal branches Inferior Division Always gives of temporo-polar, anterior temporal and middle temporal branches Remaining branches inconsistent
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- 37. Clinical syndromes: AIS MCA syndromes Perforator stroke (lacunar infarct) Branch Division Trunk
- 38. Clinical syndromes: AIS Perforator stroke Usually mild, uni-or bimodal No “cortical” signs Good rehab potential
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- 40. Clinical syndromes: AIS Branch occlusion (M3 stroke) Classic wedge-shaped infarct shape Symptoms depend on branch Cortical symptoms dominate Good rehab potential
- 41. Clinical syndromes: AIS Division stroke Much more severe, multimodal symptoms Higher risk for adverse events Less recovery potential
- 42. Clinical syndromes: AIS Divisionstroke: superior division Severe motor deficit, sensory variable Aphasia with dominant hemisphere, but mostly Broca’s type Neglect usually mild or undetectable Gaze preference: patient “looks at the lesion” Usually no visual field cut
- 43. Clinical syndromes: AIS Divisionstroke: inferior division Prominent field cut Minor or no motor/sensory deficits Prominent aphasia of Wernicke type with dominant hemisphere Neglect/behavioral problems (sometimes in isolation)
- 44. Clinical syndromes: AIS Trunk occlusion “malignant stroke” Very severe deficits (“MCA syndrome”) High risk for complications and death Little functional recovery, worse with higher age
- 45. Clinical syndromes: AIS Most stroke death occur from large MCA strokes Herniation syndromes
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- 47. hemorrhagic transformation and herniation
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