Stroke localization
Dr PRAVEEN P
MD DM Neurology MRCP UK
Professor, Dept of Medicine
MCH TVM
Stroke
• CVA is the second leading cause of death in the world
• Abrupt onset of a focal neurological deficit that last more than 24 hrs
or an infarct occurrence
• TIA – recovers less than 24 hrs without infarct on imaging
• 85 % ischemic
• 15 % hemorrhagic
Types
• Large vessel anterior circulation
• Large vessel posterior circulation
• Lacunar infarcts – 20 % strokes( 30 – 300’micromt vessels or
perforators ) 4 lacunar infarct syndromes
• Pure motor hemiplegia, pure sensory stroke, ataxic hemiparesis and
dysarthria clumsy hand syndrome
When to suspect stroke
• Sudden onset
• Focal signs obeying a vascular territory
• Risk factors
Clinical approach to a patient
History
• Mode and time of onset
• Progression – peak weakness time , recovery pattern etc
• Dense or nondense / proximal or distal
• Raised ICT features
• Is it weakness or imbalance (swaying )
• Cranial nerve symptoms , sensory symptoms
• Speech – mute or slurring
• Systemic symptoms- review of systems
• Seizures , anisognosia ,
• Comorbid medical conditions that are risk factors
• Addictions , drug history
• Family history
• Sexual history – HIV
Examination
• Vitals , cvs resp , carotid bruit , peripheral pulses
• Higher functions
• Consciousness- ARAS , brainstem
• Speech tested if conscious
• A- Aphasia , anisognosia
• B – bladder incontinence
• C – cortical sensations , convulsions
• D – dense or not
• E – eye signs , gaze palsy
• Suggest cortical lesion
• Crossed dense hemiplegia – brainstem
• UMN facial palsy and Hemiplegia on same side – contralateral
corticospinal tract lesion above the pons
• Pure motor dense hemiplegia with UMN facial – IC
• Hemiparesis grade 4 power usually with severe in cordination and
finger nose impairment- ataxic hemiparesis – pons lacunar infarct
• Homonymous hemianopia – contralateral occipital lobe or retro
lentiform part of internal capsule
• Horners , cranial nerve ipsilateral and contralateral sensory or motor –
brainstem
• Spinal hemiplegia- Brown Sequard syndrome
Hemiplegia
• Cortex – nondense , cortical signs
• Internal capsule – dense
• Brainstem – crossed dense
• Spinal – Brown sequard
• Pons lacunar infarct – ataxic hemiparesis
Artery and site wise
localization
• Ophthalmic artery – ipsilateral blindness
• Anterior choroidal – C/L homo hemianopia
• MCA STEM – dense hemiplegia + aphasia / cortical signs
• MCA striate / perforators —pure motor
• MCA CORTICAL – faciobrachial+ cortical signs
• ACA – C/l crural monoplegia + urine incontinence
• Single congenital ACA – paraplegia
• Heubner’s recurrent branch of ACA – FB monoplegia
Posterior circulation
• PCA – C/l hemianopia
• Top of basilar – cortical blindness
• Basilar artery perforators – A H
• PCA perforator- pure sensory stroke
• SCA – Weber
• AICA – Lateral pontine
• Pica – lateral medullary syndrome
• Anterior spinal – medial medullary
• Vertebral - Babinskis hemimedullary
Brainstem syndromes
Midbrain
• Weber, Claude, Benedict, Perinauds
Pons
• Millard Gubler, Foville, locked in syndrome, ataxic hemiparesis
Medulla
• Medial medullary and lateral medullary syndromes
Double hemiplegia
• Multi infarct
• All 4 quadrants of face affected
• Pseudobulbar palsy (bilateral UMN lesion)
How to write diagnosis in a
stroke case
• CVA – ischemic or hemorrhagic
• Neurological deficits list
• Site of lesion
• Vascular territory
• Risk factors
• Complications
THANK YOU
