ISCHAEMIC STROKES
MCA Stroke (Middle Cerebral artery)
Localization: middle cerebral artery - middle part of pre-central gyrus of frontal lobe–
causes contralateral motor sx.
Broca’s area – found in left inferior frontal gyrus
Wernicke’s area – left posterior superior temporal gyrus
Supplies Post. Limb of internal capsule, basal ganglia, frontal, parietal and temporal
lobes
Symptoms/signs:
Arm>leg weakness
Tingling paraesthesia
Visual field cut
Global Aphasia – Brocha speech damage (if damage on the left side only)
Wernicke area damaged
Brachofacial hemiparesis
Contralateral homonymous hemianopsia
Acute phase = turning of head to the opposite side as well as fixed gaze deviation to
opposite side
CNVII/CNXII affected
Diagnostic test: CT scan = gold standard
Differential Dx: intracerebral haemorrhage, subarachnoid haemorrhage
Treatment:
Thrombolytics (warfarin, anticoags), thrombectomy
CASE example
A 75-year-old man presents with recent onset loss of movement of his right arm. The right
side of his face also droops and there is drooling from the corner of his mouth on the right
side. He has difficulty speaking
- L. sided lesion
CASE 19 (case 4)
68-year-old woman has hypertension and Diabetes mellitus, she has weakness in her right
arm and face and this afternoon her husband said that she had drunken speech-dx MCA
stroke left side
CASE example
26yo woman, admitted to hospital, confused with CNVII and CNXII palsy in contralateral
hemianesthesia and hemiplegia. She had a hx. of TIA
CASE example
52 yo woman, hx. of TIA, one sided face drooping, HTN, neural exam 7/12 palsy. Right sided
hemiparesis and hemiplegia
CASE example
83yo woman, hx. of HTN/dyslipidaemia developed acute onset of impaired speech and
comprehension and [Link] weakness, her prev. medical hx was notable for
hyperthyroidism and a curative remote mastectomy for breast cancer, the pt. was on 2
antihypertensive medication and a statin and she was not receiving and antiplatelet med.
She was taken by ambulance to a primary stroke centre, initial exam shows global aphasia,
right homonymous hemianopia, right hemiplegia and hemisensory loss.
Main sx.
- Global aphasia
- Facial dropping
- homonymous hemianopia
- hemiplegia
- hemianesthesia
Lacunar Stroke
Associated with diabetes and smoking – type of MCA
Localization: occlusion of a single small perforating artery supplying the subcortical areas of
the brain – deep cerebral white matter, basal ganglia or pons
Diagnostic test: CT scan = gold standard
Treatment: Ischaemic (occlusion of artery)– antithrombotic therapy (warfarin, anticoags),
thrombectomy
ACA Stroke
Localization: upper part of pre-central gyrus of the frontal lobe
Damage to: occlusion of anterior cerebral artery (plaque/thrombus) or aneurysm in anterior
communicating artery
Symptoms/Signs:
Leg>arm
Hemiparesis/hemiplegia of contralateral leg, or if bilateral, paraparesis/paraplegia –
depends on where occlusion is
Diagnostic test: CT scan with angiography
Differential Dx: ischaemic stroke, subarachnoid haemorrhage, dementia
Treatment:
Thrombolytics (warfarin, anticoags), thrombectomy
CASE example
A 75-year-old man presents with acute loss of ability to move his right hip and leg. On exam,
he has decreased sensation to pinprick and vibration of his right leg
PCA (posterior cerebral artery) Stroke
Localization: posterior portion of the brain – reducing blood flow to occipital lobe, Visual
cortex damage
Occlusion of the PCA – supplies occipital lobe , calcarine artery occlusion – visual
cortex
Symptoms:
Visual hallucinations
Visual agnosia – seeing things but can’t recognise
Signs:
Midbrain syndrome – Weber’s (CNIII peripheral palsy, contralateral central
hemiplegia)
Visual defects can occur e.g contralateral homonymous hemianopsia due to
calcarine artery occlusion Or quadrantanopia/ scotoma can occur.
Diagnostic test: CT scan = gold standard
Differential Dx: intracerebral haemorrhage, subarachnoid haemorrhage
Treatment: Thrombolytics (warfarin, anticoags), thrombectomy
CASE example
An 80-year-old man presents with acute visual loss. He reports difficulty seeing objects on
his right side. His wife said he also reports seeing people who are not in the room. On exam,
there are no motor or sensory deficits. Visual fields are shown below (black = no vision)
Main sx.
- Oculomotor
- Hallucinations
Superior cerebellar artery Stroke
Localization: Superior cerebellar artery
Supplies midbrain/superior cerebellum
Symptoms/signs:
Severe ataxia – cerebellum ataxia
Astasia – lack of motor coordination, inability to stand /sit
Abasia – inability to walk
Sensory deficit same side of face, sensory deficit opposite half of body
Horner’s syndrome
Diagnostic test: CT scan = gold standard
Damage to: SCS
Differential Dx: intracerebral haemorrhage, subarachnoid haemorrhage
Treatment: Thrombolytics (warfarin, anticoags), thrombectomy
AICA Stroke
Localization: occlusion of anterior inferior cerebellar artery
Supplies pons/cerebellum
Damage to: CNVII/CNVIII
Symptoms/sign:
Ipsilateral hemiataxia – on one side of body (lack of coordination)
Nystagmus on side of lesion (ipsilateral)
CNVII/CNVIII deficits – sudden deafness/hearing loss on side of lesion, facial paralysis
Contralateral – pain, temp, sensory loss
Vertigo, nausea, vomiting, intolerance to head motions
HORNERS syndrome observed
o Miosis, ptosis, anhidrosis
Diagnostic test: CT scan = gold standard
Differential Dx: : intracerebral haemorrhage, subarachnoid haemorrhage
Treatment: Thrombolytics (warfarin, anticoags), thrombectomy
Main sx.
- Sudden deafness/hearing loss
- Horner’s – miosis, ptosis, anhidrosis
Horner’s syndrome
= rare condition resulting from disruption of sympathetic nerves supplying eye
Localization:
Compression/disruption of sympathetic ganglion
Lesion along sympathetic pathway
Central, pre-ganglionic or post-ganglionic
Usually result of tumour, spinal cord injury or stroke
Symptoms/signs:
TRIAD
Partial ptosis = dropping of eyelid
Miosis = constriction of pupil
Anhidrosis = loss of sweating
Diagnostic test: observation of signs
Damage to: sympathetic ganglion pathway
Differential Dx: neuroblastoma, argyll-Robertson
Treatment:
Depends on lesion location – surgical removal or chemo/radiotherapy
PICA Stroke
Localization: posterior inferior cerebellar artery
supplies cerebellum and choroid plexus of fourth ventricle
Damage to: CNV, CNX and CNXII
Symptoms/signs:
Wallenberg’s syndrome is observed
Dysarthria, same sided limb ataxia
Same side Horner’s
Same side sensory loss – pain/temp of face
Opposite sensory loss – pain/temp limbs and trunks
Same side laryngeal/pharyngeal paralysis
Vertigo, nystagmus
Hoarseness, dysphagia and loss of gag reflex
Diagnostic test: CT scan = gold standard
Differential Dx: intracerebral haemorrhage, subarachnoid haemorrhage
Treatment: Thrombolytics (warfarin, anticoags), thrombectomy
Main sx.
- Dysarthria
- Hoarseness
- Dysphagia
- Loss of gag reflex
Basilar artery Stroke
AKA locked-in syndrome or ventral pontine syndrome
Localization: basilar artery and its branches – superior cerebral arteries, pontine branches,
circumferential branches
Symptoms:
Paralysis of all four limbs = quadriplegia
Bulbar paralysis
Eye movement abnormalities
Nystagmus
Coma
Signs:
Pt. is quadriplegic, muted but can blink eyes
Diagnostic test: CT scan = gold standard
Differential Dx: intracerebral haemorrhage, subarachnoid haemorrhage
Treatment: Thrombolytics (warfarin, anticoags), thrombectomy
Main sx.
- Locked in syndrome
- Coma
- Mute
- Can’t hear
Transient ischemic attack (TIA)
Localization: Most common in middle cerebral artery – reduce blood flow through vessel
However localisation depends on where infarction is
Symptoms/signs: <24hrs = transient neurological deficits (usually <30mins)
Sudden weakness on one side of body (contralat)
Sudden numbness on one side of body (contralat)
Sudden difficulty with speech
Sudden loss of vision (particularly in 1 eye)
Sudden severe dizziness
Sudden severe headache
Diagnostic test: CT scan = gold standard
Damage to: MC = middle cerebral artery
Differential Dx: intracerebral haemorrhage, subarachnoid haemorrhage
Treatment: Ischaemic (occlusion of artery)– antithrombotic therapy (warfarin, anticoags),
thrombectomy
Haemorrhagic Stroke - Intracranial type Haemorrhage
Types: Epidural Haemorrhage, Subdural Haemorrhage, Subarachnoid Haemorrhage
Localization: between meningeal layers of brain
Symptoms/signs:
depends on location of the aneurysm and adjacent structures they affect
can have general sx.
Epidural Haemorrhage – lucid interval: pt. can remain awake immediately after the
traumatic event and do not lose consciousness until sometime later
Diagnostic test: CT scan = gold standard, lumbar puncture
Differential Dx: Ischaemic stroke, brain tumour, migraine
Treatment:
Prevent further bleed
Surgical – metal clipping/coiling
Subarachnoid Haemorrhage
Localization: rupture of aneurysm of one of the arteries at the base of the brain – bleeding
in subarachnoid space (between arachnoid mater and pia mater) – common in anterior
communicating artery (ACA)
Types of aneurysm: saccular ‘berry’ aneurysm, fusiform aneurysm, mycotic
aneurysm
Symptoms/signs:
sudden onset of headache – described as ‘the worst headache of their life’
meningeal irritation – nuchal rigidity
consciousness may be impaired
CN palsies, focal neurological deficits – depending on site
Diagnostic test: CT scan = gold standard, lumbar puncture
Differential Dx: meningitis, Ischemic stroke
Treatment:
Prevent further bleed
Surgical – metal clipping/coiling
Intracerebral Haemorrhage
Causes: arterial hypertension
Localization: any artery in the brain – MC sites: basal ganglia, thalamus, cerebellar nuclei,
pons
Symptoms/signs:
Depends on location
Diagnostic test: CT scan = gold standard, lumbar puncture
Differential Dx: Ischemic stroke, subarachnoid haemorrhage
Treatment:
Prevent further bleed
Surgical – clipping/coiling
Case example
Sensory hypertension, 50yo man, vertigo, vomiting, severe headache, loss of consciousness,
can’t remember anything, confused, extremities, upper limb are fine. Lower limb paralysed
Dx. Haemorrhagic stroke of the ACA in upper area of pre-central gyrus
Haemorrhagic Stroke - Cerebellar Haemorrhage
Localization: cerebellar – usually rupture of superior cerebellar artery – causes acute mass
affect in posterior fossa
Symptoms/signs:
Severe occipital headache
Dysarthria
Nausea and vomiting
Vertigo
Head turning and gaze deviation to opposite side of lesion
Limb ataxia – pt. falls to side of lesion
Diagnostic test: CT scan = gold standard, lumbar puncture
Differential Dx: Ischemic stroke, subarachnoid haemorrhage
Treatment:
Prevent further bleed
Surgical – clipping/coiling
