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Neuroanatomy of a Stroke
Joni Clark, MDProfessor of Neurology
Barrow Neurologic Institute
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• No disclosures
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• Stroke case presentations– Review signs and symptoms– Review pertinent exam findings– Identify the neuroanatomy of the stroke– Identify the vascular territory– Discuss likely etiology
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Case 1
• 75 yr old female presents to the ER with trouble speaking and rt face, arm and leg weakness
• Exam– BP= 160/90 HR= 90 irregularly irregular – Expressive aphasia– Left gaze preference – Right homonymous hemianopia– Right hemiparesis/hemianesthesia
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Radiopaedia Frank Gaillard
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Left MCA Occlusion
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Etiology
• Embolic stroke• EKG: atrial fibrillation• Likely etiology is cardiac embolus secondary to
atrial fibrillation• Treatment: long term anticoagulation
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Case 2
• 70 yr old male with a history of HTN and DM presents with the following symptoms:– Vertigo– Veers to rt on walking– Nausea and vomiting– Numbness rt cheek
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Lateral Medullary Syndrome
• Symptoms– Ataxia– Numbness– Dysphagia– Vertigo– Nausea/Vomiting– Dysarthria– Diplopia or blurred vision– Hoarseness– Facial Pain– Hiccups
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Lateral Medullary Syndrome
• Neurologic Findings– Pain and temperature hypesthesia (contralateral
limbs)– Horner’s syndrome (sympathetic tract)– Gait and limb ataxia– Facial hypesthesia (ipsilateral)– Nystagmus– Pharyngeal and vocal cord paralysis
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Etiology
• Most frequent arterial lesion is occlusion of the vertebral artery– ¾ are thrombotic and remainder cardioembolic – Rarely is the lesion confined only to the PICA– In young patients with headache vertebral artery
dissection may be the cause
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Case 3
• 85 yr old male with HTN presents with face, arm and leg weakness;
• Exam significant for rt facial weakness and 0/5 strength in the rt arm and leg
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Lacunar Strokes
• Infarct caused by the occlusion of a single penetrating artery
• Lacunar infarcts are less than 15 mm in diameter
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Clinical Lacunar Syndromes
• Pure Motor Hemiparesis• Pure Sensory Hemiparesis• Mixed motor/sensory• Dysarthria clumsy hand syndrome• Ataxic Hemiparesis
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Case 4
• 70 yr old male with DM presents with complaints of double vision and weakness on the rt face, arm and leg
• Exam shows left third nerve palsy and rt face, arm and leg weakness
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Radiopaedia
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Oculomotor Nerve
• Clinical signs of CN III injury are:– Ptosis (drooping upper eyelid) –due to paralysis of the
levator palpabrae superioris– Eyeball resting in the down and out position – due to
the paralysis of the superior, inferior and medical rectus and the inferior oblique. The patient is unable to elevate, depress or adduct the eye.
– Dilated pupil – due to the unopposed action of the dilator pupillae muscle
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Weber Syndrome
• Ipsilateral third nerve palsy and crossed hemiplegia
• Likely to be due to occlusion of the posterior cerebral artery at the P1 segment
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Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org, rID: 2665
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Case 5• A 78 yr old male began having episodes of rt
arm numbness, decreased coordination and weakness lasting 5 min. and self resolved
• He was diagnosed with TIAs and started on aspirin
• Work up was reported as normal• Spells stopped but had a slowly progressive
cognitive decline• He presented to the ER two years later with
several days of increased confusion and walking into walls
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Cerebral Microhemorrhages
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Cerebral Amyloid Angiopathy
• Characterized by amyloid B fibril deposition in the media of small to medium sized vessels
• Risk factor: increased age• Recurrent hemorrhages : lobar• Can have superficial siderosis• Age 55 or older• Microhemorrahges on MRI GRE images
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CAA
• About 20% of patients may have transient focal neurologic spells, “amyloid spells”
• Usually seen in those with superficial siderosis
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CAA
• No treatment but avoid anti-platelet agents and anticoagulants.