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Ischemic and Hemorrhagic Stroke
Neuro Assessment 7
80
Anatomy
10/08/2011

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Term
Ischemic Stroke
Definition
brain injury caused by interruption of the brain's blood supply
Term
Hemorrhagic Stroke
Definition
brain injury caused by bleeding into or around the brain
Term
Transient Ischemic Attack (TIA)
Definition
abrupt onset of focal neurological deficits cause by loss of blood supply
Reversible within <1 hour
Term
Resolving Ischemic Neurologic Deficits (RINDs)
Definition
Acute focal neurologic symptoms that resolve completely but take longer then an hour
Term
What are an important warning sign of future stroke?
Definition
TIAs
Term
What are the causes of Ischemic Stroke?
Definition
Atherosclerotic CV disease
Embolism
Lacunar Infarcts
Cryptogenic
Term
What are the 2 types of Hemorrhagic Stroke?
Definition
Intracerebral
Subarachnoid
Term
What are the non-modifiable risk factors for ischemic stroke?
Definition
Age (doubles each decade >55y)
Gender (male 1.5 x risk of female)
Race (AA 2 x risk of EA)
Family History
Term
What are the modifiable risk factors for Stroke?
Definition
Hypertension
Diabetes
Hyperlipidemia
Smoking
Carotid artery stenosis
A. Fib
Obesity
Physical inactivity
Term
What is the #1 risk factor for Stroke? Why?
Definition
Hypertension
Relative risk is low (3-5fold) but its prevalence is very high in the population
Term
What is the a goal for acute stroke intervention?
Definition
Normalize elevated body temperature
Treat Hyperglycemia
Term
What 2 factors can accelerate Ischemic brain injury?
Definition
elevated temperatures
elevated circulating glucose
Term
Ischemic Core
Definition
The central area with sever blod flow reduction
Term
Ischemic penumbra
Definition
the peripheral areas with less severe ischemia
Term
How long until the ischemic core sufferes irreversible injury? Penumbra?
Definition
Core - <1hr
Penumbra - ~4-6hrs
Term
What is the therapeutic window for acute stroke?
Definition
4-6 hours
Term
What is the normal CBF? What range of MAP is the CBF constant?
Definition
55ml/100gmbrain/min
55 - 155mmHg
Term
In Chronic Hypertension how does the CBF curve shift?
Definition
Right
Term
At what BP is it recommended to lower the BP for acute stroke?
Definition
Systolic >220 or diastolic >120
Only lower 10-15% in 24hrs
Term
What are the Neurologic signs and symptoms commonly caused by a stroke?
Definition
Weakness or paralysis
Loss of sensation
Loss of vision
Difficulty talking or understanding
Difficulty with organization or perception
Clumsiness/lack of balance
Term
What are the 2 categories of ischemic stroke?
Definition
Blood vessel location
Blood vessel Size
Term
What arteries are included in an Anterior Circulation stroke?
Definition
Internal Carotic
Middle cerebral
anterior cerebral
Any of their branches
Term
Arteries of Posterior Circulation?
Definition
Posterior cerebral
vertebral
superior cerebellar
anterior inferior cerebellar
posterior inferior cerebellar
Any Branches
Term
What Functional brain areas does the Middle cerebral artery supply?
Definition
Dorsal to Rostral
Hip
Trunk
Shoulder
Arm
Hand
Fingers
Thumb
Face
Lips
Tongue
Larynx
Term
What areas of the brain do the Lenticulostriate arteries supply?
Definition
Internal capsule and Basal Ganglia
Term
What artery supplies blood to the Visual Radiations?
Definition
Posterior cerebral a., Branches to the Occipital lobe
Term
What artery supplies blood to the motor sensory area that controls the Hip, Leg, Foot?
Definition
Anterior cerebral A.
Branches to corpus callosum
Term
Medial Medullary Syndrome
Definition
Paramedian branches of vertebral and anterior spinal arteries
Contralateral
--arm and leg weakness
--decreased position and vibration sense
Ipsilateral
--Tongue weakness
Term
Wallenberg's Syndrome
(Lateral medullary syndrome)
Definition
Vertebral artery
Contralateral:
--decreased pain and temperature sense
Ipsilateral
--ataxia, vertigo, nystagmus, nausea
--facial decreased pain and temperature
--Horner's syndrome
--Decreased Taste
Hoarseness, dysphagia
Term
Dysarthria Hemiparesis
Definition
Paramedian Branches of Basilar artery, ventral territory
Contralateral face, arm, and leg weakness, Dysarthria
Term
Ataxia Hemiparesis
Definition
Paramedian branches or basilar artery, ventral territory

Contralateral face, arm, and leg weakness, dyarthria, ataxia
Term
Foville's Syndrome
Definition
Paramedian branches of basilar artery, ventral and dorsal territories

Contralateral face, arm, and leg weakness, dysarthria
Ipsilateral face weakness, horizontal gaze palsy
Term
Millard-Gubler Syndrome
Definition
Paramedian branches of basilar arter, ventral and dorsal territories

Conralatera face, arm, and leg weakness, dysarthria
Ipsilateral face weakness
Term
Weber's Syndrome
Definition
Branches of PCA and top of basilar artery

Ipsilateral third-nerve palsy
Contralateral hemiparesis
Term
Claude's Syndrome
Definition
Branches of PCA and top of basilar artery
Ipsilateral third-nerve palsy
Contralateral ataxia
Term
Benedikt's Syndrome
Definition
Branches of PCA and top of basilar artery

Ipsilateral third-nerve palsy
Contralateral hemiparesis, ataxia, tremor, and involuntary movements
Term
Anterior Circulation Stroke
Definition
Ipsilateral blindness or contralateral inferior quadrantanopsia
Ipsilateral gaze paresis
Contralateral mono/hemiparesis and/or mono/hemisensory deficit
Aphasia in the dominant hemisphere or neglect in the nondominant hemisphere
Term
Posterior Circulation Stroke
Definition
Unilateral, Bilateral, or crossed (face/body) weakness or sensory deficits
Contralateral homonymous hemianopsia or superior quadrantanopsia
Vertigo, N/V, gait ataxia, diplopia, dysphagia, Horner's syndrome
Altered consciousness and amnesia
Term
What will cause a right sided inferior quadrantanopsia?
Definition
occlusion of the parietal-temporal branches of the Left MCA
Term
What will cause a homonymous hemianopsia of the Right visual field?
Definition
Left Posterior Cerebral Artery occlusion
Term
Lacunar Stroke
Definition
small areas of ischemic necrosis caused by occlusion of small, penetrating arteris
Term
What are the 4 Lacunar syndromes?
Definition
1. Pure hemiparesis
2. Pure hemisensory deficit
3. Ataxia Hemiparesis
4. Dysarthria-clumsy hand syndrome
Term
What are the common sites for Atherothrombosis/Atheroemboli?
Definition
-Origins of carotid & vertebral a.
-Bifurcations of common carotid a.
Internal carotid a at carotid siphon & branch points of middle and anterior cerebral a.
-M1 segment of middle cerebral a.
-Basilar artery
Term
What are the causes of Lacunar Stroke?
Definition
Microatheroma
Microemboli
Lipohyalinosis
Fibrinoid Necrosis
Term
What is the most common cause of cardiogenic emboli affecting the brain?
Definition
A. Fib
Term
What are the causes of Cardiogenic Emboli?
Definition
Arrhythmia
Valvular Heart Disease
-mitral stenosis
-bacterial endocarditis
-prosthetic heart valves
Mural Thrombus - MI
Term
What is a paradoxical embolus?
Definition
arises from the deep venous circulation and goes through patent foramen ovale or ventricular septal wall defect
Term
What are some uncommon causes of Cardiogenic emboli?
Definition
Atrial Myxoma
Mitral valve prolapse
nonbacterial endocarditis
Mural Thrombus
Paradoxical embolus
Term
CNS Vasculitis
Definition
Inflammation of CNS vessels producing segmental narrowing and multifocal occlusions
Mulifocal presentation
Term
What are some Hyperviscosity syndromes that can cause ischemic stroke?
Definition
Polycythemia
Multiple Myeloma
Term
What are some Hypercoagulable conditions that can cause ischemic stroke?
Definition
Antiphospholipid Syndrome
Protein C & S deficiency
Cancer
Pregnancy
Leiden factor V deficiency
Thrombocytosis
Term
What is a hemoglobinopathy that can cause ischemic stroke?
Definition
sickel cell disease
Term
What are some drugs that can cause stroke?
Definition
Street Drugs: Cocaine
Ethanol
Oral Contraceptives
Term
What type of Hemorrhage showes up as blood filling in the sulci?
Definition
Subarachnoid Hemorrhage
Term
What type of hemorrhage presents with blood in the basal ganglia?
Definition
Intracerebral hemorrhage
Term
What type of hemmorrhage presents with blood between the inner plate of skull bone and the dura?
Definition
Epidural hemorrhage
Term
What is the most common cause of subarachnoid hemorrhage?
Definition
Ruptured Berry Aneurysms
Term
What are the risk factors for Subarachnoid Hemorrhage?
Definition
Tobacco
Ethanol abuse
Hypertension
OCPs
Stimulant drugs
Low Cholesterol
Genetics (Polycystic kidneys, Marfans)
Term
Symptoms of Subarachnoid Hemorrhage
(Ruptured berry aneurysm)
Definition
"Worst Headache of my life" - sudden
Rapid loss of consciousness in some
Neck stiffness/pain, photophobia, phonophobia
Nausea/vomiting
Focal Neurologic signs minimal or absent
Term
What causes neck stiffness and pain in a SAH?
Definition
irritation and inflammation of the meninges secondary to the breakdown products of red blood cell lysis
Term
Signs of Subarachnoid Hemmorrhage
Definition
Elevated BP, arrhythmias
Meningeal signs - subtle of delayed
Retinal hemorrhages
Focal signs ubtle or absent
Term
Where would an aneurysm be if the patient had Nerve III paresis?
Definition
IC/PCom aneurysm
Term
Where would an aneurysm be if the patient had Paraparesis?
Definition
ACA aneurysm
Term
Where would an aneurysm be if a patient had Hemiparesis?
Definition
MCA aneurysm
Term
What is the most helpful noninvasive diagnostic test to identify a subarachnoid hemorrhage?
Definition
Non-contrast CT
Term
What is the only way to rule out a subarachnoid bleed?
Definition
Lumbar puncture - 3-4 hours after onset of headache
Term
Why is it necessary to wait 3-4 hours to do a lumbar puncture on a possible SAH?
Definition
to distinguish the breakdown products of hemaglobin in the fluid from the presence of blood that occurred from nicking a vein while preforming spinal tap
Term
What does a spianl tap with xanthochromia show?
Definition
hemoglobin is dissolved in the spinal fluid from RBC that have been in the spinal fluid for several hours - from a ruputurd aneurysm
Term
What is the Gold Standard for neuroradiology of an SAH?
Definition
4 vessel digital subtraction arteriography
Term
What are the most common causes of parenchymal brain hemorrhage from greatest to least?
Definition
Trauma > Hypertension > Arteriovenous malformations
Term
What are Charcot Bouchard aneurysms?
Definition
microaneurysms to small cerebral blood vessels
Caused by Hypertension
Term
Where do Charcot Bouchard aneurysms develop?
Definition
basal ganglia, thalamus, pons, cerebellum
Term
Is a cortical, polar hemorrhage usually related to hypertension?
Definition
No
Term
Treatment for Parenchymal Hemorrhage
Hypertensive/Traumatic
Definition
Correct any bleed problem
Reduce BP to <160/100 or MAP <130mmHg
Monitor and treat elevated intracranial pressure CPP - 60-80mmHg
Term
Treatment for Parenchymal Hemorrhage
AVM hemorrhage
Definition
Intravascular occlusion of AVM with coils
Surgical removal or gamma knife obliteration of AVM
Term
What are the Routine Labs for possible stroke?
Definition
EKG with Rhythm strip
CXR
CBC with diff and platelet count
glucose, BUN, electrolytes (chemistry)
Lipid profile
Clotting times
Head CT without contrast
Term
When is a head CT useful?
Definition
Highly sensitive to hemorrhage - used to rule out hemorrhagic stroke
Infarcts from ischemic stroke not detected 6-12 hours
Term
What's the acute treatment for stroke if <4.5hrs from onset?
Definition
Intravenous tPA
Term
What's the acute treatment for stroke <6 hr from onset?
Definition
intraarterial tPA
Term
What is the acute treatment of Stroke if <8 hr from symptom onset?
Definition
Retrieve clot with intra-arterial retrieving device