2. SSoF
What is a stroke?
How do strokes happen?
Is stroke a common disorder?
SSoF I
3. What is a stroke?
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 strokes happen?
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 a common
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 a common
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 of Stroke
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 of Stroke
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 of Stroke
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
12. SSoF I
Carotid artery and 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…)
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 artery and 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
20. SSoF I
Carotid artery and 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 artery and 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…
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
Diversity of symptoms, depending on lesion site
Contralateral hemiparesis Arm>Face>Leg
Language dysfunction with dominant hemisphere
involvement
Neglect with non-dominant hemisphere
involvement
Apraxia syndromes
29. Clinical syndromes: AIS
Carotid artery 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
41. Clinical syndromes: AIS
Division stroke
Much more severe, multimodal symptoms
Higher risk for adverse events
Less recovery potential
42. Clinical syndromes: AIS
Division stroke: 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
Division stroke: 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
