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Cerebrovascular Accident: A Stroke of Misfortune
Sumaira Nabi, MBBS, FCPS Neurology | October 17, 2018
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Image courtesy of Wikipedia.
Cerebrovascular Accident: A Stroke of Misfortune
Sumaira Nabi, MBBS, FCPS Neurology | October 17, 2018 | Contributor Information
Stroke (or cerebrovascular accident [CVA]) is defined as the sudden occurrence of a focal, nonconvulsive neurologic deficit. Interruption of blood flow results in cell death. The presentation is variable, ranging from subtle to very severe, depending on the area of the brain involved and the nature of the attack. Stroke is the fifth leading cause of death in the United States and the leading cause of adult disability, with 15 million people affected worldwide every year.[1] The substantial socioeconomic burden imposed by stroke makes effective and urgent treatment important.
Image courtesy of Hanna Nomani, MBBS.
Cerebrovascular Accident: A Stroke of Misfortune
Sumaira Nabi, MBBS, FCPS Neurology | October 17, 2018 | Contributor Information
Stroke is broadly classified into two types: ischemic and hemorrhagic. Ischemic stroke accounts for 80-85% cases and commonly results from occlusion of the lumina of the cerebral vessels by a thrombus or embolus. Apart from thromboembolism, systemic hemodynamic failure can also result in ischemic stroke as a consequence of a decreased volume of blood flowing through the cerebral vessels. Hemorrhagic stroke, seen in 15-20% of cases, typically results from rupture of a cerebral vessel. It is further classified into two subtypes—intracerebral and subarachnoid—depending on the site of blood leakage.
Image courtesy of Muhammad Fateen Rashed, MBBS.
Cerebrovascular Accident: A Stroke of Misfortune
Sumaira Nabi, MBBS, FCPS Neurology | October 17, 2018 | Contributor Information
An 80-year-old right-handed man presents with the acute onset of impaired speech and comprehension, along with right-side weakness. He has a history of hypertension and dyslipidemia and is taking antihypertensive medication, as well as a statin. On examination, the patient has global aphasia, right upper motor neuron facial palsy, right hemiplegia with positive Babinski sign, and right hemisensory loss. Computed tomography (CT) of the head reveals ischemic changes in the left middle cerebral artery (MCA) territory with midline shift (arrow).
Which of the following describes the typical appearance of an ischemic stroke on CT of the brain?
Hypodense area in brain parenchyma
Hyperdense area in brain parenchyma
Hypodense area outside brain parenchyma
Hyperdense area outside brain parenchyma
Image courtesy of Medscape.
Cerebrovascular Accident: A Stroke of Misfortune
Sumaira Nabi, MBBS, FCPS Neurology | October 17, 2018 | Contributor Information
Answer: A. Hypodense area in brain parenchyma.
An established ischemic stroke is signaled by hypodensity on CT of the brain. The specific neurologic deficit in an ischemic stroke depends on the artery that is occluded and the area of the brain that is involved.[2] The anterior cerebral artery (ACA) supplies the medial portion of the frontal lobes; the posterior cerebral artery (PCA) supplies the occipital lobes, the medial temporal lobe, and part of the midbrain and thalamus; and the MCA supplies the parietal lobe, the lateral frontal and temporal lobes, the insula, the internal capsule, and the basal ganglia (shown).
Image courtesy of Medscape (left) / Evan Oto / Science Source (right).
Cerebrovascular Accident: A Stroke of Misfortune
Sumaira Nabi, MBBS, FCPS Neurology | October 17, 2018 | Contributor Information
The circle of Willis consists of a vascular network of blood vessels present at the base of the brain. It connects the major arteries of the anterior and posterior circulations.[3] The right and left internal carotid arteries and their branches constitute the anterior circulation of the brain, and the vertebrobasilar vessels form the posterior circulation.
Image courtesy of Hanna Nomani, MBBS.
Cerebrovascular Accident: A Stroke of Misfortune
Sumaira Nabi, MBBS, FCPS Neurology | October 17, 2018 | Contributor Information
Neurons are highly sensitive to cerebral blood flow and die within minutes of complete cessation of flow. In ischemic stroke, vascular occlusion leads to gradual progression from a reversible degree of ischemia toward irreversible infarction.[4] There is a central core of infarcted brain tissue that is surrounded by a rim of moderately ischemic tissue with relatively preserved cellular metabolism and viability. This moderately ischemic rim, known as the penumbra (shown), can be preserved with timely and appropriate intervention.
Cerebrovascular Accident: A Stroke of Misfortune
Sumaira Nabi, MBBS, FCPS Neurology | October 17, 2018 | Contributor Information
The National Institutes of Health (NIH) Stroke Scale (NIHSS) was devised to facilitate objective quantification of the deficit caused by a stroke in a standardized manner. It has 11 components, each of which grades a specific ability on a numerical scale. Typically, 0 indicates normal function, whereas higher numbers denote degrees of functional impairment.[5] The points for the 11 components are summed to yield the patient's total NIHSS score, with 0 being the minimum possible score and 42 the maximum possible score.
Image courtesy of Neilbarman at English Wikipedia.
Cerebrovascular Accident: A Stroke of Misfortune
Sumaira Nabi, MBBS, FCPS Neurology | October 17, 2018 | Contributor Information
Various therapeutic options are available to reestablish the interrupted cerebral blood flow. Intravenous administration of tissue plasminogen activator (t-PA) is the only therapy approved by the US Food and Drug Administration (FDA) for restoring cerebral perfusion. Intra-arterial administration of a thrombolytic agent through a microcatheter is another medical management option. Surgical options include mechanical thrombectomy (shown) and microsurgical embolectomy.
Image courtesy of Waleed Shazad, MBBS.
Cerebrovascular Accident: A Stroke of Misfortune
Sumaira Nabi, MBBS, FCPS Neurology | October 17, 2018 | Contributor Information
A 60-year-old man known to have had hypertension for 10 years and ischemic heart disease for 5 years presents to the clinic. The patient's son has noticed that for the past 2 weeks, his father has had difficulty in calculating routine household work and grocery shopping. He has also noticed that his father is unable to express his thoughts in writing. After 1 week of these symptoms, the patient's son further notices that his father is unable to follow directions while driving; for example, the patient might turn right after signaling a left turn, thereby causing problems for other vehicles on the road, as well as for the passengers in his car. CT of the patient's brain shows a hypodense lesion in the left inferior parietal lobule.
Which of the following is the most likely diagnosis?
Alzheimer disease
Central nervous system (CNS) infection
Gerstmann syndrome
Space-occupying lesion in the brain
Image courtesy of Waleed Shazad, MBBS.
Cerebrovascular Accident: A Stroke of Misfortune
Sumaira Nabi, MBBS, FCPS Neurology | October 17, 2018 | Contributor Information
Answer: C. Gerstmann syndrome.
Gerstmann syndrome is a classic disorder that may appear in children and adults. In adults, it can arise as a result of impaired blood flow to the brain (cerebrovascular disease), such as may occur with a stroke (as in this patient) or other damage to the brain.[6] Gerstmann syndrome affects the parietal (upper-side) lobes of the brain, which are involved with sensation and perception, as well as with understanding of sensory input.
Images courtesy of Waleed Shazad, MBBS.
Cerebrovascular Accident: A Stroke of Misfortune
Sumaira Nabi, MBBS, FCPS Neurology | October 17, 2018 | Contributor Information
Gerstmann syndrome consists of the following four neuropsychological disturbances[6]:
Acalculia (impaired arithmetical skills)
Finger agnosia (inability to identify fingers)
Confusion of left and right
Agraphia
When all four elements occur, neurologists usually attribute the syndrome to a stroke or another lesion in the angular gyrus of the dominant parietal lobe.
Image courtesy of Medscape.[7]
Cerebrovascular Accident: A Stroke of Misfortune
Sumaira Nabi, MBBS, FCPS Neurology | October 17, 2018 | Contributor Information
A 40-year-old hypertensive woman presents with a history of sudden onset of dysphagia, dysarthria, and gait ataxia. On examination, she has a Glasgow Coma Scale (GCS) score of 15/15. Her speech is dysarthric, with a nasal twang. The patient also has right-side Horner syndrome, right-side cranial nerve (CN) IX and X palsy, and right-side cerebellar signs. She has crossed sensory loss of pain and temperature sensation on the right side of the face and the left side of the body. Magnetic resonance imaging (MRI) of the brain shows an infarct on the right side of the medulla.
Which of the following is the most likely diagnosis?
Weber syndrome
Wallenberg syndrome (lateral medullary syndrome)
Medial medullary syndrome
Claude syndrome
Image courtesy of Medscape.
Cerebrovascular Accident: A Stroke of Misfortune
Sumaira Nabi, MBBS, FCPS Neurology | October 17, 2018 | Contributor Information
Answer: B. Wallenberg syndrome (lateral medullary syndrome).
Wallenberg syndrome results from involvement of the lateral medulla, usually by ischemic stroke, and presents with a characteristic clinical signature.[8] The T2-weighted MRI scan in the slide shows a hyperintense signal in the right lateral medulla (arrow). Patients with Wallenberg syndrome present with dysphagia and dysarthria from involvement of the nucleus ambiguus and vertigo from damage to the vestibular nuclei. Involvement of the spinal trigeminal nucleus leads to absence of pain on the ipsilateral side of the face, whereas damage to the spinothalamic tract results in loss of pain and temperature sensation on the opposite side of the body, producing the typical "crossed" sensory loss. The involvement of the inferior cerebellar peduncle causes ataxia. Horner syndrome results from damage to the hypothalamospinal fibers of the sympathetic nervous system.
Image courtesy of Medscape.
Cerebrovascular Accident: A Stroke of Misfortune
Sumaira Nabi, MBBS, FCPS Neurology | October 17, 2018 | Contributor Information
A 50-year-old woman presents to the emergency department (ED) with sudden-onset vertigo and right-side sway on awakening. She has a 10-year history of diabetes mellitus and hypertension. On examination, the patient's pulse is 70 beats/min and regular, and her blood pressure is 150/90 mm Hg. She has scanning speech and nystagmus. Cerebellar signs are present on the right side, with intention tremor, past pointing, and dysdiadochokinesia. There is a right falling tendency during tandem gait. No motor and sensory deficits are observed. Diffusion-weighted MRI of the brain shows a right cerebellar infarct (arrow).
Which of the following is the most likely site of vascular occlusion?
ACA
MCA
PCA
Vertebrobasilar system
Cerebrovascular Accident: A Stroke of Misfortune
Sumaira Nabi, MBBS, FCPS Neurology | October 17, 2018 | Contributor Information
Answer: D. Vertebrobasilar system.
The vertebral arteries and the basilar artery (formed by the union of the paired vertebral arteries) supply most of the cerebellum, brainstem, thalami, and occipital cortices.[9] Occlusion of these vessels, their branches, or both produces characteristic symptoms and signs (shown). Occlusion of large vessels usually results in significant disability or death (mortality, >85%). Those who survive have severe deficits (eg, quadriplegia, ataxia, dysphagia, or dysarthria). Many vertebrobasilar strokes are due to small-vessel disease and produce a variety of focal neurologic deficits, depending on their location within the brainstem and cerebellum. These patients usually have a better prognosis, with a greater likelihood of functional recovery.
Image courtesy of Sumaira Nabi, MBBS.
Cerebrovascular Accident: A Stroke of Misfortune
Sumaira Nabi, MBBS, FCPS Neurology | October 17, 2018 | Contributor Information
A 40-year-old man presents with the sudden onset of slurred speech and right-side weakness, preceded by headache and two episodes of vomiting. He has a 5-year history of hypertension and is noncompliant with his antihypertensive medications. On examination, the patient is conscious and oriented. His blood pressure is 170/110 mm Hg, and his pulse rate is 80 beats/min. Neurologic examination identifies right-side hemiparesis with an upgoing plantar response. CT of the head shows a left basal ganglia intracerebral hemorrhage (ICH; arrow) with no evidence of ventricular extension or subarachnoid hemorrhage (SAH). The ICH score (see slide 18) is 0.
Which of the following is the most common site of ICH secondary to hypertension?
Basal ganglia
Thalamus
Pons
Cerebellum
Image courtesy of Hanna Nomani, MBBS.
Cerebrovascular Accident: A Stroke of Misfortune
Sumaira Nabi, MBBS, FCPS Neurology | October 17, 2018 | Contributor Information
Answer: A. Basal ganglia.
Hypertension damages the small penetrating arteries of the brain that supply deep structures (eg, basal ganglia, internal capsule, thalamus, pons, and cerebellum).[10] There is lipohyalinosis and formation of small aneurysms that rupture, leading to leakage of blood within the brain parenchyma. The basal ganglia are most commonly involved.
Cerebrovascular Accident: A Stroke of Misfortune
Sumaira Nabi, MBBS, FCPS Neurology | October 17, 2018 | Contributor Information
The ICH score is used for predicting prognosis and mortality in patients with spontaneous ICH. It is calculated by assigning points to GCS score, ICH volume, presence or absence of intraventricular hemorrhage (IVH), infratentorial vs noninfratentorial origin, and patient age. Higher scores suggest an increased risk of 30-day mortality; with a score of 5 or 6, estimated mortality rises to 100%.[11]
Image courtesy of Anum Anis, MBBS.
Cerebrovascular Accident: A Stroke of Misfortune
Sumaira Nabi, MBBS, FCPS Neurology | October 17, 2018 | Contributor Information
A 60-year-old man presents to the ED with a history of sudden headache, nausea, and vomiting followed by loss of consciousness. On examination, his GCS score is 4/15. He has marked neck stiffness. On limb examination, the patient exhibits decerebrate posturing with bilateral upgoing plantars. CT of the head (shown) reveals extensive SAH with hydrocephalus, intraventricular extension, and bilateral frontal infarcts due to vasospasm. CT angiography (CTA) shows an aneurysm of the anterior communicating artery.
Which of the following is the most common site for aneurysm formation?
Apex of the basilar artery
MCA
Junction of the anterior communicating artery and the ACA
Junction of the posterior communicating artery and the internal carotid artery
Image courtesy of National Institutes of Health / National Heart, Lung, and Blood Institute.
Cerebrovascular Accident: A Stroke of Misfortune
Sumaira Nabi, MBBS, FCPS Neurology | October 17, 2018 | Contributor Information
Answer: C. Junction of the anterior communicating artery and the ACA.
Rupture of an intracranial aneurysm leads to SAH. Overall mortality is high, with 25% of patients dying within the first 24 hours after the event. Aneurysms are localized outpouchings of vessel walls that arise secondary to developmental abnormalities and hypertension.[12] Most saccular aneurysms occur in the anterior circulation, with the junction of the anterior communicating artery and the ACA being the most common site for aneurysm formation.
Cerebrovascular Accident: A Stroke of Misfortune
Sumaira Nabi, MBBS, FCPS Neurology | October 17, 2018 | Contributor Information
The Hunt and Hess scale, devised in 1968 as a means of grading the severity of SAH, is widely used to predict prognosis and outcome in patients with this condition. The higher the grade, the lower the likelihood of survival and the higher the mortality. In general, depression of conscious level leads to a poor outcome.[13]
Image by Sam Shlomo Spaeth for Medscape.
Cerebrovascular Accident: A Stroke of Misfortune
Sumaira Nabi, MBBS, FCPS Neurology | October 17, 2018 | Contributor Information
There are two main neurosurgical modalities for securing ruptured cerebral aneurysms—namely, neurosurgical clipping and endovascular coiling.[14] In neurosurgical clipping, an open craniotomy is done, and one or more clips are placed on the neck of the aneurysm (left). This is a time-tested procedure with well-defined efficacy. In endovascular coiling, a more recently developed procedure, one or more platinum coils are placed into the aneurysm via an angiographic catheter (right). No craniotomy is required, and short-term morbidity and mortality are reduced. However, the long-term efficacy of endovascular coiling has not yet been definitively established.
6 Body Modifications and Piercing: Dermatologic Risks and Adverse Reactions
Body modifications/piercings have become increasingly more mainstream over the last few decades. However, the risks of adverse events with these procedures may be overlooked or understated. Do you recognize the following body modifications and related potential complications?Slideshows, October 2018
Ischemic stroke is characterized by the sudden loss of blood circulation to an area of the brain, resulting in a corresponding loss of neurologic function. Acute ischemic stroke is caused by thrombotic or embolic occlusion of a cerebral artery and is more common than hemorrhagic stroke.Diseases/Conditions, February 2018
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Contributor Information
Author
Sumaira Nabi, MBBS, FCPS Neurology
Senior Registrar and Consultant Neurologist
Department of Neurology
Pakistan Institute of Medical Sciences
Islamabad, Pakistan
Disclosure: Sumaira Nabi, MBBS, FCPS Neurology, has disclosed no relevant financial relationships.
Cashman E et al. Thyroid swelling: an unusual presentation of a cervical sympathetic chain schwannoma. Medscape J Med. 2008 Aug 27;10(8):201. [PMID: 18924653]
Nickerson RB et al. Hiccups associated with lateral medullary syndrome. A case report. Am J Phys Med Rehabil. 1997 Mar-Apr;76(2):144-6. [PMID: 9129521]
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