Cerebrovascular Disease
and Stroke Clinical Case
Correlation
Teresa M. Kilgore,D.O. FACOI
2/3/2012
Objectives
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Define stroke and contrast with TIA
Identify the stroke subtypes
List common risk factors for stroke
List appropriate laboratory and imaging studies
to evaluate the acute stroke patient
Recite acute ischemic stroke therapy
Localize the pathology in six common stroke
syndromes
Case #1
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A 58 year old man comes to you
three weeks after he developed
sudden-onset right arm and leg
weakness with numbness.
Symptoms came on suddenly and
have gradually, but incompletely,
improved.
• What happened?
• What is your approach?
Definition of Stroke
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Vascular event that results in focal
brain injury
By definition, symptoms last at least
24 hours
Damage is often visualized by MRI
imaging within minutes, and by CT
imaging within 6 hours
Definition of TIA
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Vascular event that results in focal brain
injury symptoms, but may not result in
injury
By definition, symptoms last less than 24
hours, but most TIAs resolve within 1 hour
TIAs are pathologically the same as
strokes but symptoms last for less time
and usually do not result in visualized
brain injury on imaging
TIAs result from the same risk factors as
stroke and warrant the same evaluation
Case 2
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A 75 year old woman comes in to the doctor’s
office. Three days ago, she noted slurred speech
and right arm weakness that improved within 30
minutes. She has not noticed recurrence or
worsening of her symptoms since onset. Today,
her exam shows mild word-finding difficulties and
mild right arm weakness. What is the most likely
diagnosis?
A. TIA
B. Ischemic stroke
C. Intracerebral hemorrhage
D. Ruptured intracranial aneurysm
E. Hypertensive encephalopathy
CT findings
Case 3
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A 65yo female smoker presents with
a 6 month history of intermittent
episodes of left body tingling. She
has no prior history of stroke but
does have poor dietary habits and
high cholesterol.
• What is your differential diagnosis?
• What diagnostic studies are indicated?
• If you assume TIAs, how would you
treat? What are her main risk factors?
Stroke Risk Factors
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Modifiable
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Non-Modifiable
Diabetes
Age >75
Hypertension
Male gender
Tobacco use
Stroke/vascular dz in young
Dyslipidemia
family members
Heart disease
Personal history
Carotid disease
African-American
Alcohol consumption
Atrial fibrillation
Sickle cell disease
Homocysteine >12
Oral contraceptive use by smokers
Drug use (amphetamines, cocaine, ephedra)
Case 4
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A 55 year old man presents with sudden
onset vertigo, tendency to fall to the left
upon standing, left facial numbness,
dysarthria, and right arm and leg
numbness.
• What features suggest stroke?
• What tests do you want to perform to work
this patient up for stroke risk factors and
treatment options?
Stroke History
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Evaluate history given by patient and family
• Headache at onset suggests SAH, ICH, or large ischemic
stroke
• Vomiting suggests SAH, ICH, or brainstem or cerebellar
stroke
• Seizures at onset often occur with lobar hemorrhages
and brain embolism but not small or deep strokes
• Loss of consciousness at onset suggests large SAH,
emboli to the basilar artery, or EDH
• Headache and vomiting at onset, followed by
progressive neurological symptoms suggest large ICH
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Determine presence and nature of prior strokes
or TIAs
Time and activity at onset of symptoms
Timing and progression of symptoms
Any accompanying symptoms
Stroke Examination
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Heart – enlargement, murmurs, rhythm
Carotid, vertebral, and supraclavicular
bruits
Vital signs
Symmetry of blood pressures and pulses
in the arms
Evidence of peripheral vascular disease
Evidence of persisting neurological deficits
Evaluation: First 3 hours
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r-tPA candidate?
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Symptoms clearly started within 3 hours
Deficits fixed or worsening, not improving
SBP <185 (or increased risk of ICH with r-tPA)
Normal PT/PTT/INR
Not on anticoagulants (warfarin, LMWH)
CT normal, no bleeding, no large infarct
No head injury or surgery within 3 months
• No history of head bleed, ever
• No seizure at the onset of symptoms
Evaluation: First 24 hours
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Cardiac monitoring – arrhythmia
Labwork – cholesterol panel, diabetes screen,
ANA, ESR, homocysteine, hypercoagulable panel,
toxicology screen if needed/appropriate
Carotid ultrasound or MRA or CTA or angiography
Echocardiogram (transesophogeal and/or
transthoracic, which is more accurate)
Regular neuro checks (q2-4 hours)
Dysphagia screen
Monitor for signs and/or symptoms of aspiration
MRI with diffusion weighted images detects
ischemic stroke quickly and fairly accurately
Case 5
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A 16yo female non-smoker presents
with a 2 year history of infrequent
focal motor seizures, controlled on
AED’s. Early this morning after a
seizure, she developed a sudden,
severe headache, and mild
hemiparesis on the same side of her
seizure activity.
• What is the differential diagnosis?
• What diagnostic studies are indicated?
Stroke Diagnosis: Mimics
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Hypoglycemia
Tumor
Seizure
Multiple sclerosis
Migraine
Trauma
Intracranial hemorrhage
Encephalitis
Case 6
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A 24yo male is brought to the ER by
ambulance because he was difficult to
arouse at home. His mother says he was
drinking heavily last night with some
friends at a local pub. You see that he has
mild flattening of the left nasolabial fold
and a left extensor plantar response, but
seems to move his limbs equally in
response to painful stimuli.
• What is your differential diagnosis?
• What diagnostic studies would be helpful?
Intracerebral Hemorrhage
• Clinical features
 Loss of consciousness with focal findings
 Headache – generally severe
 Breathing, pupillary, and/or extraocular
movement abnormalities
• Evaluation
 CT scan; if negative, LP to look for blood
 Angiography may locate the aneurysm
• Treatment
 Supportive care
 Seizure prevention
 Medications to prevent arterial spasm
 Prevent seizures
 Neurosurgical aneurysm clipping
Case 7
A 58 year old diabetic man comes in with acuteonset right hemiplegia and aphasia. He is treated
in the ER with r-tPA. Because his blood pressure
was elevated on admission (200/120), he was
placed on IV labetolol to lower his pressures.
Upon arrival to the floor, his pressure has
normalized to 120/85. He has now developed
new-onset left hemiparesis and depressed
consciousness.
What might have happened?
What tests would you order to evaluate?
What other interventions would you start?
Definition of Penumbra
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Penumbra =
“stunned” neural
tissue surrounding
the region of
stroke (neural
tissue that is
rapidly killed in the
setting of vascular
compromise)
BEWARE low blood
pressure!!!!
Hypovolemia/Hypotension
• Reduced cardiac output or hypovolemia result in blood
pressure that is too low to maintain perfusion
• If systemic hypotension occurs in the setting of a focal
artery stenosis, the brain tissue distal to that stenosis is
particularly prone to ischemia
• Systemic hypotension even without a focal vessel
stenosis may result in infarct in “watershed” regions of
the brain – these are areas where overlap between
ACA/MCA or PCA/MCA arteries occurs (anterior frontal
and temporo-parietal lobes)
• Risk factors
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Orthostatic hypotension
Perioperative
Myocardial ischemia
Cardiac dysrhythmias
Severe large vessel stenosis
Stroke Syndrome -1
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Internal Carotid Occlusion (acute)
• Contralateral hemiplegia
• Contralateral sensory deficit
• Homonymous hemianopsia
• Conjugate eye deviation toward the lesion
• Contralateral lower facial weakness
• Either mutism, aphasia, or dysarthria
• Head position deviation toward the lesion
• Horner’s syndrome ipsilateral to lesion
• Cerebral edema may be life-threatening
Stroke Syndromes – 2
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MCA syndrome
• Contralateral hemiplegia or hemiparesis
(arm>leg)
• Contralateral hemisensory syndrome
• Homonymous hemianopsia
• Contralateral lower facial weakness
• Speech or language abnormality
Stroke Syndromes – 3
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ACA syndrome
• Contralateral hemiparesis (leg>arm)
• Akinetic mutism
• Behavioral or memory disturbance
• Dysarthria or transcortical motor
aphasia
• Conjugate eye deviation towards lesion
• Head position deviation towards lesion
Stroke Syndromes – 4
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PCA syndrome
• Contralateral homonymous hemianopsia
• May have no other symptoms other
than the visual field cut
Stroke Syndromes – 5
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Lacunar stroke syndromes
• Pure motor hemiplegia
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Contralateral face and arm>leg weakness
Possible mild dysarthria
No vision, language, or sensory disturbance
Lesion usually in the contralateral posterior
limb of the internal capsule
• Contralateral in essence of where you see the
symptoms
• Pure sensory stroke
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Contralateral face, arm, trunk, and leg
numbness, paresthesias, and reduction of
pain temperature
Lesion usually in the contralateral VPL
thalamic nucleus.
• Contralateral in essence of where you see the
symptoms
Stroke Syndromes – 6
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Vertebrobasilar artery and brain
stem syndromes
• “locked-in” syndrome
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Lesions in the bilateral ventral pons, with
sparing of the reticular activating system
Characterized by aphonia, quadriplegia, and
preserved eye movements (except for
horizontal movements which are
occasionally affected)
Wakefulness is maintained
Question #1
A right-handed patient presents with mild
right leg and moderate right arm
weakness. In addition, she mixes up
words and cannot figure out how to say
certain things. What vascular territory is
involved
A. Anterior Cerebral Artery
B. Posterior Cerebral Artery
C. Middle Cerebral Artery
D. Vertebral Artery
E. Internal Carotid Artery
Question #2
A 78-year old gentleman is seen in the ER for
confusion. Exam shows a very uncomfortable
gentleman grabbing the right side of his head.
Exam shows BP 180/90, P 120 and regular, and a
dilated right pupil, but before you proceed he
passes out and requires intubation. What
diagnosis must you consider?
A. Hypertensive intracerebral hemorrhage.
B. Acute ischemic stroke
C. Ruptured intracerebral aneurysm
D. Acute head injury
E. All of the above
Anatomy of SAH
SAH Appearance on CT
Aneurysm on Angiogram
Aneurysm Clipping
Question #3
A 47 year old comes in with acute
stroke symptoms, and you are
considering giving tPA. He arrived
1.5 hours after symptom onset, has
no historical contraindicates to tPA.
Labs come back normal. BP is
210/130. Can you give tPA?
A. Yes (how much time do you
have?)
B. No (why not?)
NIH Stroke Scale