Lectures

Ischemic Stroke Syndromes

by Carlo Raj, MD
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    00:01 Let’s take a look at ischemic stroke syndromes.

    00:04 Pure motor hemiplegia.

    00:06 Contralateral pons or internal capsule lacunar.

    00:11 In a vascular pathology, you’re going to have these larger arteries that are affected.

    00:17 Let it be the middle cerebral artery, anterior cerebral artery, so on and so forth or there’s something called a lacunar infarct.

    00:24 Let’s say that your patient has had long-term hypertension.

    00:27 Remember we said that hypertension is an extremely common risk for stroke taking place.

    00:32 And if the hypertension is taking place over a long period of time, you can only imagine that there is really no blood vessel that is left safe, right? So they’re all vulnerable to some type of pathology.

    00:45 And say that you have a little blood vessels that are now undergoing compromise and undergoing damage and injury.

    00:54 And at some point in time, maybe there’s an aneurysm that takes place and this aneurysm could be something like a Charcot-Bouchard aneurysm.

    01:02 And that particular aneurysm would be one in which little blood vessels, deep penetrating blood vessels of the brain that are being affected.

    01:10 So imagine that these little blood vessels especially around the internal capsule, which is responsible for motor functioning on the contralateral side, right? So think about that from neuroanatomy, please.

    01:22 And at some point in time, as the aneurysm gets bigger, we know that any time, there’s an aneurysm taking place.

    01:27 You’re always worried about rupture, aren’t you? And so therefore, when there’s a rupture that takes place, and you can only imagine now the little blood vessels, well, they’re infarcted.

    01:37 And you call this a lacunar infarct.

    01:39 And many times, patients with hypertension will have lacunar infarct.

    01:43 But if that part of the brain is not significant in terms of proper functioning and then the patient may be asymptomatic.

    01:50 But if it is an internal capsule that’s been affected such as a caudate or putamen or even the thalamus or a subthalamus, huh? Then you will have motor type of issues and this would be a pure motor, contralateral type of hemiplegia, would it? And so maybe therefore, those interesting gaits that you’ve talked about earlier where the arm might be adducted and the hand might be flexed and then you have circumduction that’s taking place of the leg and you have internal rotation of the ankle and so forth, and you have that particular gait.

    02:23 And so that’s referring to what’s known as your pure motor type of hemiplegia, internal capsule.

    02:29 Let’s take another one.

    02:31 Pure sensory stroke.

    02:32 The contralateral thalamus.

    02:34 Here once again, little blood vessels that might undergo strokes and lacunar type of infarct.

    02:40 Now, maybe it’s a big blood vessel that has been affected.

    02:43 All right, middle cerebral artery.

    02:45 So think about that, please.

    02:47 So this is an artery that’s been affected.

    02:49 And then you know about your watershed areas, right? And by watershed, I’m referring to two blood vessels that are coming together.

    02:55 And when they do it, it’s that particular tissue that is now susceptible to damage.

    03:02 And so for example, middle cerebral artery and anterior cerebral artery would be an area in which you call that watershed.

    03:08 And I told you earlier, middle cerebral artery would be supplying the lateral aspect of the parietal lobe, responsible for sensations and activity in the upper extremity, maybe the head and neck.

    03:21 Well, let’s say that there is an MCA type of issue and there is an atherosclerotic type of ischemic stroke taking place.

    03:28 And please understand that the hemiparesis will be taking place in the face and the arm much more so than the leg, right? because of the homunculus and the representation.

    03:40 There might be aphasia if it’s a dominant side.

    03:42 Sensory loss.

    03:44 There might be hemianopsia or eye deviation if there’s enough damage of your MCA taking place.

    03:51 Keep that in mind, aphasia.

    03:52 More or less, you’re referring to the dominant side.

    03:55 How do you know what side of the brain is dominant in your patient? You’re going to be looking for clues as to what arm your patient is more comfortable using.

    04:06 Right or left? And then obviously, the contralateral hemisphere is going to be the dominant side.

    04:14 Anterior cerebral artery, what about this syndrome? Well, here, think about the anterior cerebral artery, please.

    04:20 And you are supplying the medial aspect of your brain and so therefore this then represents your legs and lower extremity.

    04:28 So lower extremity weakness, sensory loss.

    04:31 Maybe even perhaps incontinence or limb apraxia.

    04:36 What does that mean to you? You’re not able to carry out those learned, motor type of functioning.

    04:42 Anterior cerebral artery.

    04:43 Where are you? The medial aspect of the brain.

    04:47 What about the posterior cerebral artery? Well the posterior cerebral artery, more or less, think of it as being part of your occipital lobe posteriorly.

    04:56 You should be thinking about vision.

    04:58 There might be homonymous hemianopsia.

    05:02 There might be sensory loss as well.

    05:04 Then you have from the circle of Willis, think about the posterior inferior cerebellar artery, okay? So we have PICA.

    05:11 And here, how is your patient going to present? I’m going to present with this, doc.

    05:17 So there might be hoarseness that’s taking place.

    05:20 Doc, I’m having a hard time eating.

    05:23 So there might be dysphagia that’s taking place, right? So if there’s a couple of things that you want to take out of what’s known as Wallenberg syndrome in your PICA.

    05:32 And you must keep in mind the big symptoms such as dysphagia, such as hoarseness.

    05:39 So you might have ataxia, Horner syndrome, ipsilateral loss of face sensation, contralateral loss of body sensation if it’s PICA.

    05:49 This is referred to as being your Wallenberg syndrome.

    05:52 Now, with PICA, would you call this a medial medullary type of syndrome? Or would you call this a lateral medullary type of syndrome? Keep that in mind.

    06:02 I’ll answer that question in just a minute.

    06:05 Won’t you come back and spend some time with me.


    About the Lecture

    The lecture Ischemic Stroke Syndromes by Carlo Raj, MD is from the course Stroke (Cerebrovascular Accident).


    Included Quiz Questions

    1. Pure motor hemiplegia
    2. Anterior cerebral artery syndrome
    3. Middle cerebral artery syndrome
    4. Posterior cerebral artery syndrome
    5. Wallenburg syndrome
    1. Left homonymous hemianopsia
    2. Right homonymous hemianopsia
    3. Right sided hemiperesis
    4. Left sided hemipersis
    5. Anosmia
    1. Anterior cerebral artery
    2. Posterior inferior cerebellar artery
    3. Middle cerebral artery
    4. Posterior cerebral artery
    5. superior cerebellar artery
    1. Pure motor hemiplegia
    2. Wallenberg syndrome
    3. Anterior cerebellar artery syndrome
    4. Posterior cerebellar artery syndrome
    5. Middle cerebellar artery syndrome
    1. Right side thalamus lacunae
    2. Left side thalamus
    3. Right occipital lobe
    4. Left occipital lobe
    5. Red nucleus

    Author of lecture Ischemic Stroke Syndromes

     Carlo Raj, MD

    Carlo Raj, MD


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