Stroke Syndromes

Stroke Syndromes: Excerpt from Field Guide to Bedside Diagnosis

Differential Overview

TIA/Stroke

❑ Middle cerebral artery stroke

❑ Anterior cerebral artery stroke

❑ Posterior cerebral artery stroke

❑ Watershed stroke

❑ Thalamic lacune

❑ Vertebrobasilar ischemia

❑ Pontine lacune

❑ Pontine stroke

❑ Midbrain stroke

❑ Pure motor hemiplegia

❑ Ataxic hemiparesis

❑ Lateral medullary stroke

❑ Temporal lobe stroke

Hemorrhage

❑ Subarachnoid hemorrhage

❑ Cerebellar hemorrhage

❑ Thalamic hemorrhage

❑ Pontine hemorrhage

❑ Putaminal hemorrhage

Diagnostic Approach

Brain ischemia leading to stroke may be due to embolism from carotid or cardiac sources, systemic hypoperfusion, or in situ thrombosis. Embolic strokes occur suddenly with maximal focal deficits at the onset. Rapid improvement favors an embolic TIA. Thrombosis symptoms fluctuate in a stepwise pattern. Intracerebral hemorrhage progresses gradually over minutes to hours. Aneurysmal subarachnoid hemorrhage occurs in an instant, and focal brain dysfunction is usually absent. Strokelike symptoms due to migraine are recognized by a headache, epiphenomena such as anorexia/nausea and photophobia, and occurrence in younger patients.

A TIA proceeds to stroke in 10% to 40%. Risk is especially high in “crescendo TIA,” which is usually caused by an ulcerated carotid plaque. Amaurosis fugax (“a shade coming down” or transient monocular loss of vision) is a classic presentation. Amaurosis fugax, an anterior circulation event, should be distinguished from transient hemianopsia, a posterior circulation event. An asymptomatic carotid bruit is an imperfect indicator of carotid stenosis and subsequent stroke risk, with an annual risk of an ipsilateral stroke not preceded by a TIA of 1% to 3% per year.

Examination of the optic fundus may reveal a cholesterol crystal, white platelet-fibrin or red clot emboli. Subhyaloid hemorrhage often accompanies a subarachnoid or intracerebral hemorrhage. A red patch with a white center (Roth spot) may be seen in bacterial endocarditis. With occlusion of the carotid artery, the iris may appear speckled and the ipsilateral pupil dilated and poorly-reactive.

Clinical Findings

Middle cerebral artery stroke  Hemiparesis and cortical sensory loss that is greater in the arm and face than in the leg are found along with aphasia or nondominant hemisphere dysfunction. The eyes deviate conjugately toward the side of the lesion. Partial middle cerebral syndromes due to emboli include sensorimotor paresis with little aphasia, conduction aphasia, or Wernicke aphasia without hemiparesis.

Anterior cerebral artery stroke  Presentations include paralysis, apraxia, and cortical sensory loss in the leg only. Frontal lobe findings such as incontinence, slow mentation with perseveration, and grasp and suck reflexes are found.

Posterior cerebral artery stroke  It produces homonymous hemianopsia without motor paresis, prominent sensory loss, alexia without agraphia, inability to name colors, and recent memory loss.

Watershed stroke  There is proximal arm weakness with distal sparing and transcortical aphasia.

Thalamic lacune  A pure sensory stroke occurs with sensory loss in the face, arm, and leg without hemiplegia.

Vertebrobasilar ischemia  Transient vertigo, slurred speech, ataxia, diplopia, homonymous hemianopsia, and alternating or bilateral numbness around the face or lips may occur.

Pontine lacune  Slurred speech with clumsiness and mild weakness of one arm (clumsy hand/dysarthria) occur.

Pontine stroke  A medial pons lesion produces weakness and internuclear ophthalmoplegia. A lateral or tegmental pons lesion produces sensory loss and cerebellar signs.

Midbrain stroke  Weber syndrome consists of mydriasis, ptosis, ophthalmoplegia, and contralateral hemiplegia.

Pure motor hemiplegia  Paralysis of the face, arm, and leg without sensory loss is found with a pontine or internal capsule lacune. If a right hemiplegia is present, there is no aphasia. If a left hemiplegia is present, there are no parietal lobe findings.

Ataxic hemiparesis  Ataxia and weakness of one leg occur in a pontine or internal capsule lacune.

Lateral medullary stroke  Wallenberg syndrome presents with facial numbness, limb ataxia, Horner syndrome, and supraorbital pain with contralateral pinprick and temperature loss. Vertigo, nausea, hiccups, hoarseness, dysphagia, and diplopia are also found.

Temporal lobe stroke  Visual distortions (e.g., micropsia), deja vu sensation, or recurrent fear may be experienced.

Subarachnoid hemorrhage  The classic presentation is sudden onset of a severe headache during activity, associated with an altered level of consciousness and nuchal rigidity. Focal neurological findings are not present unless intracerebral hemorrhage has also occurred. A posterior communicating artery aneurysm may have an associated third nerve palsy. An anterior communicating artery lesion may be associated with frontal lobe dysfunction. A middle cerebral artery aneurysm may have aphasia or nondominant findings. A posterior communicating artery aneurysm may produce symptoms that result from compression of the oculomotor nerve or a “herald bleed” with transient severe headache and neck stiffness, preceding a major hemorrhage.

Cerebellar hemorrhage  Headache, vomiting, and inability to walk are cardinal features. Strength and sensation are usually normal. There is gaze paresis toward the affected side, and there may be a sixth nerve palsy. Nystagmus and limb ataxia are only occasionally present.

Thalamic hemorrhage  Both eyes look down toward the nose and have small, nonreactive pupils. There is marked sensory loss with or without hemiplegia.

Pontine hemorrhage  A patient with this type of hemorrhage will be comatose with pinpoint pupils that react to strong light. The eyes are midposition with no movement to the doll’s eyes maneuver. There is quadriparesis with upgoing toes.

Putaminal hemorrhage  It presents with hemiplegia, headache, field cut, and eye deviation toward the side of the hemorrhage and away from the hemiplegia.  

Pictures

Book Source Details

• Book Title: Field Guide to Bedside Diagnosis
• Author(s): David S. Smith
• Year of Publication: 2007
• Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Field Guide to Bedside Diagnosis Authors: David S. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-78178-165-5

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