Acute Stroke Management Resource:

Types of Stroke &

Anatomy and Physiology of Acute Stroke
2007
Types of Stroke
 Objectives
 To review the two common types of stroke
 To review the stroke mechanism for the two common
types of stroke
 To review the etiology of the two types of stroke
 To describe common patient presentations of stroke
mimics
Ischemic (80%) Hemorrhagic (20%)
Mechanism of Stroke
Feature Hemorrhage Infarct
Onset sedentary With activity Nocturnal

Hypertension present Usually present Often

Clinical course static Rapidly progressive Stepwise or static

Signs of ICP Present Absent later

CT scan changes Presence of blood Normal or subtle

changes
CT: Intracerebral Hemorrhage

Intracerebral
hemorrhage

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Ischemic Stroke: Hyperdense MCA
Sign
Hyperdense MCA sign

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Ischemic Stroke: Early CT Signs
 Hyperdense middle
cerebral artery sign
 Subtle decreased
attenuation of grey matter
 Loss of grey-white
differentiation
 Loss of cortical ribbon
 “Disappearing” basal ganglia
 Early mass effect
 Sulcal effacement
 Shift
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Ischemic Stroke: Etiology
 Large Vessel Disease
 Cardioembolic
 Atherosclerosis
 Small Vessel Disease
 Lacunar Infarction
 Cryptogenic
Intracerebral Hemorrhage: Etiology
 Secondary  Primary
 Vascular Malformations  Chronic hypertension
 Aneurysms  Cerebral amyloid angiopathy
 Tumors  Anticoagulant/fibrinolytic
 Hemorrhagic transformation use
of cerebral infarction  Antiplatelet use
 Venous infarction with  Drug use
hemorrhage secondary to  Other bleeding diathesis
cerebral venous thrombosis
 Moya Moya disease
Stroke Mimics
 The following four conditions represent 62% of stroke
mimics
 Postictal deficit (unrecognized seizure)
 Systemic infection
 Tumour/abscess
 Toxic-metabolic disturbance
 Other mimics
 Bell’s palsy
 Peripheral nerve palsies
 Old stroke
 Confusion
 Head trauma
Acute Stroke Management Resource
Anatomy and Physiology Review
Objectives
 Review the major blood vessels of the cerebral
circulation
 Anterior Cerebral Artery
 Middle Cerebral Artery
 Posterior Cerebral Artery
 Review the key functional areas of the brain
 List the common patient presentations related to
carotid, vertebrobasilar and lacunar syndromes
Cerebrum Corpus Callosum

 Largest portion
 Two hemispheres
 Joined by the corpus
callosum
 Dominance

www.disenchanted.com/images/dictionary/corpus_callosum.gif
Left and Right Hemisphere
Right Hemisphere Left Hemisphere
 Spatial-perceptual deficits  Expressive aphasia
 Left sided weakness/sensory  Receptive aphasia
loss  Global aphasia
 Neglect of the affected side  Right sided weakness/sensory
 Distractible loss
 Impulsive behavior  Intellectual impairment- alexia,
 Poor judgment agraphia, acalulia
 Loss of flow of speech  Slow and cautious behavior

 Defects in left visual field-  Defects in right visual field-

homonymous hemianopsia homonymous hemianopsia

Cerebral Cortex
 Divided into 4 lobes
 Frontal
 Parietal
 Temporal
 Occipital

www.tbirecoverycenter.org/treatment.htm
Blood Supply to the Brain
 Arterial supply from carotid and
vertebral arteries which begin
extracranially
 Internal carotid arteries supply
anterior 2/3 of hemispheres
 Vertebral and basilar arteries
supply posterior and medial
regions of hemispheres,
brainstem, diencephalon,
cerebellum and cervical spinal
cord
www.heartandstroke.ca/profed
Circulation Review
 Circle of Willis
 Anterior Cerebral Artery (ACA)
 Anterior Communicating Artery Anterior Circulation
 Middle Cerebral Artery (MCA)
 Posterior Communicating Artery
Posterior Circulation
 Posterior Cerebral Artery (PCA)
Circle of Willis
Anterior Cerebral Artery
Anterior Cerebral Artery
 Arises from internal carotid
 Supplies anterior portion of
basal ganglia, corpus callosum,
medial and superior portions of
frontal lobe and anterior
parietal lobe
 Key Functional Areas:
 Primary motor cortex for leg
and foot areas, urinary bladder
 Motor planning in medial
frontal lobe
 Middle and anterior corpus
callosum- communication www.cnsforum.com
between hemispheres
Anterior Cerebral Artery
Middle Cerebral Artery Middle Cerebral Artery
 Arises from the internal carotid
 Passes laterally under frontal
lobe and between the temporal
and frontal lobes
 M1 segment- lentriculostriate
arteries supply basal ganglia
and most of internal capsule
 Superior MCA branch- supplies
lateral and inferior frontal lobe
and anterior parts of parietal
lobe
 Inferior MCA branch-supplies
lateral temporal lobe, posterior
parietal and lateral occipital www.cnsforum.com
lobe
Middle Cerebral Artery
 Key Functional Areas
 Primary motor cortex for face, arm and leg
 Brocas language area (Superior MCA)
 Wernickes language area (Inferior MCA)
 Primary somatosensory cortex for face, arm, leg
 Parts of lateral frontal and parietal lobes used in 3D
visual-spatial perceptions of own body, outside world
and ability to interpret and/or express emotions
Middle Cerebral Artery
Posterior Cerebral Artery
Posterior Cerebral Artery
 Blood supply for midbrain,
hypothalamus and thalamus,
posterior medial parietal lobe,
corpus callosum, inferior and
medial temporal lobe and
inferior occipital lobe
 Key Functional Areas:
 Primary visual cortex
 3rd nerve in midbrain
 Sensory control-temperature,
pain, sleep, ADH
 Communication between
hemispheres www.cnsforum.com
Posterior Cerebral Artery

www.strokecenter.org
Vertebrobasilar Circulation
 Arise from the subclavian
arteries
 Run alongside the medulla
 Blood supply for brainstem and
cerebellum
 Key Functional Areas:
 Spinal cord tracts-pyramidal
and spinothalamic
 Cranial nerves 3-12
www.ib.amwaw.edu.pl/anatomy/atlas/image_12e.htm
Vertebrobasilar Circulation
1- Posterior Cerebral
2- Superior Cerebellar
3- Pontine Branches of Basilar
4- Anterior Inferior Cerebellar
5- Internal Auditory
6- Vertebral
7- Posterior Inferior Cerebellar
8- Anterior Spinal
9- Basilar
www.ib.amwaw.edu.pl/anatomy/atlas/image_12e.htm
Cerebellum
 Blood supply-own arteries
from vertebrobasilar
 Superior cerebellar
 Anterior Inferior
 Posterior Inferior
 Major Functions
 Control of fine motor
movement
 Coordinates muscle groups
 Maintains balance,
equilibrium www.daviddarling.info/images/cerebellum.jpg
Cerebellar Blood Supply

www.answers.com
Brain Stem
 Blood supply: PCA & Vertebrobasilar
 Major divisions: midbrain, pons, medulla
 Houses Cranial Nerves 3-12
 Serves as a pathway
 Reticular Activating System
Cranial Nerves

http://images.encarta.msn.com/xrefmedia/aencmed/targets/illus/ilt/T012872A.gif
Reticular Activating System

www.colorado.edu/Kines/Class/IPHY3730/image/figure5-29.jpg
Collateral Circulation
 Not all vessels have capability – lenticulostriate
 Common sites:
o External and internal carotid via opthalamic artery
o Intracranial vessels of the Circle of Willis
o Small cortical branches of ACA, MCA,PCA and cerebellar
arteries
Collateral Circulation
 Effectiveness depends on vessel size
 Effectiveness depends upon speed of occlusion
 Atherosclerosis
 Circle
of Willis: vessels are often narrow and
cannot adapt for sudden onset of blockage
Collateral Circulation

www.clevelandclinic.org/heartcenter/images/guide/disease/cad/artery7.jpg
Acute Stroke Management Resource
Stroke Syndromes and Patient Presentations
Ischemic Stroke: Carotid Syndromes
 Sensory/motor deficit
 Aphasia
 Cortical sensory loss
 Apraxia, neglect
 Retinal ischemia
 Visual field deficit

www.valleyhealth.com/images/image_popup/bn7_functionalbrain.jpg
Ischemic Stroke: Vertebrobasilar Syndrome
 Diplopia
 Vertigo
 Coma at onset
 Crossed sensory loss
 Bilateral motor signs
 Isolated field defect
 Pure motor and sensory
deficit
 Dysarthria
 Dysphagia www.state.sc.us/ddsn/pubs/head/brain.gif
Ischemic Stroke: Lacunar Syndromes
 Makes up 25% of all ischemic strokes
 Presumed to be occlusion of single small perforating
artery
 Predominantly in the deep white matter, basal ganglia,
pons
 Blood vessel: lenticulostriate branches of the Anterior
Cerebral and Middle Cerebral Arteries
 30% of patients are left dependant and some long term
data suggests up to 25% have a second stroke
within 5 years (Wardlaw, 2007)
Ischemic Stroke: Lacunar Syndromes
Ischemic Stroke: Lacunar Syndromes

www.clevelandclincimeded.com/diseasemanagement/neurology/stroke/images/figure3.jpg
Ischemic Stroke: Lacunar Syndromes
Type of Syndrome Patient Presentation

Pure motor hemiparesis Contralateral Hemiparesis of face,

Results from an infarct in the arm and leg, dysarthria
internal capsule or pons

Contralateral motor Hemiparesis of face, arm and leg

hemiparesis with motor with inability to speak
aphasia
Results from an infarct of the left
frontal area with cortical
involvement
Ischemic Stroke: Lacunar Syndromes
Type of Syndrome Patient Presentation
Ataxic hemiparesis Paresis of the contralateral leg and
Results from an infarct in the pons side of the face, ataxia of the
contralateral leg and arm
Dysarthria and clumsy hand Dysarthria, dysphagia, contralateral
syndrome facial and tongue weakness, paresis
Results from an infarct in the pons and clumsiness of the contralateral
or internal capsule arm and hand
Pure sensory stroke Contralateral sensory loss to all
Results from an infarct in the modalities that usually affect the
thalamus face, upper and lower extremities
May be painful
Case Examples
 Add patient case examples of:
 Anterior circulation strokes
 Posterior circulation strokes
 Lacunar Infarcts
Ischemic Stroke: Left (dominant)
Hemisphere Stroke
 Aphasia
 Right field defect
 Left gaze preference
 Right upper motor neuron
facial weakness
 Right hemiparesis
 Right hemisensory loss

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Ischemic Stroke: Right (non-dominant)
Hemisphere Stroke
 Left neglect, inattention
 Left field defect
 Right gaze preference
 Left upper motor neuron
facial weakness
 Left hemiparesis
 Left hemisensory loss,
sensory extinction
www.heartandstroke.ca/profed
Ischemic Stroke: Cerebellar Infarct
 Headache, nausea/vomiting
 Vertigo, imbalance
 Normal tone, power,
reflexes
 Inability to sit or stand
 Ataxia
 Late signs
 Decreasing level of
consciousness
 Diplopia, gaze palsy www.heartandstroke.ca/profed
 Ipsilateral V,Vll impairment
Ischemic Stroke: Brainstem Stroke
 Decreased LOC
 Crossed findings
 Ipsilateral lower motor neuron
facial weakness or sensory loss
 Contralateral hemiparesis
 Pupillary changes
 Hiccoughs, vertigo
 Bilateral motor findings
 Diplopia, gaze palsies,
intranuclear opthalmoplegia
 Dysphagia
 Dysarthria www.heartandstroke.ca/profed
 Ataxia
Conclusions
 Rapid assessment and triage key to optimal
treatment
 CT scan required to exclude hemorrhage
 Knowledge of typical stroke symptoms key
 Anatomical and etiological diagnosis necessary
 Exclusion of stroke mimics vital
Resources
 American Association of Neuroscience Nurses
www.aann.org
 American Stroke Association
www.strokeassociation.org
 Brain Attack Coalition
www.stroke-site.org
 Canadian Hypertension Education Program
www.hypertension.ca/chep/en/default.asp
 Canadian Stroke Strategy
www.canadianstrokestrategy.ca
 European Stroke Initiative
www.eusi-stroke.com
Resources
 Heart and Stroke Foundation Prof Ed
www.heartandstroke.ca/profed
 Heart and Stroke Foundation of Canada
www.heartandstroke.ca
 Internet Stroke Centre
www.strokecenter.org
 National Institute of Neurological Disorders and Stroke
www.ninds.nih.gov
 National Stroke Association
www.stroke.org/site/PageServer?pagename=HOME
 Scottish Intercollegiate Guidelines Network
www.sign.ac.uk
 StrokeEngine
www.medicine.mcgill.ca/strokengine