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Stroke – Types, Causes, Symptoms, Diagnosis, Treatment

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Stroke is a neurological deficit of cerebrovascular causes the sudden death of brain cells due to lack of oxygen, caused by blockage of blood flow or rupture of an artery to the brain. Sudden loss of speech, weakness, or paralysis of one side of the body can be symptoms. A suspected stroke may be confirmed by scanning the brain.

 is defined by the World Health Organization as ‘a clinical syndrome consisting of rapidly developing clinical signs of focal (or global in case of coma) disturbance of cerebral function lasting more than 24 hours or leading to death with no apparent cause other than a vascular origin.’ A transient ischaemic attack () is defined as stroke symptoms and signs that resolve within 24 hours. There are limitations to these definitions. The symptoms of a TIA usually resolve within minutes or a few hours at most and anyone with continuing neurological signs when first assessed should be assumed to have had a stroke. ‘Brain Attack’ is sometimes used to describe any neurovascular event and maybe a clearer and less ambiguous term to use.

A cerebellar infarct (or cerebellar stroke) is a type of cerebrovascular event involving the posterior cranial fossa, specifically the cerebellum. Impaired perfusion reduces oxygen delivery and causes deficits in motor and balance control. In the case of hemorrhagic events, bleeding can directly damage tissue and worsen these deficits. While comprising a small fraction of strokes, cerebellar strokes are responsible for a disproportionate share of morbidity and mortality due to their sometimes subtle initial presentation and the adverse effects of reactive swelling in the posterior fossa. Of all brain strokes, Cerebellar strokes account for 1% – 4%.

Types of Stroke

Ischemic Stroke

  • Most strokes (87%) are ischemic strokes.1 An ischemic stroke happens when blood flow through the artery that supplies oxygen-rich blood to the brain becomes blocked. Blood clots often cause the blockages that lead to ischemic strokes.

Hemorrhagic Stroke

  • A hemorrhagic stroke happens when an artery in the brain leaks blood or ruptures (breaks open). The leaked blood puts too much pressure on brain cells, which damages them.
  • High blood pressure and aneurysms—balloon-like bulges in an artery that can stretch and burst—are examples of conditions that can cause a hemorrhagic stroke.

There are two types of hemorrhagic strokes

  • Intracerebral hemorrhage – is the most common type of hemorrhagic stroke. It occurs when an artery in the brain bursts, flooding the surrounding tissue with blood.
  • Subarachnoid hemorrhage – is a less common type of hemorrhagic stroke. It refers to bleeding in the area between the brain and the thin tissues that cover it.

Transient Ischemic Attack (TIA)

  • For Blanche Teal-Cruise, a smoker for 40 years who also had high blood pressure, the transient ischemic attack (sometimes called a mini-stroke) she had on the way to work was a wake-up call.
  • A transient ischemic attack (TIA) is sometimes called a “mini-stroke.” It is different from the major types of stroke because blood flow to the brain is blocked for only a short time—usually no more than 5 minutes.

Features of middle cerebral artery stroke

  • Contralateral hemiparesis and hypesthesia (Weakness of arm& face is worse than in the lower limb)
  • Gaze towards to side of the lesion
  • Ipsilateral hemianopsia
  • Receptive or expressive aphasia is dominant hemisphere is affected
  • Agnosia
  • Inattention, neglect

Features of anterior cerebral artery stroke

  • Speech is preserved but there is a disinhibition
  • Mental status is altered
  • Judgment is impaired
  • Contralateral cortical sensory deficits
  • Contralateral weakness greater in legs than arms
  • Urinary incontinence
  • Gait apraxia

Posterior cerebral artery stroke

  • Cortical blindness
  • Contralateral homonymous hemianopsia
  • Altered mental status
  • Visual agnosia
  • Memory impairment

Vertebral/basilar artery stroke

  • Nystagmus
  • Vertigo
  • Diploma and visual field deficits
  • Dysarthria
  • Dysphagia
  • Syncope
  • Facial hyperesthesia
  • Ataxia

Subtypes

  • Pure motor hemiparesis – The patient presents with weakness on one side of the body (face, arm, and leg) without cortical signs and sensory symptoms.
  • Pure sensory stroke – The patient presents with unilateral numbness of the face, arm, and leg without cortical signs or motor deficits. All sensory modalities will be impaired.
  • Ataxic hemiparesis – These patients present with unilateral limb ataxia and weakness that is out of proportion to the strength/motor deficit. Patients may also exhibit other ipsilateral cerebellar signs such as dysarthria, dysmetria, and nystagmus without exhibiting cortical signs.
  • Sensorimotor stroke – Patients present with weakness and numbness of the face, arm, and leg without cortical signs. Cortical function testing must be done meticulously to distinguish between a frontoparietal lobe (MCA) stroke and a subcortical stroke (posterior thalamus and internal capsule).
  • Dysarthria-clumsy hand syndrome – This is the least common of all lacunar syndromes. Patients present with facial weakness, dysarthria, dysphagia and dysmetria/clumsiness of one upper extremity.

If the area of the brain affected includes one of the three prominent central nervous system pathways—the spinothalamic tract, corticospinal tract, and the dorsal column–medial lemniscus pathway, symptoms may include:

  • hemiplegia and muscle weakness of the face
  • numbness
  • reduction in sensory or vibratory sensation
  • initial flaccidity (reduced muscle tone), replaced by spasticity (increased muscle tone), excessive reflexes, and obligatory synergies.[rx]

In addition to the above CNS pathways, the brainstem gives rise to most of the twelve cranial nerves. A brainstem stroke affecting the brainstem and brain, therefore, can produce symptoms relating to deficits in these cranial nerves

  • altered smell, taste, hearing, or vision (total or partial)
  • drooping of the eyelid (ptosis) and weakness of ocular muscles
  • decreased reflexes: gag, swallow, pupil reactivity to light
  • decreased sensation and muscle weakness of the face
  • balance problems and nystagmus
  • altered breathing and heart rate
  • weakness in sternocleidomastoid muscle with the inability to turn head to one side
  • weakness in the tongue (inability to stick out the tongue or move it from side to side)

If the cerebral cortex is involved, the CNS pathways can again be affected, but also can produce the following symptoms

  • aphasia (difficulty with verbal expression, auditory comprehension, reading, and writing; Broca’s or Wernicke’s area typically involved)
  • dysarthria (motor speech disorder resulting from neurological injury)
  • apraxia (altered voluntary movements)
  • visual field defect
  • memory deficits (involvement of temporal lobe)
  • hemineglect (involvement of parietal lobe)
  • disorganized thinking, confusion, hypersexual gestures (with the involvement of frontal lobe)
  • lack of insight of his or her, usually stroke-related, disability

If the cerebellum is involved, ataxia might be present and this includes

  • altered walking gait
  • altered movement coordination
  • vertigo and or disequilibrium

Symptoms associated with PCA strokes like diplopia, visual field defects, dysphagia, vertigo, alteration in consciousness, memory impairment, or difficulty reading may help us to understand the localization of stroke.

Visual Field Defects

  • PCA and deep branches of MCA supply the optic radiations. The lower part of the optic radiations receives blood supply from the PCA. The upper part gets blood supply from the MCA.
  • Unilateral infarctions of the occipital lobe may cause contralateral homonymous hemianopia with macular sparing.
  • Quadrantanopia may be seen if the defect is limited. If there is an infarction in the temporal lobe involving the Meyer loop or infracalcarine, it may present with superior quadrantanopia. Inferior quadrantanopia is caused by infarctions in the optic radiation of the inferior parietal lobe or supracalcarine. In a study with pure superficial PCA strokes in 117 patients, 26 (22%) presented with quadrantanopia. Twenty (17%) is superior.
  • Visual field defects (hemianopia, quadrantanopia, deuteranopia), hemisensory deficit, and neuropsychological dysfunction (transcortical aphasia, memory disturbances) may be seen after occlusion of the posterior choroidal artery.
  • Bilateral infarction of the occipital lobes may cause cortical blindness. The patient may have visual anosognosia. The patient is not aware of her/his deficit. The patient may confabulate and deny blindness.

Visual Dysfunction 

  • Visual Agnosia: Patients may not understand or describe uses for the objects seen. Patients can name objects when they touch them or when the objects are described to them. The two forms of visual agnosia are apperceptive and associative. Apperceptive involves poor perception and ability to understand while associative involves a poor ability to match and use. It is caused by a large left PCA stroke, which likely causes a disconnect between language and visual systems.
  • Prosopagnosia is difficulty recognizing familiar faces due to lesions in the inferior occipital areas, fusiform gyrus, and the anterior temporal cortex. In literature, deficits are shown in the right PCA territory only.
  • Alexia refers to difficulty in reading. Alexia without agraphia (pure alexia) is caused by a lesion to the dominant occipital lobe and splenium of the corpus callosum and is often accompanied by right homonymous hemianopia.
  • Achromatopsia refers to difficulty perceiving colors. It is due to infarctions in the ventral occipital cortex and/or infracalcarine. The patient may present with hemiachromatopsia if the infarction is unilateral. Tests to check for achromatopsia are Ishihara color plates or the Farnsworth-Munsell 100-hue test.

Cognitive and Behavioral Dysfunction

  • Aphasia can be due to an infarction large enough to cover the left parietal lobe or temporal lobe. Transcortical sensory aphasia is caused by infarctions to the parietal-occipital region on the left side. The patient may have amnestic aphasia (inability to name but repetition and comprehension intact) due to infarction to the left temporal lobe of PCA territory.
  • Memory impairment is caused by infarction of the hippocampus and parahippocampus.
  • Aggressive behavior can be caused by PCA strokes as well. In a study 41 PCA stroke patients, 3 (7.3%) patients showed aggressive behavior such as shouting obscenities and hitting and bitting others. These patients may become anxious, aggressive, and frustrated when they are stimulated by the environment.
  • Hallucinations are uncommon but may develop from PCA strokes to any side of the brain.
  • Palinopsia refers to seeing images persist even after an image has been removed. Infarctions can be in the lingual and fusiform gyri.

Other Dysfunctions

  • Midbrain infarction may present differently, depending on the location of infarction. Patients may present with ataxic hemiparesis due to an anterolateral midbrain infarction or oculomotor or pupillary problems due to a paramedian rostral midbrain infarction.
  • Pure sensory stroke may result from a lesion in the ventral posterolateral nucleus, which receives the blood supply from thalamogeniculate (inferolateral) arteries.
  • Infractions to the artery of Percheron infarction can result in bilateral paramedian thalamus infarction with or without midbrain involvement. Patients may present with confusion, hypersomnolence, dysarthria, amnesia, and ocular movement disorders.
  • Balint syndrome is caused by infarctions to the bilateral occipitoparietal border. This presents with optic ataxia (inability to reach targets one is looking at), oculomotor apraxia (inability to intentionally move eyes towards an object), and simultagnosia (inability to synthesize objects within a visual field).
  • Anton syndrome is due to a sudden onset of bilateral occipital strokes leading to cortical blindness. The patient will deny the blindness.

Symptoms of Stroke

The words BE FAST can help you recognize stroke signs:

  • (B)Balance: Sudden loss of balance.
  • (E)Eyes: Sudden loss of vision in one or both eyes
  • (F)ACE. Ask the person to smile. Check to see if one side of the face droops.
  • (A)RMS. Ask the person to raise both arms. See if one arm drifts downward.
  • (S)PEECH. Ask the person to repeat a simple sentence. Check to see if words are slurred and if the sentence is repeated correctly.
  • (T)IME. If a person shows any of these symptoms, time is essential. It is important to get to the hospital as quickly as possible.

Common Signs of Stroke

Common signs of a stroke include sudden weakness, numbness and signs of paralysis, speech problems, trouble seeing, dizziness, difficulty walking, and a severe headache. Usually, only one side of the body is affected, making it impossible to move the right arm and/or right leg, for example. Nausea and vomiting are also possible symptoms. The type and severity of stroke symptoms depend on the area of the brain that is affected.

Signs and symptoms of stroke in both men and women may include:

  • Sudden numbness, weakness, or inability to move the face, arm, or leg (especially on one side of the body)
  • Confusion
  • Trouble speaking or understanding speech
  • Trouble seeing in one or both eyes
  • Dizziness, trouble walking, or loss of balance or coordination
  • Sudden, severe headache (often described as “the worst headache of my life”)
  • Trouble breathing
  • Loss of consciousness

If the area of the brain affected contains one of the three prominent central nervous system pathways—the spinothalamic tract, corticospinal tract, and dorsal column (medial lemniscus), symptoms may include:

  • hemiplegia and muscle weakness of the face
  • numbness
  • reduction in sensory or vibratory sensation
  • initial flaccidity (reduced muscle tone), replaced by spasticity (increased muscle tone), excessive reflexes, and obligatory synergies.
  • altered smell, taste, hearing, or vision (total or partial)
  • drooping of eyelid (ptosis) and weakness of ocular muscles
  • decreased reflexes: gag, swallow, pupil reactivity to light
  • decreased sensation and muscle weakness of the face
  • balance problems and nystagmus
  • altered breathing and heart rate
  • weakness in sternocleidomastoid muscle with the inability to turn head to one side
  • weakness in tongue (inability to stick out the tongue or move it from side to side)

If the cerebral cortex is involved, the CNS pathways can again be affected, but also can produce the following symptoms:

  • aphasia (difficulty with verbal expression, auditory comprehension, reading, and writing; Broca’s or Wernicke’s area typically involved)
  • dysarthria (motor speech disorder resulting from neurological injury)
  • apraxia (altered voluntary movements)
  • visual field defect
  • memory deficits (involvement of temporal lobe)
  • hemineglect (involvement of parietal lobe)
  • disorganized thinking, confusion, hypersexual gestures (with the involvement of frontal lobe)
  • lack of insight of his or her, usually stroke-related, disability

If the cerebellum is involved, ataxia might be present and this includes:

  • altered walking gait
  • altered movement coordination
  • vertigo and or disequilibrium

Stroke Symptoms in Women

Stroke is the third leading cause of death in women (and the fifth leading cause of death in men).

Each year stroke kills twice as many women as breast cancer, according to the National Stroke Association.

The stroke symptoms women may experience can be different from those experienced by men. These include:

  • Fainting
  • Difficulty or shortness of breath
  • Sudden behavioral changes
  • Agitation
  • Hallucination
  • Nausea or vomiting
  • Seizures
  • Hiccups

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