STROKE SYNDROMES:

RAPID RECOGNITION & TRIAGE

David Lee Gordon, M.D., FAAN, FANA, FAHA

Professor and Chair
Department of Neurology
The University of Oklahoma Health Sciences Center

OU Neurology
STROKE SYNDROMES: RAPID RECOGNITION & TRIAGE
DISCLOSURES
Under Accreditation Council for Continuing Medical
Education guidelines disclosure must be made
regarding relevant financial relationships with
commercial interests within the last 12 months.
David Lee Gordon, M.D.
I have no relevant financial relationships or affiliations
with commercial interests to disclose.

OU Neurology
 STROKE SYNDROMES: RAPID RECOGNITION & TRIAGE
LEARNING OBJECTIVES
At the end of this session, the attendee will be able to:
Describe the three major types of stroke
Identify the five major stroke syndromes
Relate clinical presentation (stroke syndrome)
to appropriate triage of patients with acute
stroke

OU Neurology
 STROKE DEFINITION & 3 TYPES
Sudden brain dysfunction due to artery problem
Focal Brain Dysfunction

Ischemic Intracerebral Subarachnoid

Stroke Hemorrhage Hemorrhage

85% 10% 5%

Clot blocking Bleeding Bleeding

artery into brain around brain

Diffuse Brain Dysfunction

Primary Stroke Centers manage ischemic strokes.
Comprehensive Stroke Centers manage all three stroke types.
OU Neurology
 STROKE CENTER LEVELS
Parallel Trauma Levels
Level 1 = Comprehensive Stroke Center (TJC certification)
Comprehensive management of AIS, ICH, & SAH including
all therapeutic options and levels of care, including ED,
ASU, NSICU, neurointervention, surgery
Level 2 = Primary Stroke Center (TJC certification)
ED & ASU management of AISdrip & keep
Level 3 = Acute Stroke-Ready Hospital (TJC certification)
ED management of AISdrip & ship
Level 4
Not prepared to manage acute stroke patients
Drip refers to administration of IV tPA; TJC = The Joint Commission;
AIS = acute ischemic stroke; ICH = intracerebral hemorrhage; SAH = subarachnoid
hemorrhage; ED = emergency department; ASU = acute stroke unit;
NSICU = Neurosciences Intensive Care Unit
OU Neurology
 ISCHEMIC STROKE & TIA
Both are usually caused by a traveling blood clot

Acute ischemic stroke (AIS)

Focal brain ischemia with infarction, usually with sequelae,
because clot did not dissolve in time
Equivalent term is cerebral infarction

Transient ischemic attack (TIA)

Focal brain ischemia with transient episode of neurologic
dysfunctionbut NO infarction or sequelae, because clot
dissolved in time
Signals that patient is at risk for an ischemic stroke in the
near futurenext time, the clot may not dissolve in time
Partial seizures and migraines can mimic TIAs
OU Neurology
 ISCHEMIC STROKE & TIA PATHOPHYSIOLOGY
Ischemia to focal area of brain
Usually due to thromboembolus
INFARCT
Thrombus = blood clot
Embolus = floating plug
Blood clot forms in vascular system (arteries or heart),
travels downstream, plugs a brain artery
CLOT Blood clots form for 1 of 2 reasons:
Platelets (Velcro) stick to bumpy pipes (white clot)
Clotting factors (Jello) clump when blood stagnant
(red clot)
Blood clots come from 1 of 3 locations:
Artery esp. hardening of artery wall (atherosclerosis)
Heart esp. irregular heart rhythm (atrial fibrillation)
Blood blood too sticky (hypercoagulable state)

OU Neurology
 ISCHEMIC STROKE TREATMENT
Treat current stroke, prevent future strokes
Acute therapy Time is Brain, Save the Penumbra!
INFARCT Thrombolysis (IV tPA) within 3 or 4.5 hours
Thrombectomy
After IV tPA
With distal ICA or proximal MCA occlusion
CLOT
Do NOT lower blood pressure
Avoid aspiration & IV glucose/dextrose

Secondary prevention Same for AIS & TIA

Vascular risk factor therapy (hypertension, DM, cholesterol, etc.)
Antithrombotic therapy (blood thinners)
Antiplatelet agent(s) or anticoagulant
Carotid revascularization procedure (for ICA stenosis in neck)
Carotid endarterectomy (CEA) or
carotid angioplasty & stenting (CAS)

MCA = middle cerebral artery; ICA = internal carotid artery OU Neurology

 CEREBRAL ARTERY ANATOMY
R ACA
L Anterior Circulation
MCA ICA = internal carotid a.
MCA = middle cerebral a.
ACA = anterior cerebral a.

PCA
Posterior Circulation
Proximal MCA VA = vertebral a.
= M1 segment BA = basilar a.
PCA = posterior cerebral a.
BA
a. = artery
ICA Distal ICA/proximal MCA occlusion
may be eligible for mechanical
VA thrombectomyand time is brain.
Obtain CT angiography (CTA) of
head in all Stroke Alert patients.

Normal MRA, coronal view (looking at patients face)

OU Neurology
 ACUTE ISCHEMIC STROKE PATHOPHYSIOLOGY:
THE PENUMBRA & CORE
Penumbra
Penumbra is zone of reversible
ischemia around core of irreversible Core
infarction during first few hours
after ischemic stroke onset
Penumbra is damaged by:
Low BP hypoperfusion
Hyperglycemia lactic acidosis
Fever metabolic demand
Seizure metabolic demand

Note: Low BP & high blood glucose pen (paene) = almost

hurt the penumbra! umbra = shadow
OU Neurology
 AIS EMERGENCY THERAPIES
Time is brain, save the penumbra!
Tissue plasminogen activator (tPA) IV Penumbra
Thrombolytic (specifically fibrinolytic) agent
Lyses clot & reperfuses penumbra
Core
Saves penumbra neurons & improves patient
outcome if administered within hours of
stroke onset
Different criteria for 3- and 4.5-h windows
May cause fatal intracranial bleeding if given
too latebut excellent safety if given early

Endovascular/IA therapy
= Neurointervention
Clot in
Mechanical thrombectomy Artery
Proven benefit with IV tPA & in pts
w/ distal ICA or proximal MCA (M1) occlusion
& evidence of salvageable penumbra pen (paene) = almost
Maximum benefit & safety w/in 6 h of onset umbra = shadow
OU Neurology
 AIS EMERGENCY THERAPY
IV tissue plasminogen activator (tPA)
Stroke onset = last time known to be without symptoms
FDA-approved < 3 h, consensus guidelines < 4.5 h, but:
The earlier you give IV tPA, the better the outcome
Do NOT give if BP > 185/110 or blood glucose < 50
Disability risk 30% despite ~5% symptomatic ICH risk
Lawsuits for not giving >>> lawsuits for giving
< 3.0 Hours 3.0-4.5 Hours
No upper age limit Do NOT give if:
No limit on stroke size Pt > 80 yo
Can give if taking warfarin & Stroke too large (NIHSS > 25)
INR < 1.7 Ischemia > 1/3 MCA on scan
Taking warfarin at all
DM w/ previous stroke
OU Neurology
 AIS EMERGENCY THERAPY
Neurointervention / IA treatment
Intra-arterial (IA) mechanical thrombectomy using stent
retriever device improves outcomes in acute ischemic
stroke patients if:
Imaging modality (e.g., CT angiography) demonstrates distal
ICA or proximal MCA (M1) occlusion
Performed in addition to IV tPA administration
Performed w/in 6 h of stroke onset (onset-to-groin puncture time)
Patient prestroke neurologic function was good (mRS 0-1)
Patients deficit is severe (NIHSS score > 6) & brain imaging
shows minimal infarction/gray-matter blurring (ASPECTS > 6)
Using IA stent retrievers as described above results in:
mortality
morbidity ( likelihood of functional independence)
OU Neurology
 BRAIN ANATOMY BASICS
View from the side

CEREBRAL CORTEX CEREBRAL SUBCORTEX

gray matter deep white matter wires
computer center gray matter balls
front motor motor modifier (basal ganglia)
back sensory sensory relay (thalamus)
left language
right attention

BRAINSTEM
funnel/connector between
CEREBELLUM cerebrum and spinal cord
coordination nerves to face/head
center (cranial nerves)
primitive centers
OU Neurology
BRAIN ANATOMY BASICS
View from the front
Cerebral cortex (LEG)
Cerebral
Cerebral cortex (ARM) Cortex
Cerebral cortex (FACE)

Deep white matter

Cerebral
Thalamus Subcortex
Basal ganglia

Brainstem
Cerebellum

OU Neurology
 BRAIN ANATOMY BASICS
View from the front with cerebral artery territories
Cerebral cortex (LEG)
ACA Cerebral
Cerebral cortex (ARM) Cortex
MCA Cerebral cortex (FACE)

Deep white matter

Cerebral
Thalamus Subcortex
Basal ganglia

PCA Brainstem
ACA = anterior cerebral artery
Cerebellum MCA = middle cerebral artery
PCA = posterior cerebral artery

OU Neurology
 BRAIN ANATOMY BASICS
MCA infarction also involves leg if blockage at beginning of M1

MCA supplies:
L
MCA A Cortex for face & arm AND
F Subcortex for face, arm, leg

Blockage of:
End of M1 segment causes
only face &/or arm
symptoms
Beginning of M1 segment
causes face, arm, & leg
symptoms

OU Neurology
5 MAJOR STROKE SYNDROMES

1. Left hemisphere
1
2. Right hemisphere 2
5
3. Brainstem

4. Cerebellum
4
5. Possible hemorrhage 3

OU Neurology
 5 MAJOR STROKE SYNDROMES
And Correlation w/ Ischemic Stroke Arteries
& Intracerebral Hemorrhage Locations
Ischemic Intracerebral
Stroke Stroke Hemorrhage 1
Syndrome Main Arteries Common 2
Involved Locations 5
1. Left Hemisphere L MCA
L basal ganglia
L thalamus
4
2. Right Hemisphere R MCA
R basal ganglia
R thalamus 3
3. Brainstem
BA Pons MCA = middle cerebral artery
BA = basilar artery
4. Cerebellum BA or VA VA = vertebral artery
L/R cerebellum
branches
5. Possible Hemorrhage

OU Neurology
 LEFT (DOMINANT) HEMISPHERE
Typical signs: Right body deficits (visual, motor, sensory), aphasia

Right Visual Aphasia

Field Deficit (Expressive &/or
Receptive)*
Right Hemiparesis
Right Hemisensory Left Gaze Deviation
Loss (Preference)

M1 OCCLUSION MORE
LIKELY IF ALL FINDINGS
ARE PRESENT: *Expressive (motor) aphasia:
Assoc w/ paresis (weakness)
Aphasia
Visual field deficit Receptive (sensory) aphasia:
Gaze preference Assoc w/ sensory, visual field loss
Hemiparesis (at least F & A)
Hemisensory loss (at least F & A)

OU Neurology
 LEFT HEMISPHERE SYNDROMES
L MCA infarctions w/ CT-exam correlations
Small-artery occlusion End-of-M1 Occlusion Beginning-of-M1 Occlusion
Unlikely thrombectomy Possible thrombectomy Possible thrombectomy

Subcortex infarction Cortex infarction Subcortex + cortex infarction

R hemiparesis (F, A, L) Aphasia Aphasia
R hemisensory loss (F, A, L) L gaze preference L gaze preference
R visual field deficit R visual field deficit
R hemiparesis (F, A) R hemiparesis (F, A, L)
R hemisensory loss (F, A) R hemisensory loss (F, A, L)

MCA ACA PCA infarction

F = face, A = arm, L = leg OU Neurology
 RIGHT (NONDOMINANT) HEMISPHERE
Typical signs: Left body deficits (visual, motor, sensory), neglect

Left Hemi-inattention
(Neglect)

Left Visual Field

Right Gaze Deviation Deficit
(Preference)

Left Hemiparesis
M1 OCCLUSION MORE
LIKELY IF ALL FINDINGS Left Hemisensory
ARE PRESENT: Loss
Neglect
Visual field deficit
Gaze preference
Hemiparesis (at least F & A)
Hemisensory loss (at least F & A)

OU Neurology
 RIGHT HEMISPHERE SYNDROMES
R MCA infarctions w/ CT-exam correlations
Small-artery occlusion End-of-M1 Occlusion Beginning-of-M1 Occlusion
Unlikely thrombectomy Possible thrombectomy Possible thrombectomy

Subcortex infarction Cortex infarction Subcortex + cortex infarction

L hemiparesis (F, A, L) Neglect Neglect
L hemisensory loss (F, A, L) R gaze preference R gaze preference
L visual field deficit L visual field deficit
L hemiparesis (F, A) L hemiparesis (F, A, L)
L hemisensory loss (F, A) L hemisensory loss (F, A, L)

MCA ACA PCA infarction

F = face, A = arm, L = leg OU Neurology
 BRAINSTEM
Typical signs: Bilateral long-tract signs or crossed signs

Bilateral
Long-tract Signs
Quadriparesis Crossed Signs
One side of face &
Sensory Loss contralateral body
in All 4 Limbs
Hemiparesis
Hemisensory Loss

OU Neurology
 BRAINSTEM
Typical signs: Primitive center deficits, cranial nerve deficits

Primitive Center Deficits Cranial Nerve Deficits

Consciousness Vertigo, Tinnitus
Nausea, Vomiting
Hiccups, Abnormal
Respirations Eye Movement
Cranial Nerve Deficits Abnormalities:
Oropharyngeal Diplopia
Weakness: Dysconjugate Gaze
Dysarthria, Dysphagia Gaze Deviation (Palsy)

Dysarthria = poor articulation when speaking Tinnitus = ringing in the ears

Dysphagia = difficulty swallowing Diplopia = double vision
Vertigo = hallucination of movement Dysconjugate = not conjoined

OU Neurology
 CEREBELLUM
Typical signs: Dyscoordination (= ataxia) of limb(s), trunk

Ipsilateral Limb Truncal or Gait

Ataxia Ataxia
(dyscoordination) (imbalance w/
wide-based gait)

Note:
Cerebellum controls
same side of body
because cerebral cortex
controls opposite side of
cerebellum

OU Neurology
 HEMORRHAGE &
THE BRAIN COVERINGS
Two Types of
Spontaneous (nontraumatic)
Cranium (skull): hard Intracranial Hemorrhage
container enclosing brain
Intracerebral Subarachnoid
Meninges: 3-layered sack Hemorrhage Hemorrhage
surrounding brain and (ICH) (SAH)
spinal cord, lined with pain
nerves
Both ICH & SAH: suddenly
increase intracranial
pressure (ICP)
SAH: irritates meninges Bleeding
into brain
Bleeding
around brain

OU Neurology
 FINDINGS CONSISTENT WITH
INTRACRANIAL HEMORRHAGE
Both Subarachnoid
Subarachnoid Hemorrhage:
and Intolerance to light
Intracerebral Neck stiffness / pain
Hemorrhage: (due to meningeal irritation)
Headache
Nausea, vomiting Intracerebral
Consciousness Hemorrhage:
(due to ICP) Focal signs such
as hemiparesis
(due to focal lesion)

OU Neurology
 ISCHEMIC STROKE MIMICS
Differential diagnosis of sudden onset focal neurologic deficit

Intracerebral hemorrhage CT
Tumor with bleed or partial seizure CT
Abscess with partial seizure CT
Subdural hematoma (esp. acute on chronic) CT
Hypoglycemia labs (fingerstick glucose)
Toxic-metabolic insult w/ old cerebral lesion labs/normal MRI (DWI)
Partial seizure w/ postictal state History
Migraine History/normal MRI (DWI)
Conversion reaction (rare) History/normal MRI (DWI)

If patients symptoms completely resolve,

the differential diagnosis of transient neurologic deficits
is TIA, seizure, migraine
OU Neurology
 HEMISPHERE STROKE SYNDROMES
CT Correlations
ISCHEMIC INTRACEREBRAL HEMORRHAGE
STROKE Basal Ganglia Thalamus

Normal
sulcus
Blurring of gray-white junction
Sulcal effacement
Hemiparesis + Hemiparesis + Hemiparesis +
aphasia/neglect, VF deficit, gaze Depending on size of ICH, may be associated w/
preference, hemisensory loss all hemisphere signs + ICP signs
OU Neurology
 BRAINSTEM STROKE SYNDROMES
CT Correlations
ISCHEMIC STROKE INTRACEREBRAL HEMORRHAGE
Basilar artery occlusion Pontine ICH

Vertigo, dysarthria, dysphagia, Coma w/

nausea, quadriparesis, abnormal abnormal eye movements
eye movements, LOC
Case courtesy of Dr Donna D'Souza, Radiopaedia.org, rID: 3829

OU Neurology
 CEREBELLUM STROKE SYNDROMES
CT Correlations
ISCHEMIC INTRACEREBRAL
STROKE HEMORRHAGE

Right
Cerebellum
plus
Right
ICP
Cerebellum
plus
brainstem
compression

Right hemiataxia, cant walk, Posterior headache, nausea,

+/- nausea vomiting, right hemiataxia,
cant walk coma +

OU Neurology
 STROKE SYNDROMES: RAPID RECOGNITION & TRIAGE
LEARNING OBJECTIVES
At the end of this session, the attendee will be able to:
Describe the three major types of stroke
Identify the five major stroke syndromes
Relate clinical presentation (stroke syndrome)
to appropriate triage of patients with acute
stroke

OU Neurology
THE END

OU Neurology