⚜ Case: A young girl , her father complains that she was very polite and wise then suddenly

she became
shameless and extravert, after 1 & half months she started to have dysphasia &drop of some words in while
speaking , she seeked neurologist, by examination she had emotional numbing , dysphasia, the neurologist
said that she have organic lesion in frontoparatemporal region, because speech center are present front-
temporal area & he told them to do MRI, After doing MRI , She diagnosed by having "Brain tumor", so (
Organic lesion could be presented by psychiatric Manifestations ).

(Hemi= half , Plegia=paralysis)

(v.i.p.)

U.M.Neurons (1ry motor area 4 ,premotor area 6) in frontal & temporal lobes nerve fibers will pass to ➡ Corona
radiata (subcortix) ➡ then to Internal Capsule ➡ thin to Midbrain ➡ thin to Pons ➡ thin to Medulla ( here
Decussation happens ). So, lesion in left frontal lobe will cause Right sided hemiplegia (contralateral hemiplegia).

✴ Developmental (Intrauterine life), (Archinoid cyst in brain witch will cause lack of brain formation &
cause compression on pyramidal tract causing Hemiplegia).

✴ Traumatic {car accidents, head Trauma, spine Trauma, fracture spine, large Subdural hematoma,
depressed fructure of skull , birth trauma (ventose: witch will cause cephalohematoma & Intracranial Hemorrhage
witch compresses the midline structures causing Hemiplegia), Narrow pelvis in female}.

✴ Inflammatory (meningitis, encephalitis, meningioencephalitis).

✴ Neoplastic (meningioma).

✴ Vascular (most important): -

� Intracerebral Hemorrhage

� Intracerebral Infarction.

✴ Cortical: patient is (Monoplagic, Aphasic, Disturbed conscious level, Fits, hemihypoesthesia, up to

coma).(MCQ)

✴ Subcortical (weakness in upper & lower limb, but upper > lower).

✴ Capsular (Diffuse complete hemiplegia with equal effect on upper &lower limbs, hemi hypoesthesia,
homonyms hemianopia & there maybe Auditory weakness in both side but not always present).

✴ Brainstem {crossed Hemiplegia (v.v.i.p) (epsilateral cranial nerve palsy & contralateral Hemiplegia),
(Midbrain: 3,4 cranial nerves, Pons: 5,6,7,8 cranial nerves, Medulla: 9,10,11,12 cranial nerves & if there is
medullary syndrome: 9,10,11,12 cranial nerves are vasomotor cranial nerves ,so patient will complain of : vertigo ,
unsteadiness, vomiting, Ataxia, hemisweating }.

✴ Spinal.

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✴ Laboratory: (CBC, LFT, KFT, Bl.lipids, Bl.Sugar).

✴ Radiological: (CT brain, MRI brain).

✴ Electrophysiological: (EEG).

✴ Histopathological: (Steriotactic biopsy under local anesthesia), like brain tumor patient.

✴ Miscellaneous.

✴ Treatment of the Cause.

{Any focal neurological deficit caused by cerebrovascular hemorrhage or infarction}.

(MCQ)

✴ Diabetes.

✴ Hypertension.

✴ Heart diseases (especially IHD).

✴ Cigarette Smoking (especially in young age).

✴ Dyslipidemia, Hypertriglyceridemia, High serum Uric acid.

✴ Cerebral Thrombosis:

� Cerebral atherosclerosis.

� Myocardial infarction.

� Occlusive blood diseases (Thalassemia, Polycythemia, Polycythemia rubra vera (RBCs

>16000/mm3, which causes hyperviscosity & hypcoagulability leading to vasooclusion).

✴ Cerebral Embolism.

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 (v.v.v.i.p)

✴ Blood diseases: (Hemorrhagic blood diseases).

✴ Hemophilia.

✴ Protein C&S deficiency.

✴ Migraine (especially girls in young age).

✴ Cigarette smoking.

✴ OCPS (most important) {contraindicated after age of 30}.

✴ Hypertension (less extent).

✴ Acute Major Stress.

{Focal weakness in one side of the body according to the extension of infarction and the type of vessel occluded}:

✴ Anterior cerebral Artery Occlusion (heaviness in his legs).

✴ Middle cerebral Artery Occlusion (Severe weakness in Contralateral side (contralateral dense
Hemiplegia), hemi hypoesthesia, aphasia in dominant hemisphere affection, (acute major stress may cause
this situation).

✴ Posterior cerebral Artery Occlusion (Blindness), due to Infarction in visual cortex.

✴ Laboratory: (CBC, LFT, KFT, Blood lipids, Blood Sugar).

✴ Radiological: (CT brain, MRI brain).

✴ Electrophysiological: (EEG).

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 (v.v.v.v.i.p)

✴ History taking while doing examination & Blood sampling for (Blood Sugar, Urea, Creatinine, blood
gases), ECG, plain X-Ray chest.

✴ Heart examination, blood pressure, pulse, temperature.

✴ If the patient came before 3-6 hours of onset of infarction (v.v.v.i.p):-

� Give rTPA (Recombinant tissue plasminogen activator) 0.9 mg/kg ✖ 500 cc normal saline patient
health state may improve in 4 hours.

✴ If the patient came in the 2nd day of the onset of infarction:

� Admission to ICU, Give antiplatelet (Aspirin), control blood pressure.

N.B: The ideal Therapeutic Window of rTPA injection in acute Ischemic Stroke is in “The first 3 hours”. (MCQ)

✴ Thrombotic: ✴ Embolic:

� Onset: Stroke in evolution in first 24 hours. � Onset: Sudden, Dramatic.

� Risk factors (Atherosclerosis, Diabetes, and � Source of Emboli must be present: (Rheumatic
Hypertension) Heart, Atrial fibrillation, double mitral, Mitral
stenosis, DVT).