Neurology:

 
Cerebrovascular  
Disease  
Final  Year  CUCMS  Teaching  Module  
 
Dr  Nor  Shuhaila  Shahril  
B.Med  (Southampton)  MRCP  (UK)  
Case  
•  A  68  year  old  lady  
•  Underlying  diabetes  mellitus  for  7  years,  hypertension  
for  4  years.  
•  c/o  sudden  onset  of  right  sided  limb  weakness  at  8  
am  yesterday  
•  Unable  to  liF  up  her  right  arm  and  leg  off  the  bed  
•  Weakness  remained  the  same  
•  Slurring  of  speech  
•  Manages  food  with  difficulty    in  chewing–  saliva  
drools  out  with  food  parLcles  
Case  
•  Denies  numbness,  pain  or  Lngling  sensaLon  of  limbs  
•  No  visual  disturbance.  
•  Bladder  and  bowel  conLnent  
•  No  loss  of  consciousness/  headache.  
•  Previous  hospital  admission  for  unstable  angina  2  
months  ago.  
•  DH:  MeTormin  500  mg  BD,  Hydrochlorothiazide  12.5  mg  
OD  
•  FH  of  hypertension  and  diabetes  –  2  siblings  
•  Non-­‐smoker.  No  alcohol  
Case  
•  Conscious,  orientated  to  Lme/  place/  person  
•  Xanthelasma+,  corneal  arcus  
•  BP  180/100  mmHg,  PR  80  irregular    
•  No  goitre  
•  CVS  S1S2  no  murmurs  
•  Lungs  clear  
•  PA  soF,  no  tenderness,  no  liver  or  spleen,  BS+  
•  No  renal/  caroLd  bruit  
•  Peripheral  pulses  palpable  
Case  
•  Facial  asymmetry  with  drooping  of  mouth  on  the  right  
side,  loss  of  nasolabial  fold  
•  Forehead  crease  maintained  
Is  this  how  you  
•  Tone  increased  Rt  side   document  your  
•  Power  Rt  UL  1/5,  Rt  LL  2/5   findings?  

•  Power  Lt  UL  5/5,  Lt  LL  5/5  

•  Babinski  posiLve  Rt  side  
•  SensaLon  reduced  on  the  Rt  side  –  all  modaliLes  
(forehead  sensaLon  intact)  
•  Fundoscopy:  background  reLnopathy  

 
 Upper  motor  neuron  versus    
lower  motor  neuron  
UMN   LMN  
Was)ng/  atrophy   Not  prominent   Prominent  

Fascicula)on   Absent   Present  

Tone   Hypertonic   Hypotonic  /  flaccid  

Power   Contralateral  hemiparesis   Paresis  limited  to  

specific  muscle  groups  

Reflexes     Brisk     Reduced/  absent  

Abdominals   Absent   Present  
Plantars   Extensor   Flexor/  absent  
Where  is  the  site  of  lesion?  
•  Upper  motor  neuron   •  Lower  motor  neuron  
•  Cortex   •  Anterior  horn  cell  
•  Internal  capsule   •  Nerve  root  
•  Brainstem   •  Peripheral  nerve  
•  Spinal  Cord   •  Neuromuscular  
  juncLon  
•  Muscle  
Case  
•  What  can  you  conclude  from  the  history  and  physical  
examina)on?  
•  Sudden  onset  of  right  sided  hemiparesis  
•  Upper  motor  neuron  lesion  involving  face,  arm  and  leg  
•  Risk  factor  for  Cerebrovascular  Disease:  diabetes,  
hypertension,  age,  underlying  IHD,  atrial  fibrillaLon  
•  Neurological  deficit  >  24  hours  

Diagnosis:  Stroke  –  ischaemic/  haemorrhagic  

Stroke:  de@inition    
•  A  clinical  syndrome  
characterized  by  rapidly  
developing  clinical  symptoms  
and/or  signs  of  focal,  and  at  
Lmes  global,  loss  of  cerebral  
func6on,  with  symptoms  lasLng  
>  24  hours  or  leading  to  death,  
with  no  apparent  cause  other  
than  that  of  vascular  origin  
Transient  ischaemic  attack  (TIA)  

•  A  clinical  syndrome  
characterized  by  an  acute  
loss  of  focal  cerebral  or  
monocular  func6on  with  
symptoms  lasLng  <  24  
hours  and  which  is  though  
to  be  due  to  inadequate  
cerebral  or  ocular  blood  
supply  as  a  result  of  
arterial  thrombosis  or  
embolism.  
 Importance  of    
recongnizing  and  treating  TIA  
Following  a  TIA,  
there  is  a  :   4.4%  risk  of  stroke  in  the  1st  month  

12%  risk  of  stroke  in  the  1st  year  

29%  risk  of  stroke  over  5  years  

2.4%    annual  risk  of  myocardial  

infarcLon  
ISCHAEMIC  STROKE  
 
 
 
 
 
 
 
HAEMORRHAGIC    STROKE  
3  main  causes  of  ischaemic  strokes  

Atherothromboembolism  (50%)  

Intra-­‐cranial  small  vessel  disease  [penetraLng  

artery  disease]  (25%)  
•  Lacunar  infarcLon  

Cardiogenic  embolism  (20%)  

•  Atrial  fibrillaLon,  valvular  heart  disease  

Diagnosis  in  neurology  case  
What  is  the  neurological  deficit?  

Where  is  the  lesion?  

What  is  the  lesion?  

Why  has  the  lesion  occurred?  

What  are  the  potenLal  complicaLons  and  prognosis?  

Hemiparesis/  hemiplegia  
In  the  context  of  stroke,  this  
The  weakness  oFen  follows  
refers  to  spas>c  
a  “pyramidal”  distribuLon  
hemiparesis,  which  means  
with  weaker  extension  in  
weakness  of  the  arm  and  
the  arm  and  weaker  flexion  
leg  and  some6mes  the  face  
in  the  leg.    
with  associated  rigidity.    

The  paLent  may  have  a  

typical  hemiplegic  posture  
with  bent  elbow  and  sLff,  
straight  leg.    
Higher  cerebral  de3icit  
Loss  or  impairment  of  the  higher  
cerebral  funcLons  e.g:    
• dysphasia    
• sensory  neglect    
• dyspraxia    
• consciousness    

Clock  drawing  in  a  paLent  with  leF  sensory  neglect  

Homonymous  hemianopia  
•  Blindness  in  the  inner  half  of  one  visual  field  and  the  
outer  half  of  the  other.  
Brainstem  signs  
•  Lower  motor  neurone  cranial  nerve  palsy  plus  contralateral  
hemiparesis    
•  Disorders  of  conjugate  gaze  
•  Bilateral  motor  or  sensory  signs    
Ataxia  
•  Impairment  of  co-­‐ordinaLon    
•  Can  result  from  lesions  in    
•  cerebellum    
•  pons  and  medulla    
•  cervical  cord    
Anterior  
circulation  stroke  
 Anterior  circulation  stroke  
Total  anterior  circula)on  stroke   Par)al  anterior  circula)on  stroke  
(TACS)   (PACS)  
•  MCA  and/or  ACA   •  Occlusion  of  branches  of  
occlusion   MCA  or  isolated  ACA  
•  “massive  CVA”     occlusion  
•  higher  cerebral  dysfuncLon   •  Syndromes:    
[HCD]  (dysphasia,   •  HCD  alone    
dyscalculia,  visuospaLal   •  Restricted  motor  deficit    
disorder)    
•  Hemiparesis  +  HCD    
•  homonymous  visual  field  
deficit     •  Hemiparesis  +  hemianopia    
•  Contralateral  motor/ •  Hemianopia  +  HCD    
sensory  deficit  of  at  least  2  
areas  of  face/arm/leg    
Posterior  
circulation  stroke  
Lacunar  strokes  
•  PerforaLng  artery  occlusion    
•  Syndromes    
•  pure  motor  (“capsular  CVA”)    
•  MCA  perforaLng  arteries  in  basal  ganglia    
•  pure  sensory    
•  thalamogeniculate  artery  occlusion  giving  
hemianaesthesia    
•  ataxic  hemiparesis  (pons  and  midbrain)    
•  sensori-­‐motor  stroke  (pons  and  midbrain)    
Stroke  Pathophysiology  Algorithm  
Stroke Pathophysiology Algorithm

ISCHAEMIC STROKE

ATHEROTHROMBOTIC PENETRATING EMBOLISM OTHER

CEREBROVASCULAR ARTERY DISEASE CAUSES
DISEASE (“lacunes”)

CARDIOGENIC
Atrial fibrillation
LARGE ARTERY Valve disease
HYPOPERFUSION Ventricular thrombi
ATHEROMA
PFO and ASA
Intracardiac tumour

ARTERY TO ARTERY PROTHROMBOTIC

Carotid stenosis STATES:
Aortic Arch Atheroma Dissection
INTRACRANIAL EXTRACRANIAL Arteritis
Migraine
Drug abuse
What  investigation  would  you  like  to  
do  for  this  lady?  
•  FBC  
•  Polycythaemia  (hyperviscosity)  
•  Platelet  disorders  –  thrombocytopenia  (bleeding),  
thrombocytosis  (hyperviscosity)  
•  WCC  –  elevaLon  suggests  infecLon  (aspiraLon  
pneumonia,  differenLal  diagnosis  of  cerebral  abscess)  
•  ESR  
•  Raised  ESR  suggests  infecLon,  systemic  vasculiLs  or  
carcinoma  
•  Should  lead  to  further  invesLgaLon  e.g.  autoanLbody  
screen  
What  investigation  would  you  
like  to  do  for  this  lady?  
•  RP  
•  Target  organ  involvement  in  DM  and  HPT  
•  RBS  
•  To  assess  current  glycaemic  control  
•  To  detect  diabetes  if  a  person  without  history  of  DM  
•  HbA1c  if  diabeLc,  to  assess  overall  glycaemic  control  for  
past  3/12.  
•  FSL  
•  To  assess  for  dyslipidaemia  
•  PT/PTT  
•  Especially  in  intracerebral  and  subarachnoid  
haemorrhage.  
What  investigation  would  you  
like  to  do  for  this  lady?  
•  Thrombophilia  screening  
•  Send  for  young  ischaemic  strokes  or  TIA  (under  age  of  
40s)  
•  AnL-­‐cardiolipin  anLbodies,  lupus  anLcoagulant,  
protein  C  and  S  deficiency,  anL-­‐thrombin  III  deficiency  
(predisposes  to  thrombosis)  
•  Syphilis  serology  (VDRL)  
•  Untreated  late-­‐stage  terLary  syphilis  causes  
inflammaLon  and  thrombosis  of  the  arteries.  
•  Blood  C&S  
•  Consider  in  embolic  stroke  from  infecLve  endocardiLs  
What  investigation  would  you  
like  to  do  for  this  lady?  
•  CXR  
•  Cardiomegaly  (HPT),  consolidaLon  (aspiraLon  
pneumonia)  
•  ECG  
•  To  detect  atrial  fibrillaLon,  presence  of  LVH  
(hypertensives),  ST-­‐T  changes  (underlying  IHD)  
•  ECHO  
•  Atrial  thrombus  (AF),  mural  thrombus  (post-­‐MI),  valve  
(endocardiLs,  mitral  stenosis  causing  AF),  LVH  (HPT),  
regional  wall  moLon  abnormality  (IHD)    
What  investigation  would  you  
like  to  do  for  this  lady?  
•  CaroLd  ultrasound  doppler  
•  Do  in  paLents  with  TIA  and  ischaemic  stroke  in  the  
caroLd  territories  
•  To  idenLfy  caroLd  artery  stenosis,  occlusion  and  
dissecLon  
•  A  caroLd  bruit  is  not  a  reliable  indicaLon  of  significant  
internal  caroLd  artery  stenosis  
What  investigation  would  you  
like  to  do  for  this  lady?  

•  CT  scan  brain  
•  To  disLnguish  between  ischaemic  and  haemorrhagic  
stroke  
•  Preferably  done  within  1st  48  hours  
•  CT  scan  may  be  normal  in  the  first  few  hours  
•  But  will  become  abnormal  if  repeated  days  later  
CT  scan  brain  

•  To  establish  diagnosis  by  showing  infarcLon  or  

haemorrhage    
•  And  to  exclude  condiLons  that  may  mimic  stoke  (e.g.  
subdural  haematoma,  intracranial  tumour)  
•  DisLncLon  of  haemorrhage  from  infarcLon  is  important  to  
facilitate  appropriate  management  
•  Aspirin  indicated  in  ischaemic  strokes,  but  
contraindicated  in  intracerebral  haemorrhage  
•  MRI  more  sensiLve  
•  Beter  imaging  of  the  brainstem.  
 Schematic  CT  scan  of  different  types  
of  infarction  

Within  the  right  cerebral  hemisphere,  

infarc>on  corresponding  to  the  regions  
supplied  by  the  middle  cerebral  (A)  and  
posterior  cerebral  arteries  (B),  respec>vely   C  
 
Central  lacunar  infarcts  within  the  basal   D  
ganglia  (C).    
  A  
In  the  leI  cerebral  hemisphere,  central  
infarc>on  (caput  nucleus  caudatus)  (D),  as  well  
as  infarc>on  in  the  border  zone  between  the  
area  of  supply  of  the  middle  cerebral  and   E  
posterior  cerebral  arteries  (watershed   B  
infarc6on)  (E).  
CT  scan  of  a  large  right-­‐sided  
middle  cerebral  artery  infarc>on.  
Indication  for  urgent  CT  scan  
•  Required  to  exclude  surgically  treatable  condiLons  (e.g.  
SAH,  cerebellar  haematoma,  space-­‐occupying  lesion)  if  
the  paLent:-­‐  
•  Has  progressive  or  fluctuaLng  symptoms  
•  Drowsy  or  comatose  
•  Has  brainstem  symptoms  or  signs  
•  Has  papilloedema,  neck  sLffness  or  fever  
•  Deteriorates  unexpectedly  
•  If  anLcoagulaLon  is  contemplated  (in  case  of  AF)  
Case  
•  FBC  Hb  12.1,  Plt  290,  TWC  4.8  
•  BU  7.8,  Na  134,  K  3.4,  Creat  56  
•  RBS  18  
•  HbA1c  8.8%  
•  TC  7.1,  LDL  4.9,  HDL  1.0,  Tg  2.0  
•  CXR  cardiomegaly,  clear  lung  fields  
•  ECG  as  shown  
Case  
•  CaroLd  doppler  ultrasound:  minimal  atherosleroLc  
plaques  in  internal  caroLd  arteries  bilaterally  

•  ECHO:  LVEF  45%,  apical  wall  hypokinesia,  valves  normal.    

LVH.  No  pericardial  effusion  
Investigations  in  stroke  
Investigations  in  stroke  
Investigations  in  stroke  
Case  
•  Her  CT  scan  showed  hypodense  lesion  in  the  leF  internal  
capsule.  
Ischaemic  Stroke:  Management  
General Management of Acute Ischaemic Stroke
Level of
Factors Recommendation Grade
evidence
Airway & Breathing Ensure clear airway and adequate oxygenation.
Elective intubation may help some patients with III C
severely increased ICP.
Mobilization Mobilize early to prevent complications. II-3 C
Blood Pressure Do not treat hypertension if < 220mmHg systolic III C
or < 120mmHg diastolic. Mild hypertension is
desirable at 160-180/90-100mmHg.
Blood pressure reduction should not be drastic. III C
Proposed substances: Labetolol 10-20mg
boluses at 10 minute intervals up to 150-300mg
or 1mg/ml infusion, rate of infusion for labetolol
as 1-3mg/min or Captopril 6.25-12.5mg orally.
Blood Glucose Treat hyperglycaemia (Random blood glucose II-3 C
>11mmol/l) with insulin.
Treat hypoglycaemia (Random blood glucose III C
<3mmol/l) with glucose infusion.
Nutrition Perform a water swallow test. (Refer appendix F) III C
Insert a nasogastric tube if the patient fails the III C
swallow test.
PEG is superior to nasogastric feeding only if II-1 B
prolonged enteral feeding is required.
Infection Search for infection if fever appears and treat with III C
appropriate antibiotics early.
Fever Use anti-pyretics to control elevated II-1 B
temperatures.
Raised Intracranial Hyperventilate to lower intracranial pressure. II-2 B
Pressure Mannitol (0.25 to 0.5g/kg) intravenously II-2 B
administered over 20 minutes lowers intracranial
pressure and can be given every 6 hours.
If hydrocephalus is present, drainage of III C
cerebrospinal fluid via an intraventricular catheter
can rapidly lower intracranial pressure.
Hemicraniectomy and temporal lobe resection II-3 C
have been used to control intracranial pressure
and prevent herniation among those patients with
very large infarctions of the cerebral hemisphere.
Ventriculostomy and suboccipital craniectomy is II-3 C
effective in relieving hydrocephalus and brain
stem compression caused by large cerebellar
infarctions.
Acute Stroke therapy
Level of
Treatment Recommendations Grade
evidence
rt-Pa Intravenous rt-PA (0.9mg/kg, maximum 90mg), with I A
10% of the dose given as a bolus followed by a
60-minute infusion, is recommended within 4.5 hours
of onset of ischaemic stroke. (new recommendation)

Intra-arterial Reasonable to consider intra-arterial thrombolysis in II-2 C

thrombolysis selected patients with major stroke syndrome of
<6 hours’ duration and ineligible for intravenous
thrombolysis. (new recommendation)

Endovascular May be reasonable to perform mechanical disruption III C

mechanical
thrombectomy with major stroke syndrome of <8 hours’ duration
and ineligible for or failing intravenous thrombolysis.
(new recommendation)

Concentric Merci or other endovascular device can III C

be useful for extraction of intra-arterial thrombi in
appropriately selected patients, but the utility of the
device in improving outcomes is still unclear.
(new recommendation)

Aspirin Start aspirin within 48 hours of stroke onset. I A

Use of aspirin within 24 hours of rt-PA is not II-1 A
recommended.
Anticoagulants The use of heparins (unfractionated heparin, low I A
molecular weight heparin or heparinoids) is not
routinely recommended as it does not reduce the
mortality in patients with acute ischaemic stroke.
Neuroprotective A large number of clinical trials testing a variety of I A
Agents neuroprotective agents have been completed. These
trials have thus far produced negative results.
To date, no agent with neuroprotective effects can be I A
recommended for the treatment of patient with acute
ischaemic stroke at this time.
(4.5  hours)  –  new  guidelines  
This  lady  has  AF.  Are  you  going  to  
anticoagulate  her?  
AntiCoagulation following Acute Cardioembolic Stroke

Treatment Recommendations Level of Grade

Evidence

Aspirin All patients should be commenced on aspirin within 48 I A

hours of ischaemic stroke.
Warfarin Adjusted-dose warfarin may be commenced within 2-4 II-2 C
days after the patient is both neurologically and
medically stable.
Heparin Adjusted-dose unfractionated heparin may be started III C
(unfractionated) concurrently for patients at very high risk of embolism.
Anticoagulation Anticoagulation may be delayed for 1-2 weeks if there III C
has been substantial haemorrhage.
Urgent routine anticoagulation with the goal of I A
improving neurological outcomes or preventing early
recurrent stroke is not recommended.
Urgent anticoagulation is not recommended for I A
treatment of patients with moderate-to-large cerebral
infarcts because of a high risk of intracranial bleeding
complications.
Bioprosthetic High risk:
heart valves AF; left atrial If high risk factors present, III C
thrombus at surgery; consider warfarin for 3-12
previous CVA/TIA or months or longer.
systemic embolism. For all other patients, give III C
warfarin for 3 months post-op,
then aspirin 75-150mg daily.
Mitral High risk:
Stenosis AF; previous If high risk factors present, II-3 B
stroke/TIA; left atrial consider long-term warfarin.
thrombus; left atrial For all other patients start aspirin II-2 B
diameter > 55mm on 75-150mg daily.
echo.
MI and LV High risk:
dysfunction Acute/recent MI (<6 If risk factors present without LV III C
mos); extensive infarct thrombus: consider warfarin for
with anterior wall 3-6 months followed by aspirin
involvement; previous 75-150mg daily.
stroke/TIA. If LV thrombus is present, III C
Very high risk: consider warfarin for 6-12
Severe LV dysfunction months.
(EF < 28%); LV For dilated cardiomyopathies III C
aneurysm; including peripartum, consider
spontaneous echo long-term warfarin.
contrast; LV thrombus;
dilated non-ischaemic
cardiomyopathies.
Recommended warfarin dose INR target 2.5 [range 2.0 to 3.0] unless stated otherwise
 CHA2DS2VASc score and stroke rate (new recommendation)
(a) Risk factor for stroke and thrombo-embolism in non-valvular AF
‘Major’ risk factors ‘Clinically relevant non-major’ risk factors
Previous stroke, TIA, or Heart failure of moderate to severe LV

Hypertension - Diabetes mellitus

Vascular diseasea
(b) Risk factor-based approach expressed as a point based
scoring system, with the acronym CHA2DS2VASc
(Note: maximum score is 9 since age may contribute 0, 1, or 2 ponits)
Risk factors Score
Congestive heart failure/LV dysfunction 1
Hypertension 1
2
Diabetes mellitus 1
Stroke/TIA/thrombo-embolism 2
Vascular diseasea 1
Age 65-74 1
Sex category (i.e. female sex) 1
Maximum score 9
(c) Adjusted stroke rate according to CHA2DS2VASc score
CHA2DS2VASc score b
)
0 1 0%
1 422 1.3%
2 1230 2.2%
3 1730 3.2%
4 1718 4.0%
5 1159 6.7%
6 679 9.8%
7 294 9.6%
8 82 6.7%
9 14 15.2%
See text for definitions.
a
Prior myocardial infarction, peripheral artery disease, aortic plaque. Actual rates of stroke in contemporary cohorts may vary from these estimates.
b
Based on Lip et al.53

cardiac magnetic resonance imaging, etc.); LV = left ventricular; TIA = transient ischaemic attack.
What  has  happened  here?  

Post-­‐hemicraniectomy  for  
raised  ICP  in  a  paLent  with  
MCA  infarct  
Secondary Prevention
Factors Level of
Recommendations Grade
Treatment evidence
Antiplatelets
Single agent
Aspirin The recommended dose of aspirin is 75mg to I A
325mg daily.
Alternatives:
Clopidogrel The recommended dose is 75mg daily. I A
or
Ticlopidine The recommended dose is 250mg I A
twice a day.
Trifusal The recommended dose is 600mg daily. I A
(new recommendation)
Cilostazol The recommended dose is 100mg I A
twice a day. (Not licensed yet for ischaemic stroke
in Malaysia.) (new recommendation)

Double Therapy Combination therapy of clopidogrel and aspirin is I A

not superior to clopidogrel or aspirin alone; but with
higher bleeding complication. (new recommendation)

Anti-hypertensive ACE-inhibitor based therapy should be used to I A

treatment reduce recurrent stroke in normotensive and
hypertensive patients.
ARB-based therapy may benefit selected high risk II-1 B
populations.
Lipid lowering Lipid reduction should be considered in all subjects I A
with previous ischaemic strokes.

Glycaemic control All diabetic patients with a previous stroke should III C
have good glycaemic control.
Cigarette smoking All smokers should stop smoking. III C
Anti-­‐hypertensives  post-­‐stroke  
CLINICAL  SCENARIOS  OF  
STROKES  
Scenario  1  
•  A  sixty  year  old  man  presents  to  Casualty  complaining  of  
a  sudden  onset  of  a  shake  in  his  leF  hand.  On  
examinaLon,  he  has  an  impaired  co-­‐ordinaLon  in  his  leF  
arm.  
•  Where  is  the  lesion?  

•  Posterior  circulaLon  stroke  –  cerebellar  

•  It  is  not  ataxic  hemiparesis  as  there  are  no  long-­‐tract  
signs  
Scenario  2  
•  A  seventy  year  old  man  presents  with  difficulty  speaking  
which  came  on  suddenly  12  hours  ago.  On  examinaLon,  
he  has  an  expressive  dysphasia.  
•  Where  is  the  lesion?  
•  ParLal  anterior  circulaLon  stroke  (PACS)  
•  Higher  cerebral  deficit  
Scenario  3  
•  An  80  year  old  man  presents  to  Casualty  aFer  a  collapse  
at  home.  On  examinaLon,  he  is  unconscious  and  has  a  
leF  hemiparesis.  
•  Where  is  the  site  of  lesion?  
•  Total  anterior  circulaLon  stroke  (TACS)  
•  Remember  higher  cerebral  deficit  includes  loss  of  
consciousness  or  drowsiness    
•  In  a  paLent  who  is  unconscious,  hemianopia  can  be  
assumed    
Scenario  4  
•  A  fiFy  year  old  woman  presents  to  Casualty.  She  is  
complaining  of  visual  disturbance  of  sudden  onset.  On  
examinaLon,  she  has  a  right  homonymous  hemianopia.  
•  Where  is  the  lesion?  
•  Posterior  circulaLon  stroke  (POCS)  –  occipital    
Scenario  5  
•  A  sixty-­‐five  year  old  man  is  brought  to  Casualty  by  his  
wife.  He  has  been  behaving  strangely  for  the  past  two  
days.  On  examinaLon,  he  has  shaved  only  the  right  half  
of  his  face.  His  visual  fields  are  intact.  
•  Where  is  the  lesion?  
•  ParLal  anterior  circulaLon  stroke  (PACS)  
•  Higher  cerebral  deficit  
Scenario  6  
•  A  fiFy-­‐year-­‐old  woman  presents  to  her  GP  with  
weakness  in  her  right  arm.  On  examinaLon,  she  has  
impaired  co-­‐ordinaLon  in  her  right  arm  and  leg.  She  also  
has  brisk  reflexes  and  an  upgoing  plantar  on  the  same  
side.  
•  Where  is  the  site  of  lesion?  
•  Ataxic  hemiparesis  (Lacunar  stroke)  
•  You  don’t  get  long  tract  signs  with  cerebellar  lesions.  
Scenario  7  
•  A  sixty-­‐year-­‐old  man  presents  with  sudden  onset  of  
weakness  in  his  right  arm  and  leg.  On  examinaLon,  he  
has  a  right  hemiparesis.  A  CT  brain  was  done  24  hours  
aFer  the  onset  of  symptoms  and  was  reported  as  
normal.  
•  Where  is  the  lesion?  
•  Lacunar    stroke  (LACS)    
•  Pure  motor  stroke  
•  CT  scan  can  be  normal  in  acute  infarcLon  
Scenario  8  
•  A  forty-­‐year-­‐old  woman  presents  with  weakness  in  her  
right  arm.  She  has  a  spasLc  weakness  in  that  arm  but  no  
neurological  signs  in  the  other  limbs.  
•  Where  is  the  lesion?  
•  ParLal  anterior  circulaLon  stroke  (PACS)  
•  Restricted  deficit  (monoparesis)  
Scenario  9  
•  A  ninety-­‐year-­‐old  man  presents  with  weakness  in  his  
right  arm  and  leg.  On  examinaLon,  he  has  grade  1/5  
power  on  the  right  side  of  his  body  and  an  expressive  
dysphasia.  
•  Where  is  the  lesion?  
•  ParLal  anterior  circulaLon  stroke  (PACS)    
•  Weakness  and  high  cerebral  deficit  
Scenario  10  
•  A  sixty-­‐three-­‐year-­‐old  man  presents  with  a  sudden  onset  of  
hiccups,  nausea,  verLgo  and  difficulty  walking.  On  
examinaLon,  he  has  a  right-­‐sided  Horner’s  syndrome,  
nystagmus  and  ataxia  on  the  leF.  There  is  also  loss  of  pain  
and  temperature  sensaLon  on  the  leF  side  of  the  face.  
•  Where  is  the  lesion?  
•  Posterior  circula)on  stroke  (POCS)  –  brainstem  
•  Remember,  things  happening  on  both  sides  of  the  body  
suggest  brainstem    
•  This  is  Wallenberg’s  syndrome  which  results  from  
dorsolateral  infarcLon  in  the  medulla  oFen  from  
occlusion  of  the  posterior  inferior  cerebellar  artery