5 Major Stroke Syndromes

Recognition, Action & Outcomes

Louise Jenkins RN, CEN, TNS, MBA

Southwest Washington Medical

Center
Vancouver, Washington
Time is Brain . . .
 Learning Objectives
1. Identify the five major stroke syndromes

2. Describe symptomology associated with each

3. Be familiar with assessment to identify them

4. Be familiar with rapid response to stroke

5. Identify major stroke prognostic indicators

Two stroke types
Focal Brain Dysfunction

Diffuse Brain Dysfunction

Anterior Cerebral
(ACA) Anterior
Communicating
(ACOM)

Internal Carotid
(ICA)

Middle Cerebral
(MCA)
Basilar Artery

Vertebral Artery

Posterior
Cerebral (PCA)
 Brain Anatomy Basics
Cerebral Cortex Cerebral Sub cortex
• Gray matter • Deep white matter, “wires”
•“Computer center” • Grey matter, “balls”
Left → language - motor modifier
Right → attention - sensory relay

Brainstem
• Funnel/connector between
cerebrum & spinal cord
Cerebellum
• Nerves to face/head
• Coordination center
• Primitive centers
5 Major Stroke Syndromes

1. Left Hemisphere
2. Right Hemisphere
3. Brainstem
4. Cerebellum
5. Hemorrhage
Left (Dominant) Hemisphere
Right visual field Aphasia
Left (Dominant)
deficit Receptive &/or
Hemisphere Stroke:
Common•Right
Pattern Expressive
Hemiparesis
•Aphasia
•Right
•Right hemiparesis Left gaze
•Right-sided sensory
Hemisensory
loss Deviation
Loss
•Right visual field (preference)
defect
•Poor right conjugate Typical signs
gaze
•Dysarthria •Right side
•Difficulty reading, affected
writing, or •Aphasia
calculating
• Left Gaze
deviation
 Right (Non-dominant) Hemisphere
Right (Non-
dominant)
Right gaze Hemisphere
Stroke: Common
Deviation Pattern 
(Preference)
Left visual •Neglect of left
visual field
field deficit
•Extinction of left-
sided stimuli
Left •Left hemiparesis
Hemiparesis •Left-sided sensory
loss
•Left visual field
Left defect
Hemi- •Poor left conjugate
sensory gaze
Loss •Dysarthria
•Spatial
disorientation
 A “pearl” about gaze…
Typically:

A stroke patient will gaze

toward the (brain) side
of their stroke

A patient with seizures

will gaze away from the
(brain) side of their
seizure.
 Brainstem
-Nausea
-Vomiting
Quadparesis -Dysarthria
Crossed
-Dysphagia
Signs:
One side of
Sensory loss face &
to all 4 contralateral
limbs side of body

Hemiparesis

Hemisensory
loss
 Brainstem
•↓ Consciousness Vertigo
Tinnitus
•Nausea/vomiting
•Hiccups
•Abnormal respirations
Eye movement
abnormalities:
-Diplopia
Oropharyngeal -Dysconjugate gaze
weakness:
- Dysarthria -Gaze deviation
- dysphagia (palsy)
Cerebellum
-N/V
-Vertigo
-Nystagmus

Ipsilateral
limb
ataxia Truncal or
gait ataxia
(Imbalance
with wide-
based gait)
 For your reading
enjoyment . . .
Stroke Syndromes by Anatomy: Cortical strokes
Middle cerebral artery
contralateral hemiparesis and sensory loss,
face and upper extremity more involved
contralateral hemianopsia
aphasia
gaze abnormalities
extinction on simultaneous touching, apraxia
Anterior cerebral artery
contralateral hemiparesis and sensory loss, lower extremity more involved
disconnection syndrome
Posterior cerebral artery
contralateral hemianopsia
locked In syndrome
Hemorrhage & the Brain Coverings
• Cranium: hard container
enclosing brain

• Meninges: 3 layered
cloth-like covering of the
brain and spinal cord

• Both ICH & SAH:

Suddenly increase ICP

• SAH: irritates meninges

Hemorrhage S/S

ICH:
• Focal sign, such as
Both ICH & SAH:
Hemiparesis
• Headache
• Nausea/vomiting
SAH:
• ↓ consciousness
• Intolerance to light
• Neck stiffness/pain
 Left Dominant Right Brainstem Cerebellum ICH/SAH
Hemisphere Non-dominant
Hemisphere

Aphasia Right gaze Hemi or Truncal/gait Headache

deviation Quad paresis ataxia
Left gaze Neck
deviation Left neglect Hemi or Quad Limb ataxia stiffness/pain
sensory loss
Right visual Left visual field Nausea/vomiti Light
field deficit deficit Crossed signs ng intolerance
right face/left body
left face/right body
Right Left Nausea/
Nausea /
Hemiparesis Hemiparesis vomiting
vomiting
Right sensory Left sensory Decreased
Dysarthria
loss loss LOC
Dysphagia

Abnormal
R Y respirations
SUMMA
Decreased LOC
 Some Stroke Mimics
These can result in focal cerebral dysfunction
Condition Comments
Hypoglycemia Treat with D50

Seizure Staring/limb shaking at onset? Todd's paralysis

w/postictal
state
Migraine Previous similar events?
Can cause focal event
Tumor Onset over weeks to months (possible bleed)

Abscess Onset over weeks to months

SDH Post-trauma?
Bells Palsy 7th CN effect
Conversion Patient must be taken serious- when ruled in,
Reaction causative factor should be investigated
 Neuro Assessments
Glasgow Coma Scale
• Valuable for ↓ level of consciousness- NOT focal injury
• Is quantitative exam for diffuse injury
NIHSS
• Reproductive, quantifies stroke deficits (0-42)
• Admission value predicts outcome
> 10 = likely d/c to rehab or NH
>15 = poor prognosis if no RX
> 20 = Increased change of post tPA ICH
• Useful for specialist clinicians at key intervals
• Impractical for all staff nurses as regular RN exam
• Does NOT NEED A PHYSICIAN ORDER!
FAST assessment
What does FAST take into account?
(F) Motor/Function
Face droop/swallow safety thought
(A) Motor/ coordination
Arm drift
(S) Mental status & understanding
Speech, follow commands, (add
asking name month= LOC
(T) = Time
of onset
Do not delay notification of patient change in function or neuro status
ACT response PCP: Notify per SBAR format
1. RN/RT respond
2. FAST/NIHSS exam S: ..has a change in function of
3. Non-contrast head CT stat right hand.
4. Get Neurology involved
(ask them to) B: right hand was working normal
5. Possible transfer to critical until 3:15
care for intervention.
A: This sudden change cannot
be explained, she has risk
Note: factors for stroke (cholesterol
elevated, smokes), It is 3:25 now,
Remain with the ACT 10 minutes since I noted this.
responders– you know
the patient’s “norm” and
history-- they do not. R: I would like to get a stat
non-contrast head CT, when can
we expect to see you, and can
we get a stat Neurology consult?
 Neurology or
Emergency Physician
have authority to assess
and determine tPA
eligibility
 Neuro
Interventions
Available

IV tPA = GOLD STANDARD

3 hours from sympton onset

IA tPA
6 hours from sympton onset

MERCI Retriever or Penumbra

8-12 hours from symptom onset-
May be used post-op since little
to no thrombolytic is used
 A Word (or two) about NIHSS
• NIHSS is needed for all R/O stroke, stroke
or tia patients.

• NIHSS is an assessment- You do NOT need a

physician order to do it. It is considered excellent
nursing care.

• Know your clinical specialists who will do accurate

NIHSS for patients on all units.
 5P’s of Stroke

• Parenchyma
• Pipes
• Perfusion
• Penumbra
• Preventing Complications
“Terms” & I do not mean college..
 Patient is 74
Month is December
Lets figure this out…

Component Examination
LOC I am 7th4, it’s Dethember, you note he does not look toward the right
when you speak to him from that side
Face Smile is equal, raises brow equally

Arms Inability to resist gravity with right arm & leg

Speech words are appropriate but slurred and hard to understand

Time Onset: noted it when he awoke 11 hours ago

Stroke Syndrome?
Left (dominant) hemisphere
Out of time window for acute intervention.
Needs complicaiton prevention, secondary
stroke prevention & stroke educaiton
 Patient is 61
Month is April Another
Component Examination
LOC I am 61, it’s April
Face smile equal bilaterally, brows raise equally

Arms no drift, does have trouble pinpointing her nose when she goes to
scratch it.
Speech clear, does C/O a lot of nausea and room spinning vividly
Time noted after her shower 35 minutes ago

Stroke Syndrome?

Cerebellum
Physician assessment warranted right away- may
be eligible for acute intervention
 Patient age 49
Month is January
Why not another…
Component Examination
LOC Bretaehfu ….. I ….Maxer
Face right face droop brows and smile, drools from right side mouth
Arms unable to hold left arm or leg up for test → it falls to the bed
Speech uses inappropriate words, difficult to understand them. Actively
vomiting and is yawning frequently
Time Wife found him this way when she came to visit. You saw him last 2
hours ago when you came on duty
Stroke Syndrome?

Brainstem
Physician assessment warranted right away-
may be eligible for acute intervention
 Patient is 55
Month is July Come on… one more
Component Examination
LOC I don’t know…. Ummmm…… 50 something…..
Face symmetrical grimace

Arms no drift, rubs neck and forehead

Speech Uses 1-2 word responses, appropriate, but slow, C/O frontal HA
Time She says it started after her PT session– about 30 minutes ago

Stroke Syndrome?

Hemorrhage
Physician assessment warranted right away-
CT needed to identify if ICH or SAH
 Patient is 68
Month is June oops, I lied…another..
Component Examination
LOC I’m 68, it is June 24th
Face smile and brows are symmetrical. You note that he does not
move his right eye past midline when he watches you
Arms Left arm is flaccid, left leg has drift, he does not feel you touch
his left arm when you apply the BP cuff.
Speech clear and appropriate

Time He has no idea, she took a nap and woke like this. She went to
sleep at 1:30pm, it is 2:40 pm
Stroke Syndrome?

Right (nondominant) hemisphere

Physician assessment warranted right away-
may be eligible for acute intervention
 noun 

1. indication of course of disease: 

an indicator used in making a
prognosis concerning a disease

2. prediction:
 a prediction as to how a
situation will develop
Prognostic indicators: Poor
•Dysphasia
• Denial
•Homonymous hemianopsia
• Spatial perception
•Poor arm and leg power problems
•Apraxia • Initial
•Neglect unconsciousness
• Prior history of stroke
Increased Short-Term Mortality
• History of congestive heart failure
• Angina and myocardial infarction
• Delay in acute hospital admission
• Poor orientation
• Increased cranial nerve deficits
• Paralyzed conjugate gaze
• Increased WBC count
 Increased Long-Term Mortality

• ST elevation and disorientation upon hospital discharge

• Poor motor persistence
• Half-hour recall
• Left versus right hemiplegia
• Diabetes mellitus
• Poor upper extremity motor recovery and control
• Prolonged onset to rehabilitation
Increased Mortality After a Stroke

• Acute congestive heart failure

• Glucose level greater than 140 mg/dL
• Nonlacunar versus lacunar stroke

o This study also noted a correlation of stroke recurrence with a

history of alcohol abuse, hypertension, and elevated blood
glucose levels in the first 48 hours after admission.
Better Outcomes associated with:

• Age younger than 65 years

• Smaller lesion on CT scanning
• Orientation at admission
• Functional improvement correlates with
lower NIHSS scores
• Specialized care i.e. Stroke Unit
His / Her Brain
http://www.exn.ca/brain/

A subject of serious research by a number of

scientists is understanding of how men's and
women's brains work.

The body of research has taught us that men are

generally better at spatial perception, while women
excel at verbal fluency, as well, in many other
categories there seems to be a better performer
between the sexes.