Inducing neuroplasticity

There are many parallels between postlesional neuro-plasticity (re-learning) and normal learning in the development of human individuals leading to changes of behavior by repetitive interactions with the social environment. In clinical neurorehabilitation the main effect of the multidisciplinary teamwork and applied therapies is to create a stimulating learning atmosphere that matches the patient's individual needs and deficits. Such learning conditions also take place in the therapeutic...

Demographic and medical characteristics of the patient

The most important demographic predictors of dementia after stroke, in sufficiently powered studies, are increasing age and low education level, but not gender when the analysis is adjusted for age 5 . The risk of dementia after stroke is higher in patients who were already dependent before stroke 5 . Pre-stroke cognitive decline without dementia, assessed by standardized questionnaires, is also associated with a higher risk of dementia after stroke 5, 32 . Diabetes mellitus, atrial...

CT angiography

Cerebral and cervical CT angiography is performed using intravenous administration of 50 ml of iodinated contrast material at a rate of 3 ml per second, and an acquisition delay of about 15 seconds. Data acquisition is performed from the origin of the aortic arch branch vessels to the circle of Willis and reconstructed as maximum-intensity projections (MIP) (Figure 3.3E) and three-dimensional reconstructions (Figure 3.3B). Figure 3.3. Same patient as in Figure 3.2. Upper row imaging at 12 hours...

Multiple overlapping causes of ischemic stroke

In some patients multiple overlapping causes of ische-mic stroke are identified. In such cases, whether these findings are purely coincidental or represent the cause of the infarct is not clear. For example, patients with clinical and neuroimaging features that are compatible with lacunar infarction may have associated findings of large artery atherosclerosis or a cardioembolic source (most commonly atrial fibrillation). In one study, 4 of all stroke patients had small artery disease coexisting...

Cryptogenic ischemic stroke

Patients experiencing a TIA stroke frequently have no determined etiology after standard diagnostic evaluation. Previous reports show that 20-25 of stroke survivors are classified as cryptogenic stroke, but it is a matter of debate which strokes should be labeled cryptogenic - what level of evidence is needed for accepting a finding or risk factor as the cause Such debate has surrounded PFO, which can be an incidental finding or possibly an underlying mechanism methods for distinguishing...

Role of functional imaging in stroke patients

The functional deficit after a focal brain lesion is determined by the localization and the extent of the tissue damage recovery depends on the adaptive plasticity of the undamaged brain, especially the cerebral cortex, and of the non-affected elements of the functional network. Since destroyed tissue usually cannot be replaced in the adult human brain, improvement or recovery of neurological deficits can be achieved only by reactivation of functionally disturbed but morphologically preserved...

Extracranial ultrasound in acute stroke

The most important diagnostic question in ultrasono-graphy is which extra- and intracranial vessel(s) is are stenotic or occluded and can it they be responsible for the clinical symptoms. Note that clinically silent sten-otic processes might also influence the cerebral circulation. Because ofthe interactions between extra- and intra-cranial hemodynamics, both extracranial and intracra-nial ultrasound techniques should be performed in acute stroke. Similarly, clinically silent stenoses should be...

Diagnostic brain perfusion imaging in stroke patients

The availability of new ultrasound contrast agents (UCAs) and the development of contrast-specific imaging modalities have established the application of ultrasound in stroke patients for visualization of brain perfusion deficits. The UCAs consist of micro-bubbles composed of a gas that is associated with various types of shells for stabilization. Because of their small size, they can pass through the microcirculation. There are interactions between ultrasound and microbubbles at low ultrasound...

Prognostic value of ultrasound in acute stroke

During recent years, ultrasound has become an important non-invasive imaging technique for bedside monitoring of acute stroke therapy and prognosis. By providing valuable information on temporal patterns of recanalization, ultrasound monitoring may assist in the selection of patients for additional pharmacological or interventional treatment. Ultrasound also has an important prognostic role in acute stroke. A prospective, multicenter, randomized study confirmed that a normal MCA finding is...

Overall lifestyle patterns and stroke risk

Recently, in the analysis of the data from the Health Professionals Follow-up Study and from the Nurses' Health Study the impact on stroke risk of a combination of healthy lifestyle characteristics was evaluated and the burden of stroke that may be attributed to these unhealthy lifestyle choices was calculated 31 . Diet and other lifestyle factors were updated from self-reported questionnaires. A low-risk healthy lifestyle was defined as (i) not smoking, (ii) a body mass index < 25kg m2,...

Diagnosis of coronary heart disease in stroke patients

When caring for stroke patients in the acute or rehabilitation phase, it is necessary to be aware of clinical symptoms of myocardial ischemia such as chest pain or exertional dyspnea, or electrocardio-graphic abnormalities such as ST-depression, T-wave abnormalities or newly developing Q-waves 20 . The detection of myocardial injury can be improved by measuring serum levels of troponin T or troponin I, biomarkers which are found to be highly specific for myocardial necrosis 24 . Elevated...

Myocardial infarction as a cause of embolism

Cardiogenic embolism from a left ventricular thrombus may occur as a complication of acute or subacute myocardial infarction or due to a ventricular aneur-ysm in the chronic phase of a large, mainly anterior wall infarction 27 . The incidence of left ventricular thrombi early after myocardial infarction has declined in recent years, most probably due to changes in the acute therapy of myocardial infarction, which now comprises intensive anticoagulant therapy and percutaneous coronary...

Relative risk of dementia after stroke

In the Rochester study, the relative risk of dementia (i.e. the risk of dementia in stroke survivors divided by the risk of dementia in stroke-free controls) was 8.8 one year after stroke, then declined progressively to 2.5 after 10 years, and 2.0 after 25 years 22 . The risk of AD was also doubled after 25 years 22 . In the Framingham study, the results were similar 10 years after stroke, after adjustment for age, gender, education level and exposure to individual risk factors for stroke 29 ....

Preexisting silent brain lesions in stroke patients

Silent infarcts, i.e. cerebral infarcts seen on CT or MRI scans that have never been associated with a relevant neurological deficit, are associated with an increased risk of dementia after stroke 5 . Their influence is more important when the follow-up is longer in the Lille study, silent infarcts were associated with dementia after stroke at year 3 25 but not at year 2 and in the Maastricht study silent infarcts were independently related to dementia after 12 months, but not after 1 or 6...

Pregnancy after an ischemic stroke

A multicenter French study 79 conducted with 373 consecutive women who had an ischemic stroke between 15 and 40 years of age and followed-up over a 5-year period found an overall risk of recurrent stroke of 0.5 at year 5 (95 CI 0.3-0.95) in periods without pregnancy and 1.8 (95 CI 0.5-7.5) during pregnancies and puerperium, without significant difference. Therefore young women who have had an ischemic stroke have an overall low risk of recurrence during a subsequent pregnancy and do not...

Secondary prevention after ischemic stroke in young adults

The main characteristics of ischemic stroke occurring in young patients, i.e. their causes, the overall good outcome and interference with hormonal life in women (contraception, pregnancy and future menopause), influence secondary prevention after stroke. As for elderly subjects, secondary prevention measures mainly depend on the presumed cause. For this reason, an extensive and early diagnostic work-up is required, as well as an extensive evaluation of risk factors. The overall management of...

Management of acute ischemic stroke and its complications

General management of elevated blood pressure, blood glucose and body temperature Monitoring the blood pressure (BP), glucose levels and temperature in acute stroke patients is an often neglected matter although it may have an important impact upon the patients' outcome. In the Tel Aviv stroke register, recorded between the years 2001 and 2003, 32 of acute stroke patients in the emergency room had glucose levels higher than 150 mg dl, higher systolic BP than 140 mmHg was found in 77 of the...

Hypertensive blood pressure values in acute ischemic stroke

Several observations have demonstrated spontaneous elevation of blood pressure in the first 24-48 hrs after stroke onset with a significant spontaneous decline after a few days 1-3 . Several mechanisms may be responsible for the increased blood pressure, including stress, pain, urinary retention, Cushing effect due to increased intracranial pressure and the activation of the sympathetic, renin-angiotensin and ACTH-cortisol pathways. Despite the increased prevalence of hypertension following...

Controlling BP in the acute stroke phase

The theory that elevated systemic BP may compensate for the decreased cerebral blood flow in the ischemic region led to attempts to elevate blood pressure as a treatment for acute ischemic stroke. The hemody-namic and metabolic impact of pharmacologically increased systemic blood pressure on the ischemic core and penumbra was evaluated in rats. The mild induced hypertension was found to increase collateral flow and oxygenation and to improve cerebral metabolic rate of oxygen in the core and...

Stroke risk and PFO

It is uncertain whether the recurrence rate of stroke in patients with cryptogenic stroke is dependent on the presence of a PFO. In one observational study of patients treated with aspirin, the incidence of recurrent stroke was higher in patients with than without PFO 47 . In a further prospective randomized study, the recurrence rate of stroke was the same in those with or without PFO in those treated with either warfarin or aspirin 44 . The question of whether subjects from the general...

Atrial fibrillation

Loop Recorder Implant

AF is a cardiac arrhythmia, defined by the absence of P waves and varying RR distances in the electrocardiogram. AF is a common arrhythmia and its prevalence increases with age up to 9 at age 80-89 years (Figure 7.1). Approximately 85 of the individuals with AF are between 65 and 85 years of age 1 . Apart from hemodynamic consequences due to the loss of atrial contraction and symptoms, such as palpitations, AF may lead to embolic stroke or peripheral or mes-enteric embolism. Compared to...

Cardioembolism

The main causes of cardioembolism in young patients are listed in Table 14.1. A few of them deserve more detail. Atrial fibrillation is associated with a very low risk of cerebral emboli in young people when occurring in the absence of underlying cardiopathy (lone atrial fibrillation) and of vascular risk factors. However, it confers a high risk of cerebral emboli when there are Table 14.1. Main cardiac sources of cerebralischemia in young adults. atrial fibrillation associated with...

Chapter Summary

The anterior circulation refers to the part of the brain perfused by the carotid arteries. The MCA territory is the one most frequently affected by acute strokes. MCA territory infarcts can be subtle or a devastating clinical syndrome, depending on the site of the occlusion, the extent of ischemia, the etiology, and the collateral arterial network. Symptoms of an acute complete MCA infarction contralateral hemiparesis, hemihypesthesia, hemianopsia, ipsilateral conjugated eye and head deviation...

Cognitive recovery after stroke

Besides defined neuropsychological syndromes, cognitive impairment after a stroke is very common and may persist in the postacute and also the chronic phase. Individual assessment includes evaluation of several aspects of attention, intelligence, memory, executive functions and personality prior to devising an individual treatment schedule, which can be neu-ropsychologically specific but should also be interdisciplinary, as the impairment usually has an impact on several aspects of the...

CVT in neonates

While the symptomatology, etiology and therapy of CVT in older children resemble those of adult CVT in most respects, in neonates the causes, clinical presentation, outcome, and management are very different. Manifestation of CVT in neonates seems to be associated with maternal risk factors (hypertension, pre- eclampsia, gestational or chronic diabetes mellitus). The vast majority of neonates present with an acute illness at the time of diagnosis, most often dehydration, cardiac defects, sepsis...

Dyslipidemia

Older epidemiological studies found no relationship between total serum cholesterol level and overall stroke incidence 111 . This might be due to different relationships for ischemic and intracerebral hemorrhages. In prospective cohort studies stroke risk was found to be positively associated with serum cholesterol level in ischemic stroke but negatively for intra-cerebral hemorrhages 112 . Age, sex and vascular risk factors can modify the relationship between blood cholesterol and vascular...

Etiology

CVT may be due to infectious and non-infectious causes. Septic CVT is observed as a complication of bacterial infections of the visceral cranium, namely otitis, sinusitis, mastoiditis and bacterial meningitis. The infectious agents reach the cerebral sinuses ascending Table 11.1. Potentialcauses of and risk factors associated with cerebralvenous thrombosis 3, 4, 14 . Mutations in the methylenetetrahydrofolate reductase (MTHFR) gene Systemic infectious disease Inflammatory disease Systemic lupus...

Incidence and prevalence rates

ICH, like ischemic stroke, has a clear age-dependent incidence rate, occurring slightly earlier in life than ischemic attacks. Most population-based registries report an incidence of 10 per 100 000 per year, and variations exist towards higher rates in some populations. A decrease of rates has been reported over time from several regions of the world. While the exact reasons for this decline are not known, it is reasonable to assume that a decline in rates as well as severity of arterial...

Incidence of newonset dementia in stroke survivors

Incidence studies are limited by similar methodological issues 5 . The incidence of dementia after stroke depends on whether the study excluded patients with pre-existing cognitive decline or dementia or not. Many so-called PSDs are not actually new-onset dementia, but pre-existing dementia revealed after stroke, pre-existing dementia being present in 7-16 of stroke patients, and often undiagnosed before stroke 15-21 . In a community-based study conducted over a 25-year period, the cumulative...

Intracerebral hemorrhage

Hemorrhages into the brain occur unexpectedly and are often lethal events. Typical warning signs are not known rarely a feeling of unsteadiness, dizziness or a tingling sensation can precede an intracere-bral hemorrhage (ICH), but such symptoms do not have localizing value such as in ischemia, where stroke-like warning signs (transient attacks) can occur days or weeks before the onset of a stroke. Often enough only a history of elevated blood pressure is known. Thus, for most patients, it comes...

Isolated cranial nerves

Stroke in the brainstem is typically indicated by (a) ipsilateral cranial nerve (III-XII) palsy (single or multiple) together with contralateral motor or sensory deficit, (b) bilateral motor and or sensory deficits or (c) disorders of conjugate eye movements. Rarely, cranial nerve palsy without any sensory or motor deficits may indicate a focal brainstem ischemia. Two out of 22 patients with focal ischemic lesions in the mesencephalon had an isolated palsy of the oculomotor nerve 14 . Thomke et...

Lacunar stroke syndromes

Lacunes are defined as small subcortical infarcts less than 1.5 cm in diameter occurring in perforator territories. Together with leukoaraiosis, microbleeds, and hypertensive (deep) intracerebral hemorrhages, they are part of the spectrum of small-vessel disease. This disease is tightly related to chronic hypertension, but diabetes, male gender, increasing age, smoking, previous lacunar TIA or stroke, and coronary artery disease are also risk factors. About 20 of all strokes are considered to...

Large artery atherosclerosis

Atherosclerosis of the major vessels supplying the brain is an important mechanism in ischemic stroke. Although the common occurrence of atherosclerosis in the region of the carotid bifurcation was observed early in the twentieth century, and the mechanism of distal embolization in causing strokes was proposed, it was widely assumed that most cerebral ischemic strokes were caused by in situ middle cerebral artery (MCA) thrombosis. The full implications of extracranial atherosclerosis for...

Lifestyle factors

Stroke prevalence has been associated with individual lifestyle factors (e.g. smoking, exercise, body mass index (BMI), alcohol consumption) in several studies. Healthy lifestyle in general was considered in one large prospective cohort study of healthy women. In this study, healthy lifestyle, consisting of abstinence from smoking, low-normal body mass index, moderate alcohol consumption, regular exercise and healthy diet, was found to be associated with a reduction in ischemic stroke (RR 0.3...

Microbleeds

MRI visualizes acute and chronic hematomas, but also old, clinically non-apparent cerebral microbleeds that are not detected on CT. Microbleeds have a hypointense appearance on MRI and are usually smaller than 5-10 mm. Pathological studies have shown that microbleeds seen with GRE MRI usually correspond to hemosiderin-laden macrophages adjacent to small vessels and are indicative of previous extravasation of blood 35 . One review 36 included 53 case series studies involving 9073 participants,...

Motor and somatosensory deficits

Motor function may be impaired by damage to a widely distributed network, involving multiple cortical representations and complex fiber tracts. The degree of motor impairment and the potential for recovery depends on the site of the lesion, the association of lesions in cortical areas and in fiber tracts and the involvement of deep gray structures, e.g. the basal ganglia, thalamus and brainstem. The patterns of altered metabolism and blood flow and the patterns of activation after stimuli or...

Poststroke dementia

Stroke is an important risk factor for dementia and cognitive decline. According to the NINDAS-AIREN criteria, in order to make the diagnosis of post-stroke dementia (PSD) the patient has to be demented, with either historical, clinical or radiological evidence of cerebrovascular disease and the two disorders must be reasonably related 77 . On the other hand, according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-4) 78 , vascular dementia is diagnosed by the...

Poststroke depression

Post-stroke depression is a prominent and persistent mood disturbance characterized by depressed mood or lack of interest or lack of pleasure (anhedonia) in all or almost all activities. Post-stroke depression has two subtypes with depressive features and similar to a major depressive episode. Figures related to the epidemiological features of post-stroke depression are highly variable, because they depend on the setting of the study, the time since stroke, the case mix and the criteria method...

Prevalence of dementia in stroke survivors

Prevalence studies include both dementia pre-existing to stroke and new-onset dementia occurring after stroke 5 . The prevalence of PSD ranges from 5.9 to 32 , depending on the mean age of the study population, exclusion or not of patients with aphasia or severe physical disability, mortality rates, delay between stroke onset and cognitive assessment, and criteria used for the diagnosis of dementia 5, 12 . Dementia is 3.5-5.8-fold more frequent in patients who have had a stroke than in...

Recurrence of cerebral venous thrombosis

After the acute phase of CVT, anticoagulation is continued not only to facilitate the recanalization of the occluded cerebral veins, but also in order to prevent the recurrence of intra- or extracerebral thrombosis. Recurrent CVT may be difficult to diagnose, if follow-up MRI or MRV examinations are not available. Therefore, it seems feasible to repeat MR venography in CVT patients after 4-6 months, as further recana-lization cannot be expected after this point. This follow-up venography may...

References

Kreisler A, Godefroy O, Delmaire C, Debachy B, Leclercq M, Pruvo JP, et al. The anatomy of aphasia revisited. Neurology 2000 4 1117-23. 2. Martin A. The representation of object concepts in the brain. Annu Rev Psychol 2007 58 25-45. 3. Saur D, Lange R, Baumgaertner A, Schraknepper V, Willmes K, Rijntjes M, et al. Dynamics of language reorganization after stroke. Brain 2006 129 1371-1384. 4. Plaut D, McClelland J, Seidenberg M, Patterson K. Understanding normal and impaired word reading. Psychol...

Rehabilitation of speech disorders

Aphasia with its affection of different modalities, including speech, comprehension, reading, and writing, is a common consequence of stroke, mainly of the left hemisphere. Because of its enormous impact on patients' lives rehabilitative therapy is mandatory and uses principles such as forced-use for treatment concepts 85 . Even more than in other therapeutic modalities, the importance of a high treatment intensity has been demonstrated a meta-analysis 86 shows that studies which demonstrated a...

The basilar artery BA

The BA lies on the ventral surface of the brainstem and vascularizes the pons, the mesencephalon and the middle and upper cerebellum through the AICA and SCA. Its territory can be subdivided into three parts on a ventro-dorsal level 11 . The anteromedial territory receives its blood supply from the paramedian arteries, the anterolateral territory from the short circumferential arteries (or anterolateral arteries) and the dorsolateral territory from the long circumferential arteries (or...

The scope of the problem

Stroke is the second leading cause of death worldwide in the adult population, the first being coronary heart disease 2 . Of note, stroke is an increasing problem in developing countries, 87 of stroke deaths occurring in low- and middle-income countries 2-4 . Stroke is the fourth leading cause of disease burden (as measured in disability-adjusted life years DALYs ) after heart disease, HIV AIDS and unipolar depressive disorders 2 . In the 1990s, it caused about 4.4 million deaths worldwide in...

The vascular origin of cerebrovascular disease

All cerebrovascular diseases (CVD) have their origin in the vessels supplying or draining the brain. Therefore, knowledge of pathological changes occurring in the vessels and in the blood is essential for understanding the pathophysiology of the various types of CVD and for the planning of efficient therapeutic strategies. Changes in the vessel wall lead to obstruction of blood flow, by interacting with blood constituents they may cause thrombosis and blockade of blood flow in this vessel. In...

Thrombolysis

In respect of acute interventions, one of the most significant advances during the last two decades has been the introduction of intravenous thrombolysis as a standard therapy for a well-selected population of patients with acute ischemic stroke. At present, the only thrombolytic agent licensed in Europe for the treatment of ischemic stroke is recombinant-tissue plasminogen activator (rtPA), alteplase. The evidence for its use comes from six landmark clinical trials the Alteplase Thrombolysis...

Ultrasound diagnosis of intracranial stenosis and occlusion

Intracranial disease corresponds to approximately 8-10 of acute ischemic stroke, depending on gender and race. Diagnosis is frequently reached through Table 4.1. Highlights of the guidelines of the European Federation of NeurologicalSocieties 5 . Table 4.1. Highlights of the guidelines of the European Federation of NeurologicalSocieties 5 . Ultrasonography is the non-invasive screening technique indicated for the study of vessels involved in causing symptoms of carotid stenosis Transcranial...

Urinary tract infections

Urinary tract infections (UTI) are common infections post-stroke, since many patients have indwelling catheters in place, which convey a significant risk of infection. Asymptomatic occurrence of bacteria in the urine (bacteriuria) needs to be distinguished from a true infection. Signs of UTI include mild irritative symptoms, such as frequency and urgency, dysuria, fever, and severe systemic manifestations, such as bacteremia and sepsis. Microbiological examination of a urine specimen confirms...

Visual agnosia

The human brain has two parallel visual systems a ventral occipito-temporal stream, whose main function is the recognition of visual stimuli (the what system) and a dorsal occipito-parietal stream, whose main function is the spatial localization of visual stimuli (the where system) 20 . The paradigm of human dysfunction of the ventral system is visual agnosia while that of the dorsal system is Balint's syndrome. Visual agnosias are disorders of visual recognition and are one of the clinical...

Chronic infections and stroke

Atherosclerosis is a common disease and a major risk factor for stroke. Its etiology can largely be explained by the classic risk factors (age, gender, genetic predisposition, hypertension, diabetes, hypercholesterolemia, diet, smoking, low physical activity, etc.). Additionally, pathogens such as Helicobacter pylori, cytomegalovirus, herpes simplex virus and Chlamydia pneumoniae have been proposed to be associated with atherosclerosis. Most studies on the infectious etiology of atherosclerosis...

Motor rehabilitation

Motor impairment is the most common deficit in stroke, often resulting in reduced independence and mobility. Beside the concepts of physical, occupational and other therapies (see below) the following methods are aimed especially at motor recovery. Walking is an important objective in stroke rehabilitation, conventional gait training programs on the floor being routine practice. With the aim of enhancing the efficacy of gait training and also of easing the burden on the therapists, three groups...

Meningitis as a cause of stroke

Meningitis denotes the inflammation of the leptome-ninges, which consist of the pia mater and arachnoid mater. These layers ensheath the spinal cord and brain and confine the subarachnoidal space, which contains cerebrospinal fluid (CSF). Infection of the meninges by bacteria or fungi leads to an inflammatory response which causes the typical clinical symptoms, headache and nuchal rigidity. Depending on the time course, meningitis can be classified as acute or chronic. Acute bacterial...

Hypertension smoking alcohol cholesterol and drugs

Hypertension is the most common risk factor for spontaneous intracerebral hemorrhage and the frequency has been estimated to be between 70 and 80 . The causative role of hypertension is supported by the high frequency of left ventricular hypertrophy in autopsy of patients with ICH. The role of hypertension and the beneficial effect of antihypertensive treatment with regard to risk of ICH were verified in several large clinical trials. In the PROGRESS trial 21 the relative risk of ICH was...

Energy requirements of brain tissue

The energy demand of the nervous tissue is very high and therefore sufficient blood supply to the brain must be maintained consistently. A normal adult male's brain containing approx. 130 billion neurons (21.5 billion in the neocortex) 49 comprises only 2 of total body mass, yet consumes at rest approximately 20 of the body's total basal oxygen consumption supplied by 16 of the cardiac blood output. The brain's oxygen consumption is almost entirely for the oxidative metabolism of glucose, which...

Embolic stroke

Infective endocarditis (IE) is an infection of the endocardium, a thin tissue layer that lines heart valves and mural myocardium (Figure 18.1). The incidence of IE Table 18.1. Infectious causes of stroke and associated mechanisms. Table 18.1. Infectious causes of stroke and associated mechanisms. Staphylococcus aureus, Streptococcus spp., Enterococcus spp., Aspergillus spp., and others Neisseria meningitidis, Haemophilus influenzae, Streptococcus pneumoniae, and others Mycobacterium...

Clinical and neuroimaging features of cardioembolic ischemic strokes

Although cardioembolism may cause almost any clinical stroke syndrome, some features are statistically linked to this cause and are therefore characteristic (Table 2.3). However, it should be borne in mind that the positive predictive value of clinical features suggesting cardioembolism is very modest, at only about 50 20, 21 . Conversely, some clinical and neuro-imaging syndromes, such as a lacunar syndrome found on dw-MRI to be due to a single small infarct, are very unlikely to be due to...

Bilateral blindness top of the basilar artery

Top Basilar Artery Stroke

Sudden cortical blindness is a rare symptom of TIA or stroke and has been explained by an occlusion of the top of the basilar artery at the origin of the posterior cerebral arteries 11 . The visual field defects may be Figure 9.4. Blind sight. A 65-year-old patient with known Parkinson's disease and vascular risk factors (diabetes mellitus, hypertension, obesity and smoking) suddenly lost muscle tone and consciousness. On admission he was awake, responded to verbalcommands and was partially...

Hyperviscosity and low flow

Blood flow in the brain is determined by the size of blood vessels, blood pressure and hemorrheological factors ofthe blood. Abnormal changes ofblood plasma with hematological disease (e.g. Waldenstrom's macro-globulinemia or paraproteinemia), increase in cell counts (e.g. in diseases such as polycythemia vera, ery-throcytosis or hyperleukotic leukemias), and decreased red cell deformability (sickle-cell anemia, spherocytosis, hemoglobinopathies) lead to a hyperviscous state 9 . Cerebral blood...

Cardioembolic sources major and minor

There are several cardiac disorders that may constitute a source of embolus, but not all sources pose equal threats. They are commonly divided by origin in the heart (atrial, valvular, ventricular) and potential for embolism (high risk versus low or uncertain risk, or major versus minor) (Table 2.2). The clinically most important cardioembolic sources are non-rheumatic atrial fibrillation (AF), infective endocarditis, prosthetic heart valve, recent myocardial infarction, dilated cardiomyopathy,...

Intracranial vasculopathies caused by virus and bacterial infection

Intracranial Infection

Varicella zoster virus (VZV) vasculopathy may often be clinically silent but may present with stroke and can be diagnosed because of the following symptoms, signs and findings (for review Nagel et al. 28 ). (1) About two-thirds of patients have a history of zoster rash, particularly ophthalmic-distribution zoster or a history of chicken pox. There is a delay between the onset of zoster chicken pox and the onset of stroke averaging 4.1 months (range between same day and 2.5 years). But about...

Stroke manifestations of systemic disease

Infective and non-infective endocarditis multi-territorial pattern of ischemic stroke Endocarditis of the heart and its valves in particular can be classified into infective and non-infective types. The vast majority of endocarditis is secondary to infections caused by bacterial (Staphylococcus aureus, coagulase-negative Staphylococcus or Enterococcus) or, rarely, fungal (Candida, Aspergillus) organisms 19 . Cerebral embolism from infected valves is the central mechanism of neurological injury...

Clinical syndromes

Clinical presentation of spontaneous ICH depends on site and size. Therefore, clinical investigation as well as neuroimaging are both important for a reliable diagnosis. All attempts to make a probabilistic diagnosis on clinical grounds alone to differentiate between ischemic and hemorrhagic stroke have not been considered satisfactory 45 . In our series of 1539 ICH cases we have located 45 in the putaminal region and in the thalamus, 34 in a lobar location, 5 in the cerebellum, about 4 in the...

Hereditary causes of stroke single gene disorders and their clinical presentation

Narp Syndrome

CADASIL (cerebral autosomal dominant arteriopa-thy with subcortical infarcts and leukoencephalo-pathy), Fabry disease and MELAS (mitochondrial encephalopathy lactic acidosis and stroke) are genetic disorders associated with their own clinical and radiological presentation. Genetic and pathological research suggests that the accumulation of the ectodomain of the NOTCH 3 protein is associated with severe ultrastructural alterations of the arteriolar wall 30 . The earliest clinical manifestation...

Coexistence of coronary heart disease and stroke

There is a frequent coexistence of coronary heart disease and stroke, most probably due to common atherosclerotic risk factors such as arterial hypertension, diabetes mellitus, smoking, and hypercholes-terolemia. A history of symptomatic coronary heart disease, either myocardial infarction or angina pec-toris, is found in up to 33 of patients with ischemic stroke 21 . An autopsy study of patients with fatal stroke found coronary plaques in 72 , coronary stenosis in 38 and myocardial infarction...

Types of acute cerebrovascular diseases

Numbers relating to the frequency of the different types of acute CVD are highly variable depending on the source of data. The most reliable numbers come from the in-hospital assessment of stroke in the Framingham study determining the frequency of complete stroke 60 were caused by athero-thrombotic brain infarction, 25.1 by cerebral emboli, 5.4 by subarachnoid hemorrhage, 8.3 by intracerebral hemorrhage and 1.2 by undefined diseases. In addition, isolated transient ischemic attacks (TIAs)...

Ischemic strokes and transient ischemic attacks caused by low cerebral flow posterior circulation

Vertebral Artery Tortuosity After Fall

Rotational vertebral artery occlusion (RVAO) and stroke Rotational vertebral artery occlusion (RVAO) is caused by mechanical compression of vertebral arteries during head rotation. The vertebral artery is usually compressed at the atlantoaxial C1 -C2 level. Tendinous insertions, osteophytes or degenerative changes resulting from cervical spondylosis may be the cause of compression. Most RVAO patients exhibit an ipsilateral stenosis or vessel malformation (e.g. hypoplasia) and a contralateral...

Clinical clues to differentiate posterior from anterior circulation strokes

Important clinical symptoms and signs point to a posterior circulation stroke and should be recognized. Preceding TIAs and strokes in the days and hours before are more frequent in the posterior circulation. Similarly, headache is more frequent in the posterior circulation, is typically ipsilateral to the infarct, and may have features of primary headaches such as migraine 10 . Past diplopia, tilt of the vision, true rotatory or linear vertigo, drunken-type gait, hiccup, bilateral or crossed...

Bradycardia and tachycardia

If brady- or tachycardia is observed in a stroke patient, the initial diagnostic steps are very similar and aim to assess the clinical severity and to differentiate between cardiac and non-cardiac causes. A suggested practical approach to stroke patients with brady- or tachycardia is given in Table 7.1. Brady- or tachycardia causes symptoms such as dizziness, light-headedness, spells or fainting. These symptoms may erroneously be interpreted as epileptic seizures. Thus, Holter monitoring to...

Poststroke fatigue

Another common and disabling late sequel of stroke is general fatigue 90, 91 . It is important to distinguish between normal fatigue, which is a state of general tiredness that is a result of overexertion and can be ameliorated by rest, and pathological fatigue, which is a more chronic condition, not related to previous exertion and not ameliorated by rest. Many other central and peripheral neurological conditions, beside stroke, are known to be a cause of fatigue, including multiple sclerosis,...

Psychotic disorders hallucinations and delusions

Psychotic disorders due to stroke are rare. They are classified according to the predominant symptom, with prominent hallucinations or with delusions. Delusions are of two main types delusional misiden-tification syndromes and delusional ideation. This can be observed in patients with Wernicke's aphasia and severe comprehension defect. Kumral and Ozturk 35 found that delusions started 0-3 days after stroke, and the predominant types were mixed, perse-cutory, jealousy and suspicion. Delusional...

The anterior inferior cerebellar artery AICA

The AICA vascularizes the dorsolateral inferior pons, the antero-inferior cerebellum, the cochlea, the labyrinth, and the Vlllth cranial nerve. Major variations of the extent of cerebellar supply by the three cerebel-lar arteries may make localization to the AICA difficult unless certain cranial nerve deficits are present. The classic AICA syndrome includes vertigo with vomiting and nystagmus (vestibular nuclei, vestibular nerve or labyrinthine artery), ipsilateral deafness with tinnitus...

The posterior cerebral artery PCA

The PCA is subdivided into four segments with associated clinical presentation. An occlusion of the proximal segment (P1 or precommunal) usually causes a total PCA infarction, including upper midbrain, variable parts of the thalamus and posterior hemispheric territory. Occlusions of the P2 (or postcommunal) segment before the branching of the thalamogeniculate arteries provoke ischemic lesions in the lateral thalamus and the hemispheric PCA territory. Lastly, cortical PCA branch occlusion...