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Here is a structured summary of the Stroke lecture (EU Neurology 9, Dr. Khatuna Katsadze):
🧠 Stroke - Lecture Summary
1. Cerebrovascular Anatomy
Circle of Willis
- Anterior circulation: Internal carotid arteries (ICA) → ACA + MCA
- Posterior circulation: Vertebral arteries → basilar artery → PCA
- Communicating arteries (AComm, PComm) link both circulations
Main arterial territories:
| Artery | Area Supplied |
|---|---|
| ACA | Medial frontal & parietal cortex (leg/foot area) |
| MCA | Dorsolateral convexity - frontal, temporal, parietal |
| PCA | Inferior/medial temporal & occipital cortex |
Deep structures are supplied by lenticulostriate arteries (from MCA), anterior choroidal artery (from ICA), and thalamoperforator arteries (from PCA). These are especially vulnerable in hypertension (lacunar infarcts, ICH).
2. Clinical Syndromes by Artery
MCA (most common stroke territory)
- Aphasia, hemineglect, hemianopia, face-arm weakness/sensory loss
- Gaze preference toward lesion side (acute)
- Superior division: frontal/motor deficits; Inferior division: temporal/language deficits
ACA
- Contralateral leg > arm weakness and sensory loss
- Frontal lobe dysfunction: grasp reflex, abulia, apraxia, incontinence
- Alien hand syndrome (supplementary motor area damage)
- Transcortical motor aphasia (dominant hemisphere)
PCA
- Contralateral homonymous hemianopia
- Thalamic infarcts: contralateral sensory loss, hemiparesis, thalamic aphasia
- Alexia without agraphia (left occipital + corpus callosum splenium)
Lateral Medullary Infarction (Wallenberg syndrome - PICA occlusion)
- Vertigo, nystagmus, nausea/vomiting, gait ataxia
- Ipsilateral face numbness + contralateral body pain/temp loss
- Dysphagia, dysarthria (nucleus ambiguus CN X)
- Ipsilateral Horner's syndrome (ptosis, miosis, anhidrosis)
3. Pathophysiology of Ischemic Stroke
- Brain = 2% body weight, uses 20% of total energy
- Normal CBF: 50-60 mL/100g/min; autoregulation fails below ~60 mmHg CPP
- Core infarct: CBF < 20 mL/100g/min → irreversible necrosis within minutes
- Penumbra: Surrounding zone - electrically silent but metabolically viable; salvageable if reperfused in time
- Cascade: Na/K pump failure → glutamate release → Ca²+/Na⁺ influx → cytotoxic edema (seen on DWI-MRI)
- Penumbra typically evolves to infarct within 3-6 hours; beyond 4 hours it becomes a thin rim
4. Stroke Classification (TOAST)
| Subtype | % |
|---|---|
| Large artery atherosclerosis | 15-40% |
| Cardioembolic | 15-30% |
| Small-vessel (lacunar) | 15-30% |
| Cryptogenic | up to 40% |
| Other determined cause | ~5% |
Key examples:
- Large artery: Amaurosis fugax from carotid plaque; vertebrobasilar TIAs
- Cardioembolic: Atrial fibrillation (thrombus in left atrial appendage), prosthetic valves, MI, endocarditis
- Lacunar: Lipohyalinosis of small perforators → pure motor, pure sensory, sensorimotor, ataxic hemiparesis, clumsy-hand dysarthria
5. Risk Factors
Modifiable: Hypertension, diabetes, smoking, atrial fibrillation, obesity, alcohol, cocaine, physical inactivity, hyperhomocysteinemia
Non-modifiable: Age, male sex, race, prior stroke
6. Symptoms - FAST Acronym
- F - Face drooping (asymmetry)
- A - Arm weakness
- S - Speech difficulty (slurred/confused)
- T - Time to call for help
Other symptoms: sudden visual loss, diplopia, vertigo, gait instability, severe headache, altered consciousness
7. Diagnosis
- CT scan - First-line; rules out hemorrhage
- MRI/DWI - More sensitive; detects early ischemic changes
- Carotid ultrasound - Carotid stenosis assessment
- Echocardiogram - Cardioembolic source (AF, thrombus)
- Blood tests - Coagulation, glucose, CBC
8. Treatment
Ischemic stroke:
- IV thrombolysis (tPA) - within 4.5 hours of onset (standard first-line)
- Mechanical thrombectomy - within 6 hours for LVO; up to 24 hours if salvageable penumbra on CT perfusion
- Antiplatelet/anticoagulant therapy for secondary prevention
- Decompressive hemicraniectomy for large MCA or cerebellar infarction
Hemorrhagic stroke:
- Surgical evacuation (depending on location/severity)
- Blood pressure control + anti-bleeding medications
- Supportive care (ICP monitoring, temperature control, respiratory support)
TIA: Antiplatelet therapy; urgent evaluation - warning sign of impending stroke
9. Hemorrhagic Stroke
- Accounts for ~15-20% of all strokes; generally more severe
- Intracerebral hemorrhage (ICH): Blood vessel rupture within brain parenchyma - most often due to hypertension
- Subarachnoid hemorrhage (SAH): Bleeding into subarachnoid space - most often from ruptured aneurysm
10. Complications
Depression, cognitive impairment, fatigue, dysphagia (risk of aspiration pneumonia), spasticity, urinary incontinence, pressure ulcers
11. Rehabilitation
Sequential steps: Assessment → Goal-setting → Treatment planning → Physical therapy (mobility/strength) → Occupational therapy (daily function) → Speech therapy (communication) → Cognitive therapy (memory/attention) → Supportive care
12. Prevention
Control BP and diabetes, maintain healthy weight, quit smoking, limit alcohol, exercise regularly, healthy diet, manage stress
Bottom line: Stroke is a time-critical emergency. "Time is brain" - every minute of large-vessel occlusion, ~1.9 million neurons are lost. Rapid recognition (FAST), early imaging, and prompt reperfusion (tPA within 4.5h, thrombectomy within 6-24h) are the cornerstones of management.
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