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Sudden onset of neurologic dificit from a vascular mechanism: 85% are ischemic;15% are primary hemorrhages (subarachnoid and intra parencymal).An ischemic deficit that resolve rapidly is termed a transient ischemic attack(TIA) ; 24h is a useful boundary between TIA and stroke.,although most TIAs last between 5 and 15 minutes.Stroke is the leading cause of neurologic disability in adults; 200.000 deaths annualy in the US.Much can be done to limit morbidity and mortality through prevention and acute intervention.

 

Ischemic stroke is most often due to embolic acclusion of large cerebral vessel;source of emboly may be heart,aortic arch,or a more proximal arterial lession.Primary involvement of intracerebral vessel with atherosclerosis is less common than in coronarry vessel.Small,deep ischemic lessions are most often seen with severe proximal stenosis and inadequate collateral chalenged by systemic hypotensive episodes.Hemorrhage most frequently results from rupture of aneurysm or small vessels within brain tissue.

 

Clinical Presentation

A)Ischemic Stroke

Abrupt and dramatic onset of focal neurologic symptom is typical of systemic stroke;with hemmorhage,dificits typically evolve more slowly and drowsiness is common.Patient may not seek assistance on their own because they are rarely in pain and may lose appreciation that something is wrong.(anosagnosia).Symptom reflect the vascular territory involved.Trasient monocular blindness(amaurosis fugax) is a paticular form of TIA due to retinal ischemia;pts describe a shade descending over the visual field.Rapid resolutions of symptoms exclude hemmorhage as cause.Variability in stroke recovey is influenced by collateral vessels,blood pressure,and spesific site and mechanism of vessel occlusion.

 

Lacunar syndrome.Most common are :

-pure motor hemiparesis of face,arm and leg(internal capsule or pons)

-Pure sensory stroke (ventrolateral thalamus)

-Ataxic hemiparesis (pons)

-Dysarthria-clumsy hand (pons or genu of internal capsule)

-Puremotor hemiparesis with motor (Broca"s) aphasia (internal capsule and adjacent corona radiata)

 

Intracranial Hemmorhage

Vomitting occurs in most cses,and headache in about one half.Sign and symptoms not usually confined to a single vascular territory.Hypertensive hemorrhage typically occur in =

-The putamen,adjacent internal capsule,and central white matter

-Thalamus

-Pons

-Cerebellum

A neurologic deficit evolves relentlessly over 5-30 minutes strongly suggest intracerebral bleeding.Occular signs are important in localization=

+putaminal( eyes deviated to side opposite paralysis ( toward lession)

+thalamic ( eyes deviated downward,sometimes with unreactive pupils

+Pontine (reflect lateral eye movements impaired and small (1-2mm),reactive pupils

+cerebellar (eyes initially deviated to side opposite lesion.