Stroke hemiparalysis specifics

[lokiki]

I'm trying to find information on some stuff and I hope maybe someone can help me.

 

I teach EMR courses. I"m pre-med and have done some intro A+P. I have a question that I haven't been able to answer about stroke. I've only had one stroke patient I dealt with as a first responder. And to be honest I don't remember the specifics becuase it was my first unconcious patient and I was pretty scared.

 

1. If the R side of the brain is affected, does facial droop happen on the R side or L? Some sources say R, some say L.

2. If the R side of the brain is affected, is the R or L pupil affected? I know this doesn't happen in all cases.

[Lactic Folly]

It depends not only on which side, but the specific part of the brain that is affected. You might consider looking through a book on clinical neuroanatomy.

[Nixon]

1) Right middle cerebral artery stroke = typically left lower hemiface + left arm paresis. There will also be left cortical sensory loss and left homonymous hemianopsia or quadranopsia. If the right hemisphere happens to be dominant in your patient, then you'll find speech disorders too (Broca or Wernicke) depending on which part of the middle cerebral artery is occluded. If it is non dominant, you'll mostly find hemineglect syndrome and visuospatial abilities impairments. These findings are all very theoretical and vary depending on which part of the middle cerebral artery is occluded (proximally or distally)

 

2) You'll find pupil abnormalities if there is enough cerebral edema to cause herniation of the temporal uncus which will compress the CN III ipsilateraly, which can be lethal

[leviathan]

If you had an unconscious patient as a first responder it probably wasn't a stroke. The vast majority of strokes do not lead to impairment of consciousness. You have to either have a stroke affecting both hemispheres OR a particular part of the brainstem, both of which are unlikely. The only other way it can happen might be from cerebral edema / elevated ICP after a major stroke, but that's a late finding.

 

The other posts are accurate. You can also have pupil involvement with brainstem strokes (e.g. Benedikt and Weber syndrome, , and it would be ipsilateral (same side) in that case.

[futureGP]

1. if the lesion is above the pons where the facial nerve nucleus is located, then it would be contralateral (Right side lesion causing left side symptoms). If the lesion is at the level of the pons directly affecting the lower motor neuron it will affect ipsilaterally although most likely you'll see bilateral lesions with any kind of significant brainstem stroke that causes loss of consciousness

 

2. is the pupil dilated? constricted?

if dilated what people said above is true,

-- uncal herniation from increased ICP from some sort of massive hemorrhage would cause ipsilateral blown pupil

-- technically speaking you can have a basilar artery aneurysm at the bifurcation point which is near the midbrain that affects the oculomotor and EW nucleus/oculomotor nerver as it travels out from the brain but it'll likely affect bilaterally

 

if constricted

-- it could possibly be a pontine hemorrhage that affects the descending sympathetic pathway so you lose the sympathetic control and you see signs of Horner's syndrome which also includes decreased sweating, mildly drooping eyelid on the same side

-- but any brainstem hemorrhage is likely to affect bilaterally

 

but yeah, do consult a clinical neuroanatomy textbook

[blindsideflank]

If you had an unconscious patient as a first responder it probably wasn't a stroke. The vast majority of strokes do not lead to impairment of consciousness.

 

What?!?!

The vast majority of strokes dont go through 911 (but the serious ones with unconscious pts always do). Also, review your pathophysiology of a stroke/icp/edema...

 

Also, all of these "you will see this" should say "you could see this" (some people recognized this)

[lokiki]

My pt wasn't fully unconscious, I should probably clarify that. I suppose it was 3-4-6 on GCS to start and got worse. I did call 911 early. There was some paralysis on one side. It could have been something else, but as I always tell my students, we treat what we have, we don't diagnose, and the treatment is the same regardless of what the exact problem is. It was obviously a serious problem and it was the first time I remained cool in an emergency situation and I was pretty proud of myself.

 

Thanks for all the info- I will definitely look at a neuroanat text if I can find one (I live in a pretty small city with just a community college for info). It helps.

[A-Stark]

For specific books, try to find the Board Review Series Neuroanatomy book. It's great.

[leviathan]

What?!?!

The vast majority of strokes dont go through 911 (but the serious ones with unconscious pts always do). Also, review your pathophysiology of a stroke/icp/edema...

 

Also, all of these "you will see this" should say "you could see this" (some people recognized this)

I think you should heed your own advice, since you don't seem to understand the natural time progression of ICP/edema in strokes . Cerebral edema so severe that it leads to elevated ICP and coma is not that common, especially in the prehospital setting. It usually has to be a pretty major insult. The last guy I saw who went unconscious had a massive L MCA stroke and was completely aphasic and motor strength of 0 on R side, and it took 2 days before he lost consciousness. As the OP just said, the patient had a GCS of 13 which is more believable.

[blindsideflank]

In this thread limited anecdotal evidence trumps science

[leviathan]

How about knowledge and experience trumps your lack of both. If you want to talk about 'science', then enlighten us with your textbook knowledge and show us a book or article that explains how you can go comatose from a unilateral ischemic stroke, that doesn't affect the reticular activating system, in an acute setting before even getting to a hospital. This should be interesting.

[blindsideflank]

"I have a question that I haven't been able to answer about stroke. I've only had one stroke patient I dealt with as a first responder. And to be honest I don't remember the specifics becuase it was my first unconcious patient and I was pretty scared."

 

"If you had an unconscious patient as a first responder it probably wasn't a stroke. The vast majority of strokes do not lead to impairment of consciousness."

 

"show us a book or article that explains how you can go comatose from a unilateral ischemic stroke"

 

im struggling with the continuity of this conversation

 

 

and I apologize to the OP, I dont try to derail threads.

check out kernohans notch syndrome for a neat read. (this is more of a hemorrhagic thing i believe (subdural)

[A-Stark]

It does occur to me that any kind of hemorrhagic phenomenon could cause both focal deficits and decreased level of consciousness. An ischemic etiology would not likely cause any change in LOC per se where the ischemia occurs in the anterior circulation. Though of course if Wernicke's area or any other language centre was affected they wouldn't have a GCS more than 14.

[leviathan]

You're like a living version of Fox News. It doesn't help to cherry pick statements out of order and conveniently leave out the explanation that cerebral edema only occurs in massive strokes and only days later after it's been diagnosed. It doesn't happen in the acute pre-hospital setting.

[leviathan]

It does occur to me that any kind of hemorrhagic phenomenon could cause both focal deficits and decreased level of consciousness. An ischemic etiology would not likely cause any change in LOC per se where the ischemia occurs in the anterior circulation. Though of course if Wernicke's area or any other language centre was affected they wouldn't have a GCS more than 14.

I thought about hemorrhagic strokes in relation to the fact that strokes don't usually impair consciousness. That is a pretty commonly taught fact or pearl in internal medicine, so you can tell blindsideflank is pre-clerkship if not premed. All of his knowledge is from a textbook without the understanding how it applies in the real world.

 

I'm guessing hemorrhagic strokes do not really cause enough of a space-occupying lesion to raise ICP, at least if they're intracerebral bleeds. I've heard some people define bleeding into the subarachnoid space as a type of stroke, which would impair consciousness, but I don't know if that leads to focal CNS damage to really consider it a stroke.

[Lactic Folly]

I'm guessing hemorrhagic strokes do not really cause enough of a space-occupying lesion to raise ICP, at least if they're intracerebral bleeds.

? Intracranial hemorrhages can cause herniation.

Re: discussion of LOC - it is part of the NIH stroke scale:

http://www.ninds.nih.gov/doctors/NIH_Stroke_Scale.pdf

[A-Stark]

I thought about hemorrhagic strokes in relation to the fact that strokes don't usually impair consciousness. That is a pretty commonly taught fact or pearl in internal medicine, so you can tell blindsideflank is pre-clerkship if not premed. All of his knowledge is from a textbook without the understanding how it applies in the real world.

 

Perhaps even high school! I've lost any sense of what point he's trying to argue, except that he should review his functional neuroanatomy.

 

I'm guessing hemorrhagic strokes do not really cause enough of a space-occupying lesion to raise ICP, at least if they're intracerebral bleeds. I've heard some people define bleeding into the subarachnoid space as a type of stroke, which would impair consciousness, but I don't know if that leads to focal CNS damage to really consider it a stroke.

 

I'm not sure why SAHs cause decreased LOC, but patients tend to be drowsy on presentation if it's more severe, with focal signs suggesting an even worse prognosis. Or so I learned from the Hunt and Hess score.

 

Anyway around here all the bleeds go to neurosurgery not the Stroke unit, so we can define them as "not a stroke".

[leviathan]

? Intracranial hemorrhages can cause herniation.

Re: discussion of LOC - it is part of the NIH stroke scale:

http://www.ninds.nih.gov/doctors/NIH_Stroke_Scale.pdf

IntraCRANIAL, yes. IntraCEREBRAL, I'm not actually sure but my guess is no. So meaning epidural, subdural, subarachnoid bleeds but not within the parenchyma itself.

 

LOC is part of NIH stroke scale because they can impair consciousness. It would just be a lot lower on my differential for someone presenting with a sudden loss of consciousness / sudden coma.

[leviathan]

Perhaps even high school! I've lost any sense of what point he's trying to argue, except that he should review his functional neuroanatomy.

Based on his prior posts it sounds like he's a paramedic. It seems like he's one of those paramedics who reads just enough to know more than he needs to, but not enough that he actually understands what he's arguing. Like one of those situations where you don't know what you don't know.

 

Bottom line, I've had multiple attendings on CTU and neuro rotations who all teach that dogmatic fact that strokes rarely impair consciousness, because you'd have to infarct both hemispheres or the reticular activating system. This is meant in the context of working up a patient with an acute loss of consciousness and what should be on your differential diagnosis, not on whether or not a stroke patient can later become comatose for various reasons.

[Lactic Folly]

IntraCRANIAL, yes. IntraCEREBRAL, I'm not actually sure but my guess is no. So meaning epidural, subdural, subarachnoid bleeds but not within the parenchyma itself.

 

Sure, if the intraparenchymal hematoma is large enough, there will be mass effect and vasogenic edema. It's not that uncommon.

http://frontalcortex.com/?page=oll&topic=24&qid=299

http://openi.nlm.nih.gov/detailedresult.php?img=3088377_wjem12_1p0067f4&req=4

 

Also, my understanding is that the cerebrum is inside the cranium - therefore intraparenchymal hemorrhages are a subtype of intracranial hemorrhage.

[BoyInTheBubble]

Also, my understanding is that the cerebrum is inside the cranium

 

tee hee hee

[leviathan]

Also, my understanding is that the cerebrum is inside the cranium - therefore intraparenchymal hemorrhages are a subtype of intracranial hemorrhage.

Correct you are. Some intracranial bleeds(extracerebral) =/= all intracranial bleeds.

[leviathan]

I think you're missing the point here. If stroke is on the top of your differential diagnosis for an unconscious patient NYD, then you might want to go back to the drawing board.