8/24/2015. It is divided into an a. Anterior limb b. Posterior limb c. Genu (or knee)

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Joint Commission Technical Advisory Panel (TAP) for Comprehensive Stroke Centers no monetary benefits Debbie Summers, MSN, RN,

contrast the classical lacunar syndromes and what differentiates deficits between subcortical and cortical Summarizes the

allow information to be transferred between: the cerebral cortex and the spinal cord, brainstem and subcortical structures The

1 Joint Commission Technical Advisory Panel (TAP) for Comprehensive Stroke Centers no monetary benefits Debbie Summers, MSN, RN, ACNS-BC, CNRN, SCRN, FAHA, ANVP Evaluates the structures of the internal capsule and related cerebral blood supply Compare and contrast the classical lacunar syndromes and what differentiates deficits between subcortical and cortical Summarizes the clinical significance of subtle to clinically silent symptoms associated with lacunar strokes Contains all of the pathways that allow information to be transferred between: the cerebral cortex and the spinal cord, brainstem and subcortical structures The internal capsule is one of the subcortical structures of the brain. It is divided into an a. Anterior limb b. Posterior limb c. Genu (or knee) 1

Right anterior limb, internal capsule (White matter) Thalamus (gray matter) Caudate nucleus (Ganglia

matter) White arrows point to the internal capsule Black arrow points to the genu C Caudate Nucleus G -

(blue) formed of neurons receiving impulses from below into thalamus and transmitted to the cortex

Afferent Ascending Motor Efferent Descending Internal Capsule Basal ganglia caudate nucleus putamen

Basal Ganglia striatum (caudate nucleus and putamen) The function of the basal ganglia in motor control

behavior From your motor memory, basal ganglia facilitates in preparing for motor action It controls

2 Right anterior limb, internal capsule (White matter) Thalamus (gray matter) Caudate nucleus (Ganglia gray matter) Lentiform Nucleus (Ganglica gray matter) Left posterior limb, internal capsule (White matter) White arrows point to the internal capsule Black arrow points to the genu C Caudate Nucleus G - Globus pallidus P Putamen (Lentiform Nucleus) T thalamus Lateral ventricles are white The sensory tract (blue) formed of neurons receiving impulses from below into thalamus and transmitted to the cortex (somatosensory pathways) Motor tract (red) The optic radiation (occipitothalamic) (violet) SAME Sensory Afferent Ascending Motor Efferent Descending Internal Capsule Basal ganglia caudate nucleus putamen nucleus accumbens (or ventral striatum) globus pallidus lentiform nucleus Subsubstantia nigra Thalamus Basal Ganglia striatum (caudate nucleus and putamen) The function of the basal ganglia in motor control is not understood in detail The basal ganglia allow you to automatically perform a learned motor behavior From your motor memory, basal ganglia facilitates in preparing for motor action It controls and modifies your movements It is one of the brain structures that maintain posture Basal ganglia play a role in memory retrieval 2

It is a continuous sheet of fibers that forms the medial boundary of the

envelop this nucleus Inferiorly many of the fibers of the internal capsule funnel

lenticular nucleus Posterior limb separates the thalamus and lentiform nucleus

and pre-frontal cortex That send information from the frontal cortex to the pons

3 It is a continuous sheet of fibers that forms the medial boundary of the lenticular nucleus It continues around posteriorly and inferiorly to partially envelop this nucleus Inferiorly many of the fibers of the internal capsule funnel into the cerebral peduncles Anterior limb separates the caudate nucleus and lenticular nucleus Posterior limb separates the thalamus and lentiform nucleus Contains axons: That send information between the thalamus and the cingulate gyrus and pre-frontal cortex That send information from the frontal cortex to the pons Tracts: Thalamocortical fibers (thalamus to frontal lobe) Frontopontine fibers (frontal cortex to pons) 3

Contains axons Originate in the motor areas of the frontal lobes and extend to the cranial nerve nuclei in the brainstem Connect the motor section of the thalamus with the motor areas of the frontal

premotor cortex for initiation and planning of movement) Contains axons: That come from the motor area of the frontal cortex and extend to the anterior horns of the spinal cord Contains sensory

tract) Lenticulostriate arteries, small arteries originate from the first portion of the MCA (supplies anterior limb and genu) Left MCA Lenticulostriate Branches Right MCA Lenticulostriate Branches

4 Contains axons Originate in the motor areas of the frontal lobes and extend to the cranial nerve nuclei in the brainstem Connect the motor section of the thalamus with the motor areas of the frontal cortex Tracts: Corticobulbar fibers (cortex to brainstem) Ventral anterior (VA) and Ventral lateral (VL) nucleus receives information from the cerebellum and globus pallidus that pass into the premotor cortex for initiation and planning of movement) Contains axons: That come from the motor area of the frontal cortex and extend to the anterior horns of the spinal cord Contains sensory information coming from the body Corticospinal tract Posterior (dorsal) column-medial lemniscus pathway - touch, vibration, twopoint discrimination and proprioception Anterior lateral (Spinothalamic tract) Lenticulostriate arteries, small arteries originate from the first portion of the MCA (supplies anterior limb and genu) Left MCA Lenticulostriate Branches Right MCA Lenticulostriate Branches Right pure upper-motor hemiparesis due to damage to the basal ganglia (globus pallidus and striatum) and the genu of the internal capsule on the left side Left pure upper-motor hemiparesis due to damage to the basal ganglia (globus pallidus and striatum) and the genu of the internal capsule on the right side 4

Anterior choroidal artery branch of ICA supplying the inferior portion of

geniculate nuclei and ventral posterolateral nuclei) Optic tracts portion

parts of the pyriform cortex, uncus, and amygdala) Substantia nigra

Hemiparesis (weakness on the opposite side) Hemianesthesia Homonymous

Optic tracts and lateral geniculate nucleus of the thalamus Noted involving

5 Anterior choroidal artery branch of ICA supplying the inferior portion of the posterior limb Portions of the thalami (specifically the lateral geniculate nuclei and ventral posterolateral nuclei) Optic tracts portion Middle third of the cerebral peduncles Portions of the temporal lobes (ie: parts of the pyriform cortex, uncus, and amygdala) Substantia nigra Portions of the globus pallidus Choroid plexus in the lateral ventricles Hemiparesis (weakness on the opposite side) Hemianesthesia Homonymous hemianopsia Corticospinal tracts Posterior (dorsal) column-medial lemniscus Optic tracts and lateral geniculate nucleus of the thalamus Noted involving the posterior limb of right internal capsule as well as the head of the right hippocampus CT Head MRI 5

Recurrent artery of Heubner is a branch of the ACA.

caudate Infarction results in prominent motor and neuropsychological

abnormality confusion Linguistic abnormalities, frontal system dysfunction, and

anterior putamen and anterior limb of the internal capsule consistent with

Supplies the head of caudate, anterior portion of the lentiform nucleus and

6 Recurrent artery of Heubner is a branch of the ACA. It supplies the inferior portions of the anterior limb, the genu and head of caudate Infarction results in prominent motor and neuropsychological Contralateral weakness of the face and arm findings Cognitive and behavioral abnormality confusion Linguistic abnormalities, frontal system dysfunction, and amnesic deficits There is loss of substance in the head of the caudate, anterior putamen and anterior limb of the internal capsule consistent with infarction in the territory of right recurrent artery of Heubner (RHA). Supplies the head of caudate, anterior portion of the lentiform nucleus and anterior limb of the internal capsule. This patient had an ACOM aneurysm clipped. Either sacrificed with clipping or with vasospasm it occurred 6

The original pathological descriptions of lacunar infarcts were made by the beginning of this century Lacunar infarcts vary from 3-20 mm, and are most commonly found in the putamen

Common in hypertension and diabetes Small vessel disease includes atherosclerosis of small arteries but refers more specifically to lipohyalinosis and hyaline atreriolosclerosis,

capsule is the most common lacunar syndrome.

7 The original pathological descriptions of lacunar infarcts were made by the beginning of this century Lacunar infarcts vary from 3-20 mm, and are most commonly found in the putamen (lentiform), caudate, thalamus, pons, internal capsule and cerebral white matter, in descending order of frequency About 20 % of all strokes. Common in hypertension and diabetes Small vessel disease includes atherosclerosis of small arteries but refers more specifically to lipohyalinosis and hyaline atreriolosclerosis, vascular lesions that are seen primarily in hypertension and diabetes Weakness of the face, arm, and/or leg (pure motor stroke) Pure motor stroke caused by an infarct in the internal capsule is the most common lacunar syndrome. Upper motor neuron signs hyperreflexia, Babinski, clonus spasticity and Hoffman present Mixed sensorimotor stroke Since both motor and sensory fibers are carried in the internal capsule, a stroke to the posterior limb of the internal capsule (where motor fibers for the arm, trunk and legs and sensory fibers are located) can lead to contralateral weakness and contralateral sensory loss 7

If a patient has weakness +/- sensory deficits, how can you tell whether the

localize the stroke to the internal capsule as opposed to the cortex?

internal capsule stroke or a large ACA + MCA cortical stroke Looking at the

supplied by the MCA The presence of these cortical signs may exclude an

receptive aphasia visual field deficits visual or spatial neglect A vascular

8 If a patient has weakness +/- sensory deficits, how can you tell whether the stroke subcortical or cortica l What other symptoms or signs can help you localize the stroke to the internal capsule as opposed to the cortex? A patient who presents with arm and leg weakness may have either a small internal capsule stroke or a large ACA + MCA cortical stroke Looking at the homunculus, the cortical leg area is supplied by the ACA and the arm area is supplied by the MCA The presence of these cortical signs may exclude an internal capsule stroke: gaze preference or gaze deviation expressive or receptive aphasia visual field deficits visual or spatial neglect A vascular lesion of the visual cortex is likely to result in a quadrantic defect and/or macular sparing 8

Name Location Presentation Pure motor Stroke (most common lacunar syndrome: 33-50%) Ataxic hemiparesis (second most frequent lacunar syndrome) Posterior limb Basis pontis (anterior portion), corona

hemiplegia that typically affects the face, arm, or leg of one side. Dysarthria, dysphagia, and transient sensory symptoms may also be present.

9 Name Location Presentation Pure motor Stroke (most common lacunar syndrome: 33-50%) Ataxic hemiparesis (second most frequent lacunar syndrome) Posterior limb Basis pontis (anterior portion), corona radiata Posterior limb and basis pontis Corona radiata, red nucleus, lentiform nucleus, Superior Cerebellar Artery (SCA) and Anterior Cerebella Artery (ACA) infarcts It is marked by hemipareis or hemiplegia that typically affects the face, arm, or leg of one side. Dysarthria, dysphagia, and transient sensory symptoms may also be present. It displays a combination of cerebellar and motor symptoms, including weakness and clumsiness, on the ipsilateral side of the body. It usually affects the leg more than it does the arm; hence, it is known also as homolateral ataxia and crural paresis. The onset of symptoms is often over hours or days. Name Location Presentation Dysarthria/clumsy hand (sometimes considered a variant of ataxic hemiparesis, but usually still is classified as a separate lacunar syndrome) Pure sensory stroke Anterior limb Basis pontis, or genu of internal capsule, corona radiata, basal ganglia, thalamus, cerebral peduncle Contralateral thalamus, internal capsule, corona radiata, midbrain The main symptoms are dysarthria and clumsiness of one hand (weakness) plus or minus central facial paralysis, which often are most prominent when the patient is writing If central facial paralysis Dysphagia Tongue deviation Marked by persistent or transient numbness, tingling, pain, burning, or another unpleasant sensation on one side of the body absent of motor weakness, visual symptoms, or imbalance Name Location Presentation Mixed sensorimot or stroke Thalamus and adjacent posterior internal capsule, lateral pons This lacunar syndrome involves hemiparesis or hemiplegia with ipsilateral sensory impairment 1. Memory impairment 2. Dementia 3. Cognitive impairment 4. Emotional disturbance 9

Very small lesions of the internal capsule can cause loss of function of large areas of cerebral cortex by severing their ascending and descending connections with subcortical structures Top of the

10 Very small lesions of the internal capsule can cause loss of function of large areas of cerebral cortex by severing their ascending and descending connections with subcortical structures Top of the funnel is the cerebral cortex and the stem is the cerebral peduncle. Last seen normal by a neighbor at 1310 today Pt was eating lunch with neighbor and she noticed pt was unable to get up from chair then started to have slurred speech with left facial droop. EMS was called and presented to local hospital Hypertension had not taken BP med for a number of weeks Hyperlipidemia Lipitor Stroke History of CEA on plavix every other dayreport per family Left-sided weakness and dysarthria Intact to light touch and pinprick throughout. Vibratory sense is reduced to the knees bilaterally Small right thalamic/posterior limb lacunar infarction hours to days in age. 10

11 Right basal ganglia stroke with resolved dysarthria and left hemiparesis and facial weakness, embolic due to PAF. HTN HLD Treatment Plan Start apixaban 2.5 mg bid Change back to ASA 81 mg because of chronic severe small vessel disease Home with home health RN and PT Presented with right facial droop, slurred speech and feeling of falling to the right. He went to an outside hospital the night before and CT head was negative so he was discharged home. Since that time, he has continued to have right facial weakness and some "bumping into things". He denies unilateral weakness or numbness. His gait in the room appears steady. He reports feeling slightly "dyscoordinated". Suspect left subcortical small vessel stroke with right facial droop, dysarthria and ataxia. Not a candidate for intervention due to time Dyslipidemia Hypertension Pt denies Smoking. He drinks once every 3 nights Takes No Medications Neurological: Positive for facial asymmetry, speech difficulty, weakness and numbness. AAO to person, place, event and time, Follows commands Speech: mild dysarthria PERRL, VFF, EOM's intact Face asymmetrical with right facial weakness Tongue ML, palate elevates bilaterally Motor 5/5 x 4 extremities Sensation intact to light touch and pinprick No drift of extremities Finger to nose and heel to shin testing normal Plantar reflex with bilateral down going toes. Gait steady in room. Normal tandem He was started on an aspirin and a statin for secondary stroke prevention. Improved gait but set up for outpatient speech therapy. 11

MRI: Small focus of restricted diffusion with associated FLAIR

corona radiata and centrum semiovale Presented as transfer

gait and balance disturbance and dizziness.

known history of hypertension, dyslipidemia, or diabetes

00 packs/day for 40 years She was found to be markedly

12 MRI: Small focus of restricted diffusion with associated FLAIR hyperintensity involving the left putamen/extern al capsule, corona radiata and centrum semiovale Presented as transfer from regional hospital sudden onset of unilateral weakness, gait and balance disturbance and dizziness., affecting primarily the right arm and right leg She has no known history of hypertension, dyslipidemia, or diabetes mellitus. Current Every Day Smoker packs/day for 40 years She was found to be markedly hypertensive in the emergency room and also had an elevated blood glucose at 355. Physical Exam: General appearance: alert, appears stated age and cooperative Neuro: Right hemiplegia - right arm flaccid. Right leg 2+ strength. Mild right facial droop 12

The gray-white matter junction is normal.

infarction. Given labetalol for her blood pressure and was on a nicardipine gtt.

The pt was also noted to have a BG of 300+ in the ER with uncontrolled HTN as well.

capsule, left lateral thalamus, and right putamen.

13 The gray-white matter junction is normal. Ageindeterminate however likely subacute to chronic left anterior limb lacunar infarction. Given labetalol for her blood pressure and was on a nicardipine gtt. IV TPA was given in outlying hospital and transferred to SLH for CTA head and neck with perfusion which was negative.. An MRI per neurology does show multiple embolic strokes. The pt was also noted to have a BG of 300+ in the ER with uncontrolled HTN as well. Small areas of acute infarction, hours to days in age, within the left internal capsule, left lateral thalamus, and right putamen. Potential etiologies include vasculitis or an embolic source. Embolic stroke HTN (hypertension), malignant Diabetes mellitus type 2 with complications HBA1C 11 Hyperlipemia Tobacco abuse Lipitor Coreg and Lisinopril Plavix Lantus Humalog Nicotine patch 13

Stroke School for Internists Part 1

Stroke School for Internists Part 1 November 4, 2017 Dr. Albert Jin Dr. Gurpreet Jaswal Disclosures I receive a stipend for my role as Medical Director of the Stroke Network of SEO I have no commercial