STROKE SYNDROMES AND RULE OF 4

0:00 [Music] hi friends welcome to my channel dr. Srinivas medical concepts and I am dr. Sweeney was neurologist from Andhra Pradesh today are we talking a very important topic stroke which is not only useful for practice but also from for exams in fact dr. C efficient a great neurologist said that nuraghes learnt stroke by stroke and therefore if you

0:45 learn the stroke syndromes the stroke by stroke you are not even on G so today I am going to talk about all these stroke syndromes and a very interesting rule the rule of four but what is stroke stroke Oh Sandro vastra accident is defined as an abrupt onset of neurological deficit which is attributed to a focal wrestler caused as a semi it is because of master cause so to understand the stroke syndromes we need to understand the vascular Anatomy basically we can do in

1:30 stroke syndromes in two cortical syndromes and the brain stem syndromes that is midbrain pons and medulla oblongata but to understand that we need to understand circle of villas what does the Circle of Willis Circle of Willis is an anastomosis which is formed between the puppy brew business system and the internal carotid artery system so Circle of Willis is formed by anastomosis of the vertebral baseness system and the internal carotid artery system if you understand the vascular Anatomy the vessels supplying each part of the brain understanding stroke syndrome is very

2:15 very easy and then and I can summarize with a rule of four for the brainstem strokes so the entire brain is supplied by the Circle of Willis which is formed by the vertebral based our system and the Celtic arterial system the multiple basilar artery system and the strokes because of this we call that as posterior circulation stroke so the vastly broad-based our system supplying the brain stem we call that us posterior circulation stroke the internal carotid artery which predominantly supplies the cortex through MCA AC we call that us anterior circulation

3:02 stroke fortunately anterior circulation strokes are more common than the posterior separation strokes and this is good news one posterior circulation strokes of dangerous because they are basically brain stem strokes maintain our own little pawns make brain are in order you have vital structures the anterior circulation strokes are generally less dangerous as compared to the participation strokes so you have a multi probe a star system you have Celtic adenine system now just listen carefully I just give important points so the to multiple arteries join together to form the basilar artery dividing to post in

3:49 cerebral arteries and then encircles supplies the temporal cortex and the occipital cortex so the medulla oblongata is predominantly supplied by the but people are P so if there is a metamour belong at a stroke it is because of but people are 333 the to multiple arteries joined together to form the basilar artery that means pons is supplied by the basilar artery so there any point any array or any moment of the pause because of the basilar artery the basilar artery divides into two posterior cerebral arteries that means midbrain is supplied by the posterior cerebral artery it divides any circles the temporal lobe and the occipital

4:35 cortex so ops video effects is supplied by the post itself there are three that's it this is post a citation stroke so just to recapitulate the metal or grommet is applied whenever develop me bones is supplied by the busines battery the midbrain is supplied at a portal cerebral artery then temporal lobe the thalamus and the occipital cortex are supplied by the poetry cell hockey fine now let's come to the anterior circulation the internal carotid artery gives rise to the minutes of vlogging so the entire complex is supplied with a miniature gloppy then we divides into anterior gladly so the medial part of the frontal will be supplied by the anterior blocking so if you take the compact the entire

5:21 context is supplied by the Middle's of gladly accept the medial part of the frontal lobe which is supplied by and gives ambulatory and the occipital cortex which is suffering enough forces have not read so if you have understood this the overview of subproblems now understanding stroke syndromes are very very easy so now let's go step by step first I'll talk about practical syndromes then the basin's syndromes so particle syndromes first predominantly we have minutes implanted directly so minutes of magnet directly we have superior division and the Imperial division so if an emperor's Marcus into the village of like a superior division on the website the Broca's area is affected so patient will have Broca's aphasia and right

6:09 hemiplegia if an amorous log is into the imperial union of the middle cell block be on the left side patient will have a mix-up Asia that means he does not understand he keeps on talking person will have a mix of Asia usually will not a very important point because butt-nik's areas in the temp repair it later whereas corticospinal tract comes from the frontal area internal capsule midbrain pons video and goes to the opposite side so if an animal is noticing to the superior vena topics a frontal oh they have Broca's aphasia with hemiplegia whereas even impalas notice into the inferior division they

6:54 love Bernice aphasia but they usually will not have any pleasure all the races then she gets affected the superior division they may have any meddler how did the inferior even gets affected they may have visual effects so this is about the middle cerebral artery the superior mutant and the inferior division now let's see what happens if the stem of the middle cerebral artery gets affected if the stem of the middle cerebral artery gets affected they may have a hemiplegia there are chemists Asiya they have global aphasia because the superior vena salts affected the individuals affected they have global aphasia and importantly they may have gas exits

7:41 that means if loved Fontenot this affected left for life is is affected they cannot move their eyes towards the right side the second is pathways affected so eyes will look to one side and hemiplegia on the opposite side so font innovations and say in fox they can be guessed as he is looking to one side and hemiplegia on the opposite side whereas if pons gets involved the ppl has already crossed so in the PPR of gets affected ice cannot equal towards it's a eyes will move towards opposite side hemiplegia is also the opposite side so eyes will be looking towards the side of hemiplegia in a pond a lesion whereas if it's a dense NCAA stem of tension fun eyes were found 11 for annually look into one side how many we

8:28 play get towards the opposite side this is all what you know what you should know about me encephalopathy right now that's Kampala ante reserve Lobby as I said the interval character the middle cerebral artery and the anterior cerebral artery so the Anton circular be predominantly supply the medial part of the front and low so in the medial part of the frontal lobe according to the moth or harmonic plus you have the link area so both the anterior clock is get affected the legs get a bit then the legs become weakened so weakness of leg is more in failure of the anterior cerebral artery whereas weakness of the face and the hand more than the leg is impaired the middle

9:14 supplanting so the antenna signal affricates affected they'll have leg weakness they'll have primitive reflexes because for the notes are affected they have emergence of the primitive reflexes one of primitive reflexes the graph reflects sucking the fix all these reflexes are present during our infancy when the father move isn't that mature but once the Fontenot starts maturing after we pass the infancy stage these reflexes have to disappear but the real emergence of these inferences throw that the frontal lobe is getting affected so emergence of the primitive reflexes the leg area are getting affected region having behavioral changes and if the

10:01 left a circuits of it will have transcortical motor aphasia it's a king to motivate a Broca's aphasia but repetition is impact because penicillin area is in time so left AC involvement they cannot transport occur motor aphasia so now what are the signs of AC involve an antiseptic environment the link is affected because the median path of the frontal lobe is affected they have the emergence of the primitive reflexes because the fondant of is affected they'll have behavior changes they have transcortical motor aphasia this is about the anterior cerebral artery now let's see processor blood things as I said the purchaser Vlad is suffering the midplane wine

10:48 temporal lobe and the hospital so the temporal what once you can get affected they can have memory disturbances they can have the visual pathway getting affected visual field affects primarily the occipital cortex gets affected if the off speedy cortex gets affected there is cortical blindness Anton syndrome they can have visual agnosia a perceptive egg nausea associated I close here so perimeter experiments where they cannot identify if occipital temporal itself is affected it is what that means they can identify but they cannot give meaning to it so you call it as a perceptive like no self off split apparently area gets affected and if

11:34 occipital temporal area gets affected you call it also see a two ignosi a-- they can identify but they cannot give meaning to it example prosopagnosia they can identify the phaser space but they cannot give meaning to the face then you have the thalamus is getting affected of course you sell flattery you can have any sensory loss then you have this premium of the corpus callosum gets affected you have Alexia without Ignacio without a trophy a lecture without a cover means difficulty in writing but whatever they've written that is difficulty in reading and difficulty in writing and make sure you note a graph yes they can write there's no difficulty but they cannot leave what they just

12:20 written the principle being the right-sided vision the right-sided vision goes into the left occipital cortex the lopsided vision goes into the right Roxbury cortex anything on the right side is easy to convert into language form because it goes to the left of study cortex and my language areas are on the left so it is easy to access but anything on the left which go to the right of alphabets meets the premium of the corpus calm and corpus callosum to travel and access the language areas so any defect in the speedom of the corpus callosum it cannot progress and therefore it cannot access language areas and therefore they have problems so Alexia without area they don't have problem with writing but they can't read what they just written

13:06 there's no problem in writing because it goes slightly I'm did it so this is all about posterior cerebral artery strokes so we have mca strokes we have AC a stroke we see a PC a stroke now most important especially from my base point of view to some extent and the internal medicine point of view is about internal capsule internal capsule you need to know two things one the blood supply second the structures which are affected internal capsule you have the anterior lim chaemoo posterior limb return integral path and something take apart so you have anteriorly

13:51 jano posterior limb retro lenticular pi sub medical pod internal capsule the blood supply you can divide into two halves one the entire upper part and then to the entire lower part the entire upper part of internal capsule is supplied by the middle cerebral artery so the entire upper part of the internal capsule is supplied by the militant Salafi the lower part of the internal capsule you divide it into three parts the anterior most part is supplied by the AC the anterior BR the branch of it is Hubner sorry so in the internal capsule

14:37 if you take the underling they have atomic radiation sensory and then come the corticobulbar fibers and the corticospinal fibers which are more in the genome and of and therefore in the anti yester if the entire circle of the human affricates affected the corticobulbar I was a predominantly affected so they loved PSEO breaking monoply gia so anterior cerebral artery which supplies the lower part and until 1/3 if it gets affected cuteness Audrey antes empathy get submitted their arpeggio breaking more of pleasure there you have jinwu then the posterior limb so until one third is supplied by the anti circle at the branch of which is human exactly the middle one third by

15:24 the portion communicating artery and the posterior one-third again by AC this is an evil Cora dark we have branch of internal carotid artery so corticobulbar fibers are everything is in the posterior bar the amplifiers were on atomic radiation suppose you part you have corticobulbar fibers and corticospinal fibers so if the post your moves gets affected which is supplied with auntie will coil audrey a branch of internal carotid artery corticospinal fibers are fitted so they are in it easier they can have many sensory loss and then they have visual disturbances home on you must give me a Nokia why because you have anterior limb jeno pause the Avedon return it the class

16:12 compliant o'clock I'm telling them you have salami radiations generally you have corticobulbar fibers and poor children you have corticospinal fibers so the anterior tonic radiations get affected the thumb of the radiations get better you have chemists easier if the Jade oh and of course you didn't get affected you have corticobulbar fibers are canta cosine Y was getting affected you have any preacher and is a little integral path gets affected you have optic radiations so they have homonymous hemianopia the submandibular is auditory radiations so if a person has gone to a meat please yeah Hemi anesthesia and homonymous hemianopia it is because of the antique entire coil aa tree of internal

16:57 carotid artery involvement so very very important hemiplegia hemisphere homonymous hemianopia it is anterior correlative mornin even in the MCA 32 it also you can have hemiplegia finished isha and homonymous hemianopia but then they have other size like global aphasia they can have gaze palsy so other cortical things out there like gaze fancy or global aphasia then it is more of cortical region where is the internal capsule you don't have cortical signs like gaze palsy or global aphasia you have purely hemiplegia anesthesia homonymous hemianopia Henry's teacher because of the anti rattle ah McCrady ations environment in the anteroom of the internal capsule the genuine of

17:44 course in the marine world which carries carbon fiber so they'll have hemiplegia and then the appropriate lenticular part you have optic radiations they have homonymous hemianopia so internally capture the blood supply the box the structures passing through it are very very important and very important point to note is that internal capsule environment a small does it can produce a dam is an integer because corticobulbar fibers and corticospinal fibers are so close so small lesion in the internal capsule can produce a dense hemiplegia where the quanta collisions unless it is big it does not produce a dense hemiplegia so even a small impact and producer density preserve so important points to

18:31 be remembered an internal capsule are one if the anterior cerebral artery a bunch of which is shouldna sorry if it gets affected due to the anti-venom and genuine more commonly affected and they'll have facial brachial moan or pleasure whereas entire corridor the branch of internal cavities involvement is you know the portion for simply Jogja me seizure and homonymous hemianopia because you have brittle metal fibers weather optic radiations so this is about internal caption now let's come to the brainstem strokes you have big brain pons and medulla pramantha in we brain basically you have northern girl syndrome where the superior cerebellar peduncle is affected so

19:18 they'll have cerebellar ataxia you have Benedict's syndrome where the red nucleus gets affected so you have tremors and hemiplegia claude syndrome is nothing but northern in the syndrome and benedict syndrome so they'll have cerebellar ataxia they will have premise and hemiplegia finally Weber syndrome where a third now is involved so third now with any possess Weber syndrome so non hantum syndrome is superior cerebellar peduncle where you have cerebellar ataxia Benedict syndrome is red nucleus where you have tremors Claude is no kind of space Benedict so you have tremors and simpler ataxia finally that person you have no path with Kentucky hemiplegia so will be easy to remember a mnemonic is there n-b-c w

20:06 remember nice beautiful cute wife nice beautiful cute white and fern on angle before Benedict's you will see four tune that starts W find that is paper syndrome so mine is beautiful cute white if you remember I remember all these both symptoms then another important syndrome in midbrain is very not syndrome I told in previous class of Bureau of thermal energy where I discussed that the vertical gaze has got to conference up give and down gaze again fibers cross over and then descend don't guess I was this in straight away so anything goes and impinges on the midbrain the top of the midbrain like very not syndrome you have selective as a spasm so pregnant syndrome and another

20:52 two important points which you need to know when you are talking about mid brain syndromes are one-third new u-kiss in women there are no environment there are no nucleus involvement how do you differentiate between tell it not you click on that means in the midbrain per se and third no vesicle involvement in third no physical environment the levator palpebrae superioris i get submitted so you may have unilateral ptosis but if the brainstem per se gets affected if the third now nucleus gets affected you'll have bilateral doses because the levator palpebrae superioris sites it's a common supply from these centrally placed nucleus indeed there is no nucleus so the third no nucleus in

21:39 the midbrain gets affected they're both illegal to calculate superiors are affected so patient will have bilateral ptosis but once that now emerges from the nucleus and goes peripherally only there will be unilateral process so bilateral process it is a third no nuclear involvement in the midbrain very important point and then i discussed this in the last class there are no you have the parasympathetic fibers going going superficially so for any extrinsic pathway like posture communicating a key or news amor had me asian will happen to superficially plays parasympathetic fibers and there was inspire somebody causes comes to shove the pupil there will be dietitian of the pupil we're in the presence and intrinsic pathology the third no like that is it affects the

22:25 center of the third no and they force pastor superficially placed parasympathetic fibers so these are all the points usually you need to know in macdanne northern the syndrome benedict syndrome cross syndrome ever syndrome by not syndrome how do you differentiate the term now nuclear environment from the third no how do you befriend J between the extrinsic computer the third know from the instancing pathology about Burnham so midbrain is over known as both your pons pons basically you need to know about 4x4 syndrome and we believe to dress in them what is for one syndrome for one syndrome like as I said about a third now nucleus and the third now for white syndrome is a sixth note nuclear in government whereas million could get is

23:12 six no fancy climbing Mormon so the sixth now is six the nuclear requirement is there six no nuclear is not two components one one interim interim second s inter inter American is only the sixth mm on the same side inter means it connects a sixth row on the same site with a third now on the opposite say through MLM so in the sixth no nucleus gets affected both an inter component and the inter component gets affected inter nuclear component gets affected so they have gained a spicy so if sixth no nucleus gets affected since the one one said an turn on the opposite side gets a fitted so they have is only gays fancy with seventh no and the opposite hemiplegia that is for one syndrome whereas million two plus in Rome it is

23:58 the sixth now which gets affected so unlike horizontal gaze which you see in for one syndrome only the ladder lettuce gets affected so sixty opacity causing Latin letters fancy with seventh no fancy and EVP is measured googa syndrome so the fundamental difference between million ku+ syndrome and for white syndrome is Hawaiian syndrome six no nucleus gets affected so in turn you clipart and interview confer gets affected so if it is a horizontal gaze fancy whereas million to preferred is only six nope as it's only lateral rectus fancy with other components like seventh of pasión every picture right then what is logging syndrome and what is one and all syndrome log in syndrome and one enough syndrome in logged-in syndrome what happened the lesion is in deep ponds so

24:44 as I said sister nucleus and pay pra content parameters reticular formation are concerned with gays and their group in a locked-in syndrome what happens is that the horizont gains gets affected corticobulbar fibers and corticospinal gets affected so they'd have all the pleasure but green pain is intact so they'll have vertical elements so logged-in syndrome is a Ponton infarct or Ponton pathology where there's the horizonte' case Percy quarry fences but what tickling winds are present that is locked-in syndrome and what is one enough syndrome as I said people are F is is responsible for one human horizontal movement and another is responsible for half moment so if they're a combination of PPR up and a miller one women and how Kumud are gone and there is only half women present and

25:30 that too there is nystagmus because of heavy law of doer innervation what is the reason of dual innovation yo muscles get the same supply that means right lateral rectus and left meaning rectus over like this alright medial rectus so in the left medial rectus gets affected there's compensate we increase in the stimulus from the corresponding joke puzzle so right laughs rectus they'll be nystagmus abducting instance so this is lobbying syndrome you have one now syndrome you have foreign syndrome and we like Cobra syndrome so this is all about you need to know what bones now coming to the middle automata media on top basically you have two syndrome one the lateral medullary syndrome second is a medium medullary syndrome if you understand media middle is you know now we're already syndrome is easy we just

26:16 use it has got two components one the posterior column second is a fentanyl so posterior column and press the now are affected are affected along with the along with the pyramidal tract that is it is a medium very very syndrome whereas in Lata muda very syndrome you have other compounds getting affected for example spine and nucleus of the 5th century equals 50 no gets affected so they'll have finishing sensory loss the spinothalamic tract gets affected so they'll have the kondal and it also pain and temperature they have sympathetic cloud gets affected so they'll have Horner's syndrome they have spinocerebellar tract getting a bitten so they have ataxia the tenth no gets affected so they have panel pasion dysphagia the based of the nucleus gets

27:03 a patent so they'll have severe vertigo in fact any person coming with severe over tango always suspect van gogh syndrome one of the common causes of vertigo in our brainstem pathologies valve of syndrome another important and she could question another important concept you need to know about Vallon ball syndrome is that Valon birth syndrome or lateral medullary syndrome does not produce hemiplegia it does not produce any pleasure my pyramid practice medially situated where as well and exam ballon but symptom is a lateral medullary syndrome and therefore it does not that pyramid travel gotta go span that so hemiplegia is not a feature of bambor syndrome so so far I mean telling so many points you must have got

27:49 confused now let me really summarize we have super fascinating rule which is known as rule of four so if you know rule of four you will know the entire brain stem stroke such as simple but super rule the rule of four so what is Munna for according to the rule of four then for medial structures which starts with the letter M according to the rune of wood there are four structures which start with S which are placed in the sideways yes for his sideways for his medial or Midland for M and there were four cranial nose in each component for K years I was in middle of vendetta for cranial nerves and pons and for trainer

28:37 knows about bones so very easy rule of four all four for midline structures M you have four Emmys for sideways structure for s you have four clap starting with s you have four Kenya knows in each component for in the middle of no metaphor in the pawns and forever pawns so what are the four M structures which are in the midline one is the motor corticospinal tract as I said it is no venial part of the video so that remedial system does not produce any picture so it indirectly says it is placed immediately so M is for medially so what are the 4 M one M is the corticospinal tract or the Matra second is the medial meniscus or the posterior

29:22 column the word is the Montagu clay of cranial nerves are all in the center in the middle we have back and forth is the MLF medium now material fuzziness so you have 4m in the mid lane and four and month of cortical spinal tract medial meniscus posterior column more the roots of the cranial nerves and media along with new plastic as over now your 4 s 4 s in this size as far as one of the 4 s spinothalamic tract which carries painting temperature you have sympathetic tribe which can cause Hamas syndrome you have sensing you close of the fifth no that is laterally faced and if we made you know no matter sending you to the system gets affected sensory loss is there spinal curvature therefore you have the Binghamton big

30:07 loss and opposite said simple and black gets operator you can have honor syndrome and spinocerebellar tract gets affected you can have ataxia so for ss4 s4s which are paid in the sides sympathetic track spinothalamic tract spinocerebellar tract and then you have a spinal cellular taxes I'm a dominant sympathetic sac sensing you because of the 15 oh and finally will affect all these are based sideways or laterally and therefore lateral medullary syndrome balan the syndrome you have all these four structures getting affected so for m meter plays in the middle and m4m for a structures which are placed in the side OSS forest no protein you knows there are two important points one I said there are four trainee allows in

30:53 the middle of Amida nine ten eleven twelve fourteen you know the Kwan's five seven eight and six and four train along about 1/3 pull in the midbrain one two is oh so you have three four five six seven eight nine ten eleven twelve but again here again is a very fascinating rule wherein they say that all the cranial now which are placed in the midline can divide 12 into equal parts that means 3 and 4 6 and 12 they are based in the midline 3-dimensional into four parts for device one in two equal three bugs six device one win two equal to pus-y device were into one equal part so all the cranial nerves which they went well in two equal parts are placed

31:40 in the midline centrally that is three four in the palms six three four in the midbrain six in the ponds and play with them in order all the cranial nerves which do not divide 12 into equal parts have placed sideways five seven eight nine ten eleven five cannot divide twelve eight equal parts - they will know it can be right when we do equal parts neither mind and evaluate two equal parts so cranial nerves which do not divide value into equal parts are placed sideways the cranial nerves which divide when we do equal parts like three four six twelve are placed in the midline so this is some of the stroke syndromes and runa for I hope you have enjoyed it as dr. CMP sure the great you know he said you

32:25 learn neurology stroke by stroke and hence if you have understood all these strokes syndromes I think stroke by stroke you are learn and you have learned neurology I enjoy really teaching this episode and I hope you also enjoy it and if you really like it please subscribe my channel dr. seanwes concepts thank you bye