The leading clinical symptoms of acute stroke are the same in adults and children. Each vessel has a specific supply area in the brain, and each brain region is responsible for different body functions. Therefore, different symptoms may occur with strokes. However, some symptoms may occur independently of the affected vessel or brain region. These include:
- Disturbance of consciousness
- Unconsciousness up to coma
- Nausea and vomiting
- Cephalgia (headache)
- Babinski reflex – pressureful brushing of the lateral edge of the sole of the foot leads to an upward extension of the big toe
- Cranial nerve involvement with corresponding symptoms, e.g., dysphagia (dysphagia), deviation of the tongue when sticking it out, gaze paralysis
The internal carotid artery is most commonly affected, accounting for 50 percent of all strokes, and the middle cerebral artery is affected in 25 percent of cases. Likewise, vessels can be affected, which depart from them. Since the nerve fibers of the so-called pyramidal pathway – responsible for voluntary movements – cross and move to the opposite side, paralysis symptoms occur on the right side of the body in the case of a left-sided infarction and vice versa. The following symptoms occur primarily when the internal carotid artery or the middle cerebral artery are involved:
- Hemiplegia – complete paralysis of one half of the body.
- Hemiparesis – incomplete paralysis of one half of the body.
- Hemiparesis of the face
- Sensory disturbances of the affected half of the body
- Perceptual disturbance of the affected half of the body
- Visual disturbances – hemianopsia, quadrant anopsia – on both eyes half or a quarter of the visual field is no longer perceived
- Herdblick – the eyes look to the affected hemisphere of the brain.
- Diplopia (double vision, double images)
- Aphasia (speech disorders)
- Dysphagia (swallowing disorders)
- Apraxia – inability to perform certain actions, such as making phone calls.
If the posterior cerebral circulation is affected, more specifically the posterior cerebral artery, the following symptoms may be prominent:
- Dizziness
- Nystagmus – eye tremor with slow movement in one direction followed by faster movement in the opposite direction.
- Gait unsteadiness
- Ataxia – disruption of movement patterns with, for example, overshooting arm and hand movements.
- Tremor (tremor)
- Diplopia (double vision, double images)
- Gaze paresis (gaze paralysis)
- Occipital pain
- Decreased blink
In brainstem infarcts (e.g., basilar artery thrombosis, “basilar thrombosis,” brainstem hemorrhage, large hemispheric lesions, large hemispheric lesions, extensive subarachnoid hemorrhage (SAB)), the following symptoms may be prominent:
- Impaired consciousness up to coma
Note: Brief loss of consciousness without focal symptoms is usually syncope (brief loss of consciousness caused by reduced blood flow to the brain and usually accompanied by loss of muscle tone; DD loss of consciousness in epilepsy) and not a transient ischemic attack (TIA; sudden disturbance of blood flow to the brain leading to neurologic disturbances that resolve within 24 hours). Depending on the location of the damage – right or left hemisphere of the brain – different symptoms also occur:
- Visual-spatial abilities are located in the right hemisphere of the brain. Patients with a stroke in the right side of the brain are usually spatially disoriented and have attention problems. Some show what is called a “hemiplegic neglect” – the left side of the body is suddenly not perceived, even though there is no visual disturbance. Some patients run into door frames or shave only one half of their face. Furthermore, agnosia may be present – certain things are not recognized – for example objects.In a so-called “prosopagnosia”, the affected persons cannot recognize faces – sometimes not even their own reflection. Furthermore, after damage to the right side of the brain, artistic and musical abilities can be lost, as well as the melody of speech and the ability to understand jokes.
- The left hemisphere of the brain is where the language center is located in 95 percent of right-handed people. This means that a right-handed stroke patient with damage in the left hemisphere of the brain is also very likely to have aphasia (language disorder). Aphasia refers to speaking, understanding, reading and writing. In addition, these patients with aphasia often have simultaneous paralysis of the right side of the body (right-sided hemiplegia) due to damage to the left side of the brain.However, in left-handed people, it is not exactly the opposite – about 70 percent have the speech center on the left side, and the remaining 30 percent have their speech center on both sides.
Syndrome of the occipital lobe (lat. Lobus occipitalis is the rearmost part of the cerebrum).
In disorders of the visual cortex, there are sudden visual disturbances in the form of hemianopsia (hemifacial visual field loss). The patient often perceives this only as a diffuse visual disturbance.
“Face, Arm, Speech, Time” (FAST) test for rapid detection of an insult
The FAST test described below has a sensitivity (percentage of diseased patients in whom the disease is detected by the application of the history, i.e., a positive result occurs) of 64-97% and a specificity (probability that actually healthy individuals who do not have the disease in question are also detected as healthy by the procedure) of 13-63%. It depends on the following four factors:
- Face: crooked smile? Hanging face to one side?
- Arm: Numbness or weakness in arm or foot, with no explanation of this as a result of surgery?
- Speech: slurred speech? Difficulty speaking or understanding?
- Time: If any of the previously mentioned findings apply and this cannot be explained by other factors (anesthetics (narcotics), analgesics (painkillers) or other pharmaceuticals), then the patient should be transferred to a “stroke unit” immediately – in accordance with the slogan “Time is brain”
Triage due tofeeding of apoplexy patients to interventional therapy
Patients with strokes after occlusion of major vessels (intracranial internal carotid artery, cerebri media to M1 branches) should receive interventional thrombectomy (surgical removal of a blood clot (thrombus) from a blood vessel). When used with a mobile stroke unit (MSU), the decision to do so may be made with the help of angio-computed tomography (radiologic examination procedure that uses computed tomography (CT) to examine the blood vessels). A clinical assessment manual for this is the Los Angeles Motor Scale (LAMS); this defines three criteria:
- Facial paresis (no/yes = 0/1 points).
- Arm elevation (full strength/fall/arm falls = 0/1/2 points).
- Fist closure (full force/weak/not possible = 0/1/2 points).
Interpretation
- Scores ≥ 4 on one side of the body → occlusion of a major vessel is highly probable (sensitivity 81%, specificity 89%; LAMS-AUC: 0.854).
Ischemic strokes in childhood!
Occur symptomatically as epileptic seizures or clinically initially silent!The diagnosis is made on average only after 24 hours. Note: Epileptic seizures occur as the first symptom in 2-4% of cerebral ischemias (circulatory disturbances of the brain) and cerebral hemorrhages.
Acute vestibular syndrome in elderly patients
- Acute vestibular syndrome (synonym: acute vestibular syndrome) acute vestibular syndrome with dizziness, nausea, gait unsteadiness, and nystagmus/uncontrollable, rhythmic movements of the eye → think of: Apoplexy
