Stroke Mnemonics and Acronyms: Complete Guide and Notes

This topic is harassing when it comes to preparation for post-graduation studies and exams like PLAB and USMLE after MBBS. We struggle with stroke lesion localisation and create our versions of acronyms and mnemonics to mug up stroke syndromes.

However, we end up with cluttered and messy notes. Eventually, we struggle to understand what we had written initially and ended up panicking. Worry not, we will guide you with the finest notes prepared for Stroke Syndromes.


Locked In Syndrome Medical Meme

Before we start, can you guess this one?


Please note, we will use colour coding while the discussion. Here are the colour-coding interpretations:

  • Red: Extremely important or a mnemonic
  • Blue– Important
  • Yellow– Just to read
  • Orange– Sub-topics highlighting

Before starting the topic, I want you to get familiarized with a couple of words so you can grasp things better:

  • Terms Used
    • Plegia- Paralysis, Paresis- Weakness/ Partial paralysis
    • Quadriplegia- Paralysis below the neck
    • Hemiparesis- Weakness/ Partial paralysis on one side of the body
    • Hemiplegia- complete paralysis on one side of the body

Table of Contents show

Cranial Nerves Nuclei

This will help in strengthening the core concepts further. The nuclei of different cranial nerves are found in the brain as follows:

    • 1,2- Cerebral Cortex
    • 3,4- Midbrain
    • 5,6,7,8- Pons
    • 9,10,11,12- Medulla

Difficult to Retain topics

Grasping difficult concepts with easy clinchers and  stroke mnemonics:

  • With Oculomotor Nerve Palsy (Down and Out Eye, Ptosis, Mydriasis)
    • Weber’s Syndrome
      • PCA
        • Midbrain Infarct
  • With Loss of Proprioception and Contralateral Loss of Pain and Temperature Sensation
    • Brown Sequard Syndrome
      • Left Mid-Thoracic Cord
  • Paralysis of the Face and Arm (Contralateral) with
    • Hemianopia
    • Aphasia
    • Neglect
    • Gaze Ipsilateral
      • CHANG (mnemonic is discussed later)
        • MCA Stroke
  • Contralateral Hemiplegia and Sensory loss of Lower Limb
    • ACA Stroke
  • With Optic Neuritis
    • Cerebellum (NADI) + Brainstem (3-12 CN) + Transverse Myelitis (Urinary Retention) and UMN features
      • Multiple Sclerosis
  • Complete Paralysis with Dysphagia, Normal Autoimmune Panel, DTR Increased for UMN
    • ALS (Amyotrophic lateral sclerosis)
Amyotrophic lateral sclerosis Stephen Hawking
Stephen Hawking- The Legend Himself (known case of ALS)

  • Other topics to keep in mind while looking for stroke mnemonics (we will resume them later)
    • Conversion “Dissociative” Disorder
    • Acute Limb Ischaemia (6 Ps)
    • Locked-In Syndrome (Pons)
    • Lacunar Infarct
      • Ataxic Hemiparesis + Dysarthria
    • Cerebral Infarct (MCA)
    • Brainstem Infarct
      • Quadriplegia, Vertigo, Diplopia, Locked-In Syndrome
    • Hemiplegic Migraine with Aura

Mug up topics with Acronyms for Stroke

I am assuming you are already familiar with Circle of Willis?

Circle of Willis Stroke Mnemonics
Circle of Willis

Here are a couple of stroke mnemonics which require mugging: (covered in depth later on)

Cerebellum Lesion

  • NADI “stroke mnemonics”
    • Nystagmus
    • Ataxia
    • Dysarthria
    • Intentional Tremors

Ataxia based on the location of the lesion in the cerebellum:

  • Limb ataxia- Cerebellar Lobe
  • tRuncal ataxia- Cerebellar VeRmis

Posterior Circulation Stroke

  • Either Occipital Lobe, Cerebellum or Brainstem
    • Occipital Lobe– Visual disturbances (Homonymous Hemianopia WITH Macular Sparing)
    • Cerebellum– NADI
      • Dysdiadochokinesia- inability to perform rapid alternating muscle movements
        • (a feature of the Cerebellum)
    • Brainstem– CN (e.g.- 8th- Vertigo -dizziness-)
      • MRI Head (Investigation of choice) and Not CT Head
  • Key Notes

    • The cerebellum is partly supplied by the posterior inferior cerebellar artery (PICA)
      • Ischaemia to the cerebellum- Vertigo, Ataxia, Nystagmus (NADI- Nystagmus, Ataxia, Dysarthria, Intentional tremors)
    • Occipital lobes are supplied by the posterior cerebral artery
      • Ischaemia to the occipital lobes- Visual disturbances

Posterior Cerebral Artery Occlusion

  • Occipital Lobe- Visual disturbances (Homonymous Hemianopia WITH Macular Sparing)

Brainstem lesion (Midbrain, Pons, Medulla Oblongata = 3rd CN to 12th CN)

The following involvements can appear in Brainstem lesions:

  • 3rd CN to 12th CN (Multiple CN Involvement)
    • Midbrain (3,4), Pons (5,6,7,8), Medulla (9,10,11,12)
  • Cerebellum- NADI
  • Posterior Circulation
    • MRI Head

Additional Notes

  • Multiple Cranial Nerve affected (e.g., Facial numbness “5th” CN Trigeminal nerve + Diplopia and Ptosis “3rd” CN Oculomotor nerve)
  • Symptoms of Cerebellar lesion, e.g., Ataxia, Dysarthria, Nystagmus, Intentional tremors + Cranial nerve symptoms (e.g., Vertigo 9th CN Vestibulocochlear nerve, Diplopia 3rd CN Oculomotor nerve) (these are for reading, focus on stroke mnemonics and acronyms for now, along with clearing basic concepts)

Hey! Don’t snap on me yet! Before we go ahead further, let me give you a trivia question.

Delusion of Grandiosity Medical Meme
Heh? Who is that actor??

Doc, you are not done with Stroke Mnemonics and Acronyms yet. Can you guess the delusion in the following image?


Let’s try to reverse-engineer our processing of thoughts. We will begin with a summary and then understand each topic in detail.

Summary

Let’s have a quick review of stroke mnemonics and acronyms in short:

  • <24 Hours- TIA
  • >24 Hours- Stroke

1. Site of the lesion based on the affected organ

    • Anterior Circulation Stroke– ACA + MCA
    • Posterior Circulation Stroke– CN + Occipital Lobe + Cerebellum
    • Total vs Partial Anterior Circulation Stroke
      • 2 of C, H and A/N= Partial
      • 3 of C, H and A/N= Total
    • Legs– ACA
      • C/L Hemiparesis (Legs> Face and Arms)
      • C/L Sensory Loss
      • Behavioural changes
    • Face and Arms– MCA
      • CHANG
        • Contralateral Hemiparesis and Sensory Loss (Face and Arm> Legs)
        • Homonymous Hemianopia WITHOUT Macular Sparing (Contralateral)
        • Aphasia
        • Neglect
        • Gaze Ipsilateral
    • Vision and language– PCA
      • Either Occipital Lobe, Cerebellum or Brainstem
        1. Occipital Lobe– Visual disturbances (Homonymous Hemianopia WITH Macular Sparing)
        2. Cerebellum– NADI
          • Dysdiadochokinesia- inability to perform rapid alternating muscle movements
        3. Brainstem– CN (e.g.- 8th- Vertigo -dizziness-)
          • MRI Head and Not CT Head

2. Causes

  • Stroke- Atrial Fibrillation
  • TIA with LOC- Carotid stenosis
  • Amaurosis Fugax- ICA Atherosclerosis
    • Associations
      • Transient Ischaemic Attack (TIA)
      • Giant Cell Arteritis and CRAO
      • Atherosclerosis (Bruit on the neck)
      • Hypertension

3. Acute Presentation

    • NCCT Brain within 1 hour (MRI if suspected Posterior Stroke- Cerebellum> Ataxia)
      • If Ischaemic Stroke
        • <4.5 hours of Onset of the symptoms- Alteplase “Thrombolytics”
        • Start Aspirin 300mg either orally or rectally for 2 weeks
          • Followed by
            • Afib Absent- Clopidogrel 75mg (long-term)
            • Afib Present- DOAC/Warfarin
        • If presents >4.5 hours of onset or Time is not given- Aspirin 300mg ASAP
      • Haemorrhagic Stroke
        • Do- BP control
        • DO NOT– Antiplatelets, Statins

4. Secondary Prevention of TIA / Stroke

    • Statins
    • Anticoagulation
      • AFib Present
        • Warfarin or DOAC (DAREDabigatran/ Apixaban/ Rivaroxaban/ Edoxaban)
      • AFib Absent
        • Antiplatelets (Clopidogrel 75mg OD lifelong)

5. For Stroke, TIA and Amaurosis Fugax

    • Best Next Modality– Carotid Doppler Scanning within 2 weeks
      • When to perform Carotid Endarterectomy
        • if internal carotid artery stenosis is >_ 50% in Men
        • if internal carotid artery stenosis is >_70% in Women
        • 100%- Nothing needed, no risk of thrombosis
    • Long Term Mx
      • Statins
      • Anticoagulation
        • AFib Present
          • Warfarin or DOAC (DAREDabigatran/ Apixaban/ Rivaroxaban/ Edoxaban)
        • AFib Absent
          • Antiplatelets (Clopidogrel 75mg OD lifelong)
      • Lifestyle
        • Salt intake recommendation for adults in the UK is no more than 6 gm per day which is around 1 teaspoon

6. TIA (Transient Ischaemic Attack)

  • Resolved within 24 hours (>24 hours= Stroke)

7. Amaurosis Fugax

  • Painless Vision loss but 5-30 minutes only (compared to the retinal detachment where vision is not recovered)

8. Syndromes- Collection of Stroke Mnemonics

  • Weber’s Syndrome (Midbrain Infarct) (PCA block)
    • Ipsilateral Oculomotor Nerve Palsy (3rd CN) (Same side- Down and Out Eye, Ptosis, Mydriasis)
    • + Contralateral hemiparesis
  • Wallenberg’s Syndrome = Lateral MEDULLARY Syndrome (PICA Block)
    • Ipsilateral Horner’s Syndrome
    • + Ipsilateral Loss of Pain and Temperature sensation in the Face
    • + Contralateral loss of Pain and Temperature sensation in Limbs
  • Medial Medullary SyndromeASA Block
    • Ipsilateral Tongue Paresis + C/L Hemiplegia with Facial Sparing
  • Gerstman Syndrome– Parietal Lobe Lesion
    • Finger Agnosia
    • Confusion of right and left body
    • Dyscalculia
    • Dysgraphia
    • Alexia
    • Hemianopia (Homonymous Quadrantanopia- PiTs- Parietal- Inferior)
  • Brown-Sequard Syndrome- Left Mid-Thoracic Cord
    • Ipsilateral Paralysis and Loss of Proprioception
    • Contralateral Loss of Pain and Temperature sensation

9. Stroke and Lesions

Most of us are familiar with the PiTs mnemonic for stroke localisation in the lobes of the brain. Let’s recall it once again:

  • PiTs
    • Parietal lobe- inferior homonymous quadrantinopias
    • Temporal lobe- superior homonymous quadrantinopias
  • Parietal Lobe Lesion
    • Inferior Homonymous Quadrantinopias + Hemineglect Syndrome
  • Temporal Lobe Lesion
    • Superior homonymous quadrantanopia + Long-term memory loss + changes in sexual behaviour
  • Frontal Lobe Lesion
    • Changes in Personality and SOCIAL behaviour, no visual field defect

10. Lacunar Infarct vs Brainstem Infarct

  • Ataxic Hemiparesis (same side) + Dysarthria- Lacunar infarct hemiplegia (Internal Capsule) (Internal capsule is a part of lacunas)
  • Contralateral hemiplegia or sensory loss + Dysphasia + Homonymous Hemianopia- Cerebral Infarct
  • Quadriplegia, Vertigo, Diplopia, Locked-in syndrome- Brainstem infarct

11. Locked-In-Syndrome

  • Complete paralysis of all voluntary muscles + Able to blink + Vertical Eye movements

12. Hemineglect Syndrome

  • Parietal Lobe
  • Hx of Stroke

13. Central Post-Stroke Pain

  • Neuropathic pain years after CVA
  • Mx- Away Goes D neuropathic Pain

14. Stroke and Dysphagia

  • Initial- NGT, Then PEG

Causes: Stroke vs TIA vs Amaurosis Fugax

We will just discuss ischaemic stroke here, which is caused by an embolus, a blood clot that can originate from different sites in the body. The hardest stroke mnemonics are yet to arrive.

We have summarized the causes of stroke from embolus in the table below:

Condition Cause
Stroke Afib (Atrial Fibrillation)
TIA Carotid Stenosis
Amaurosis Fugax ICA Atherosclerosis

Features: Stroke vs TIA vs Amaurosis Fugax

The symptoms and duration of the three have been organized in the table below:

Condition Symptoms Duration
Stroke BEFAST mnemonic More than 24 hours
TIA Similar to stroke Resolves in less than 24 hours
Amaurosis Fugax Painless vision loss for 5-30 minutes Vision regained after the attack

Signs and Symptoms of Stroke Mnemonics

Stroke presents with neurological symptoms that are often vague and difficult to understand. The simplest mnemonic for signs of stroke is BE FAST:

  • BBalance
    • sudden changes in balance or coordination
  • EEyes
    • Sudden painless vision loss or diplopia (double vision)
  • FFace
    • Drooping of Face causing it to look uneven
  • AArms
    • Sudden arm numbness and weakness
  • SSpeech
    • Slurred, making it difficult to speak or understand
  • TTime
    • Don’t stall; Call- Note the time when the symptoms started

Stroke Mnemonics and Acronyms BEFAST

SMART Stroke Symptoms Acronym

Some other stroke mnemonics used by few also include SMART:

  • SSpecific
  • MMeasurable
  • AAchievable
  • RRelevant
  • TTimed

To be honest, I have no clue yet how it works and what are the goals of this stroke mnemonic, so I will ease my memory for a while and stretch on other topics.

Medical GIF Funny


TIA

TIA stands for Transient Ischaemic Attack. In short, TIA is a stroke that never happened. In definition, it is a syndrome of sudden onset of focal neurological loss of presumed vascular origin lasting less than 24 hours.

Symptoms

  • Sudden onset weakness of limbs + Dysphasia + HTN + Resolved within 24 hours

Next test?

  • Best Next Modality- Carotid Doppler Scanning
  • Carotid Duplex should be done within 2 weeks of admission to check for Carotid Artery Stenosis to assess for the need for carotid endarterectomy
  • When to perform Carotid Endarterectomy?
    • if internal carotid artery stenosis is >_ 50% in Men
    • if internal carotid artery stenosis is >_70% in Women
    • 100%- Nothing needed, no risk of thrombosis

Site of lesion

This is similar to a stroke. Ideally, you shouldn’t have difficulty recalling stroke mnemonics based on the organ affected.

  • Site of the lesion based on the affected organ:
    • Leg- Anterior Communicating Artery (ACA)
    • Face and Arms- Middle Cerebral Artery (MCA)
    • Vision and language- Posterior Cerebral Artery (PCA)

Cause

The cause for TIA with LOC (loss of consciousness) is Carotid Stenosis. This is in contrast to Stroke where Afib (atrial fibrillation) and Amaurosis Fugax (embolus) are the cause.

  • Cause- Carotid Stenosis
  • Side Notes

    • An elderly patient with recurrent episodes of TIAs and Loss of Consciousness
      • The likely reason- Carotid Artery Stenosis
    • Usually
      • AF is an underlying cause of Strokes
      • Carotid stenosis is an underlying cause of TIAs with LOC

Long-term management after TIA

This goes the same as stroke again. People who have had episodes of Transient Ischaemic Attack have to take antiplatelets and statins for the long term to prevent another episode.

  • Long Term Mx after TIA- Clopidogrel and Statins

Amaurosis Fugax

It is defined as transient, painless, and sudden vision loss which resolves in 5-30 minutes.

Cause

Transient occlusion of Central Retinal Artery

Symptoms

The patients describe symptoms of Amaurosis fugax as a “Black Curtain coming down“. This is painless, transient (5-30 minutes) and resolves within the period (compared to the retinal detachment where the symptoms are not recovered).

Vision Loss

Vision loss: Sudden, Painless, Transient (5-30 minutes)

Embolus

The embolus blocks Central Retinal Artery. The following describes the route of embolus to the artery causing Amaurosis Fugax:

  • Internal Carotid Artery> Ophthalmic Artery> Central Retinal Artery
    • Therefore, embolus in Amaurosis Fugax comes from an atherosclerotic Internal Carotid Artery (ICA).
    • While, in TIA, emboli of the cerebral hemispheres come from the heart

Diagnosis

The next Best Next Modality- Carotid Doppler Scanning (within 2 weeks)

  • When to perform Carotid Endarterectomy
    • if internal carotid artery stenosis is >_ 50% in Men
    • if internal carotid artery stenosis is >_70% in Women
    • What’s with 100%? Recall?

Long-term management after Amaurosis Fugax

Clopidogrel and Statins (nothing fancy, the same old blabber)

Associations

  1. Transient Ischaemic Attack (TIA)
  2. Giant Cell Arteritis and CRAO
  3. Atherosclerosis (Bruit on the neck)
  4. Hypertension

I know you are tad bit tired and exhausted. Such is the medical life; you don’t stop and never give up. Relax, have a cup of tea, and start once again with stroke mnemonics and acronyms.

Tea GIF Funny


When to classify it as a Stroke

This is easy. The neurological signs of stroke remain for more than 24 hours. However, the acute presentation will often present in less than 24 hours and therefore, requires immediate management and investigations.

This is to find the lesion of stroke, and its cause (haemorrhagic or ischaemic) and set up a treatment plan for the same.

A stroke is a sudden onset of focal neurological loss of presumed vascular origin lasting more than 24 hours

  • In a suspected Stroke
    • Initial Investigation- NCCT scan Brain “to exclude haemorrhage”
    • Most Appropriate Investigation- MRI Brain (includes Posterior Circulation Stroke)
  • This specifically applies to lesions for the posterior fossa (e.g., Cerebellum) where a patient would present with Ataxia (unsteadiness, difficulty walking) and slurred speech
    • MRI is much better than CT in posterior strokes

Acronyms for Stroke: Site of lesions based on the affected organ

Let’s break this down into two parts for easier understanding with a couple of stroke mnemonics:

1. Based on Organ

  • Leg- ACA
    • C/L Hemiparesis (Legs> Face and Arms)
    • C/L Sensory Loss
    • Behavioural changes
  • Face and Arms- MCA
    • CHANG
      • Contralateral Hemiparesis and Sensory Loss (Face and Arm> Legs)
      • Homonymous Hemianopia WITHOUT Macular Sparing (Contralateral)
      • Aphasia
      • Neglect
      • Gaze Ipsilateral
  • Vision and language- PCA
    • Either Occipital Lobe, Cerebellum or Brainstem
      1. Occipital Lobe– Visual disturbances (Homonymous Hemianopia WITH Macular Sparing)
      2. Cerebellum– “NADI”
        • Dysdiadochokinesia- inability to perform rapid alternating muscle movements
      3. Brainstem– CN (e.g.- 8th- Vertigo -dizziness-)
        • MRI Head and Not CT Head
  • Where
    • ACA- Anterior Cerebral Artery
    • MCA- Middle Cerebral Artery
    • PCA- Posterior Cerebral Artery
    • CN- Cranial Nerve

2. Classification based on Circulation- Additional Stroke Mnemonics

Recall CHANG stroke mnemonics from MCA circulation:

  • CHANG
    • Contralateral Hemiparesis and Sensory Loss (Face and Arm> Legs)
    • Homonymous Hemianopia WITHOUT Macular Sparing (Contralateral)
    • Aphasia
    • Neglect
    • Gaze Ipsilateral
  • This helps in setting up Anterior, Posterior strokes and also Total vs Partial Anterior Circulation strokes.
    • Anterior Circulation Stroke– ACA + MCA
    • Posterior Circulation Stroke– CN + Occipital Lobe + Cerebellum
    • Total vs Partial Anterior Circulation Stroke
      • 2 of C, H and A/N= Partial
      • 3 of C, H and A/N= Total

Acute presentation of Stroke

Following is the algorithm for Stroke- Acute Presentation flowchart:

  • NCCT Brain within 1 hour (MRI if suspected Posterior Stroke- Cerebellum> Ataxia)
    • If Ischaemic Stroke
      • <4.5 hours of Onset of the symptoms- Alteplase “Thrombolytics”
      • Start Aspirin 300mg either orally or rectally for 2 weeks
        • Followed by
          • Afib Absent- Clopidogrel 75mg (long-term)
          • Afib Present- DOAC/Warfarin
      • If presents >4.5 hours of onset or Time is not given- Aspirin 300mg ASAP
    • If Haemorrhagic Stroke
      • Do- BP control
      • DO NOT- Antiplatelets, Statins

I want you to focus on one thing here- “DO NOT give Antiplatelets and Statins in a haemorrhagic stroke”. Why?

Imagine diluting a leaking pipe! What will happen? It will leak more of course. *Panic mode activated

funny meme medical

Question?

In acute ischaemic stroke, what if the time of onset of symptoms is not given?

  • Start with Aspirin 300mg (we cannot give Alteplase if >4.5 hours as it would be useless)

Enjoying the post on stroke mnemonics? I know how difficult it is to stay focused. Perhaps lie back on bed and read on mobile?

Diagnostic modalities

Once the acute presentation has been managed, stroke patients must undergo carotid doppler scanning. (indeed, there is a series of tests needed). This is the same for TIA and Amaurosis Fugax.

  • Best Next Modality- Carotid Doppler Scanning within 2 weeks
    • When to perform Carotid Endarterectomy
      • if internal carotid artery stenosis is >_ 50% in Men
      • if internal carotid artery stenosis is >_70% in Women
      • 100%- Nothing needed, no risk of thrombosis

Stroke Mnemonics for Syndromes- Quick Summary

Have a look at the acronyms first so that you don’t get swayed away:

  • PCA- Posterior Cerebral Artery
  • PICA- Posterior Inferior Cerebellar Artery
  • ASA- Anterior Spinal Artery

Here are the syndromes in stroke summarised in short:

  1. Weber’s Syndrome (Midbrain Infarct) (PCA block)
    • Ipsilateral Oculomotor Nerve Palsy (3rd CN) (Same side- Down and Out Eye, Ptosis, Mydriasis)
    • + Contralateral hemiparesis
  2. Wallenberg’s Syndrome = Lateral MEDULLARY Syndrome (PICA Block)
    • Ipsilateral Horner’s Syndrome
    • + Ipsilateral Loss of Pain and Temperature sensation in the Face
    • + Contralateral loss of Pain and Temperature sensation in Limbs
  3. Medial Medullary SyndromeASA Block
    • Ipsilateral Tongue Paresis + C/L Hemiplegia with Facial Sparing
  4. Gerstman Syndrome– Parietal Lobe Lesion
    • Finger Agnosia
    • Confusion of right and left body
    • Dyscalculia
    • Dysgraphia
    • Alexia
    • Hemianopia (Homonymous Quadrantanopia- PiTs- Parietal- Inferior)
  5. Brown-Sequard Syndrome– Left Mid-Thoracic Cord
    • Ipsilateral Paralysis and Loss of Proprioception
    • Contralateral Loss of Pain and Temperature sensation

In-Depth Stroke Acronyms

  • Weber’s Syndrome (Midbrain Infarct) (PCA block: Posterior Cerebral Artery)
    • Ipsilateral Oculomotor Nerve Palsy (3rd CN) (Same side- Down and Out Eye, Ptosis, Mydriasis)
    • + Contralateral hemiparesis (CST) (e.g., right arm + right leg)
      • 3,4 + Substantia Niagara + CST + CBT + UMN

Next Level *panic mode activated

      • Weber’s Syndrome
        • PCA Block
        • 3,4 + Substantia Niagara + CST + CBT + UMN
          • 3- Down and Out Eye
          • Substantia Niagara- Contralateral Parkinsonism (difficulty in initiating movements on opposite sides)
          • Corticospinal Tract- Contralateral Hemiplegia
          • Corticobulbar Tract- Contralateral Lower Facial Muscle Weakness (Intact Upper Facial Muscles)
            • Upper facial muscles get B/L innervation while Lower Facial Muscles only get Contralateral innervation
          • Since UMN- Spastic Paralysis, Exaggerated DTR, Positive Babinski Sign
  • Wallenberg’s Syndrome = Lateral MEDULLARY Syndrome (PICA Block: Posterior Inferior Cerebellar Artery)
    • Ipsilateral Horner’s Syndrome (Sympathetic Chain) (MAP- Miosis, Anhidrosis, Ptosis)
    • + Ipsilateral Loss of Pain and Temperature sensation in Face (5th CN + STT)
    • + Contralateral loss of Pain and Temperature sensation in Limbs (STT)
      • 5,8,9,10 + STT + Sympathetic Chain

Next Level to Stroke Mnemonics *too tired to panic anymore

      • Wallenberg’s Syndrome = Lateral MEDULLARY Syndrome
        • PICA Block
        • 5,8,9,10 + STT + Sympathetic Chain
          • 5- Numbness on the face
          • 8- Vertigo (Ataxia) (Positive Romberg Test)
          • 9,10- Gag reflex, Bovine cough
          • Spinothalamic Tract- Contralateral loss of Pain and Temperature sensation in Limbs
          • Sympathetic Chain- Horner’s Syndrome (MAP- Miosis, Anhidrosis, Ptosis)
  • For Understanding Only!
    • Corticospinal Tract- Contralateral Hemiplegia
    • Spinothalamic Tract- Contralateral loss of Pain and Temperature sensation in Limbs
    • Sympathetic Chain- Horner’s Syndrome (MAP- Miosis, Anhidrosis, Ptosis)
    • Corticobulbar Tract- Contralateral Lower Facial Muscle Weakness (Intact Upper Facial Muscles)
      • Upper facial muscles get B/L innervation while Lower Facial Muscles only get Contralateral innervation
  • Brown-Sequard Syndrome
    • Ipsilateral Paralysis and Loss of Proprioception
    • Contralateral Loss of Pain and Temperature sensation
    • No Horner’s Syndrome
    • Left Mid-Thoracic Cord
  • Progressive Supranuclear Palsy (a simple yet powerful mnemonic for stroke)
    • As Falls Dig Deeper, Downgaze is Disengaged “mnemonic”
      • AsAxial Rigidity
      • FallsFalls/ Freezing-Shuffling- Gait
      • DigDysarthria
      • DeeperDysphagia
      • Downgaze– Supranuclear Gaze Palsy- Restricted Downgaze>Upward gaze (in Idiopathic Parkinsonism- upward>downward)
      • Disengaged– Frontal lobe- Disengagement
      • Others
        • Stiff -frozen- posture, shuffling and freezing gait
      • Ix- MRI

Lobes affected- Stroke Mnemonics

Here is another acronym for the lobes affected by stroke:

  • PiTs
    • Parietal lobe- inferior homonymous quadrantinopias
    • Temporal lobe- superior homonymous quadrantinopias

Symptoms in Stroke as per lobe lesion

  • Parietal Lobe Lesion
    • Inferior Homonymous Quadrantinopias + Hemineglect Syndrome
  • Temporal Lobe Lesion
    • Long-term memory loss + changes in sexual behaviour + Visual defect (superior homonymous quadrantanopia
  • Frontal Lobe Lesion
    • Changes in Personality and SOCIAL behaviour, no visual field defect

Hemineglect syndrome

    • Hx of Stroke
    • Unaware of objects or people on one side
    • Unaware of his problem
    • Structure affected
      • Parietal Lobe
    • Also, Inferior Homonymous Quadrantinopias
Hemineglect Syndrome Stroke Signs and Symptoms
Hemineglect Syndrome Stroke Signs and Symptoms

Lacunar Infarct vs Brainstem infarct

  • Ataxic Hemiparesis (same side) + Dysarthria
    • Lacunar infarct hemiplegia (Internal Capsule) (Internal capsule is a part of lacunas)
  • Contralateral hemiplegia or sensory loss + Dysphasia + Homonymous Hemianopia
    • Cerebral Infarct
  • Quadriplegia, Vertigo, Diplopia, Locked-in syndrome
    • Brainstem infarct
Internal Capsule Stroke Lesions
Internal Capsule

Let’s refreshen up the basics once again: (soft reminder, yellow markers mean “read” while red either means stroke mnemonics or urgent note on the topic)

  • Ataxia- a lack of muscle control or coordination of voluntary movements, such as walking or picking up objects
  • Dysarthria- Slurred speech
  • Dysphasia- Not able to speak properly
  • Aphasia- Not able to speak entirely
  • Plegia- Paralysis, Paresis- Weakness/ Partial paralysis
  • Quadriplegia- Paralysis below the neck
  • Hemiparesis- Weakness/ Partial paralysis on one side of the body
  • Hemiplegia- complete paralysis on one side of the body

Locked in syndrome

The first trivia question we asked, here is the answer:

  • Complete paralysis of all voluntary muscles + Able to blink + Vertical Eye movements
  • Cognitive function unaffected
  • Lesion in Pons

Locked In Syndrome Medical Meme


Management (no stroke mnemonics here!)

Acute Presentation

  1. Not Stroke? (perhaps TIA?)
  • If the symptoms subside, start with
    • Aspirin 300mg
  1. Stroke?
  • If symptoms are still there, start with
    • NCCT Head within 1 hour
    • Again, DO NOT GIVE anti-platelet in stroke unless a cause is ruled out (haemorrhagic or ischaemic)

Long-term management of Ischaemic Stroke

We have discussed this already though. Anyways, let’s have a recap:

All patients with Ischaemic Stroke must take Antiplatelets and Statins for a lifetime. The recommendations are as follows:

  1. Statins (for all patients regardless of cholesterol baseline level)
    • 80mg Atorvastatin HS
  2. Anticoagulation
    • AFib Present
      • Warfarin or DOAC (Dabigatran/ Apixaban/ Rivaroxaban/ Edoxaban)
    • AFib Absent
      • Antiplatelets (Clopidogrel 75mg OD lifelong)

And don’t forget, they must undergo Carotid Duplex within 2 weeks of admission. The recommendations are as follows:

  • Carotid Endarterectomy within 2 weeks of admission (SIGN and NICE)
    • Carotid Duplex/Doppler USG should be done within 2 weeks of admission to check for Carotid Artery Stenosis to assess for the need for carotid endarterectomy
    • When to perform Carotid Endarterectomy
      • if internal carotid artery stenosis is >_ 50% in Men
      • if internal carotid artery stenosis is >_70% in Women
      • 100%- Nothing needed, no risk of thrombosis

Secondary prevention in Ischaemic Stroke

In Short

  1. Control BP
    • Do not start controlling in the first 48 hours as this may cause an extension of the stroke
  2. Statins (for all patients regardless of cholesterol baseline level)
    • 80mg Atorvastatin HS
  3. Anticoagulation
    • Afib Present
      • Warfarin or DOAC (Dabigatran/ Apixaban/ Rivaroxaban/ Edoxaban)
    • Afib Absent
      • Antiplatelets (Clopidogrel 75mg OD lifelong)
  4.  Lifestyle
    • Salt intake recommendation for adults in the UK is no more than 6 gm per day which is around 1 teaspoon
  5. Carotid Endarterectomy within 2 weeks of admission (SIGN and NICE)
    • Carotid Duplex/Doppler USG should be done within 2 weeks of admission to check for Carotid Artery Stenosis to assess for the need for carotid endarterectomy
    • When to perform Carotid Endarterectomy
      • if internal carotid artery stenosis is >_ 50% in Men
      • if internal carotid artery stenosis is >_70% in Women
      • 100%- Nothing needed, no risk of thrombosis

In-Depth

1. Lower Blood Pressure

  • Aim for target BP of 130/80
    • Note: Do not start controlling in the first 48 hours as this may cause an extension of the stroke
  • Age>_55 or Black patients of any age can start a Calcium Channel Blocker
  • Add ACE-I, CCB, or Thiazide diuretic if the target is not achieved with the first choice

2. Lower Cholesterol

  • Aim for a 40% reduction in non-HDL cholesterol
  • Statins to be taken daily lifelong after TIA or Ischemic Stroke
    • Note: Statins for all regardless of baseline cholesterol
    • 80mg Atorvastatin recommended by both NICE and SIGN

3. Anti-platelet therapy

  • Use Antiplatelet or Anticoagulation treatment in Ischemic Stroke/TIA
  • Two conditions as discussed earlier:
    1. AF Present
      • Use an Anticoagulant- Warfarin, Dabigatran, Rivaroxaban, Apixaban, Edoxaban (Warfarin Target INR 2-3)
        • Note: In the acute setting:
          • If TIA and imaging have excluded haemorrhage, start anticoagulation at once
          • If disabling ischemia stroke, use different anticoagulation treatment for 14 days from onset. In the interim, aspirin 300mg daily can be used
    2. AF Absent
      • Give Clopidogrel 75mg OD for long-term prevention of ischemic events
        • If intolerant of Clopidogrel, give Aspirin 75mg OD plus Dipyridamole MR 200mg BD
        • And again, if this is not tolerated, use either Aspirin or Dipyridamole alone
      • Note: For acute treatment of ischemic stroke, give 300mg of Aspirin for 2 weeks

4. Lifestyle Advice

  • Low salt diet (Salt intake recommendation for adults in the UK is no more than 6 gm per day which is around 1 teaspoon)
  • Low cholesterol diet
  • Weight loss
  • Alcohol Reduction
  • Smoking cessation

5. Carotid Endarterectomy

  • Lastly, always consider Carotid Endarterectomy as secondary prevention in Ischemic Stroke within 2 weeks of admission (SIGN and NICE)

Secondary Prevention in Haemorrhagic Stroke

Special keynotes from SIGN Guidelines on secondary prevention after haemorrhagic stroke include:

  • BP control is important
  • Do not offer antiplatelets, unless at substantial risk of a cardiac event
  • Statins are not recommended
    • Note: After a haemorrhagic stroke, BP control is still critical but antiplatelets and statins are not recommended unless there are clear other indications
    • You can read the official guidelines here.

Central Post-Stroke pain

  • Neuropathic pain years after CVS
  • Mx
    • Away Goes D neuropathic Pain- Amitriptyline, Gabapentin, Duloxetine, Pregabalin

Dysphagia in Stroke

  • Initial Feeding
    • NGT
      • If recovery is seen- Remove NGT
      • If no recovery after 4 weeks and continued dysphagia- PEG
  • Long-term feeding (also in MND- Motor Neuron Disease)
    • PEG
  • If you are wondering what PEG (Percutaneous Endoscopic Gastrotomy) is, here is an image that might help:
PEG feeding in Stroke Patients MedicForYou
PEG feeding in Stroke Patients

I know Neurology sucks. But to ace in your medical career, you at least need to know basics of Stroke. Hope this post with Stroke mnemonics and acronyms helped you for understanding as well for your exams.

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