Makindo Medical Notes

Related Subjects: |Acute Stroke Assessment (ROSIER&NIHSS) |Atrial Fibrillation |Atrial Myxoma |Causes of Stroke |Ischaemic Stroke |Cancer and Stroke |Cardioembolic stroke |CT Basics for Stroke |Endocarditis and Stroke |Haemorrhagic Stroke |Stroke Thrombolysis |Hyperacute Stroke Care |Hypertension

The Oxford Community Stroke Project classification is a valuable tool for assessing prognosis based on stroke location and clinical presentation.

Terminology

• TAC: Total Anterior Circulation Stroke
• PAC: Partial Anterior Circulation Stroke
• LAC: Lacunar Stroke
• POC: Posterior Circulation Stroke

Classification Suffixes

• (S): Syndrome - Pathogenesis indeterminate, prior to imaging (e.g., TACS)
• (I): Infarct (e.g., TACI)
• (H): Haemorrhage (e.g., TACH)

Total Anterior Circulation Stroke (TACS) all three of the following criteria must be present:

• Higher cortical dysfunction: Dysphasia (usually left hemisphere) or visuospatial neglect (usually right hemisphere)
• Homonymous hemianopia: Loss of visual field on the same side in both eyes
• Weakness and/or sensory loss: Involving at least two of the three areas (face, arm, and leg)
• Prognosis: 40% mortality within 30 days

Partial Anterior Circulation Stroke (PACS) two of the following criteria must be present:

• Higher cortical dysfunction: Dysphasia or visuospatial neglect
• Homonymous hemianopia: Partial or complete visual field loss on one side
• Weakness and/or sensory loss: Involving at least two of the three areas (face, arm, and leg)
• Prognosis: 10% mortality within 30 days, typically in small cortical infarcts

Lacunar Stroke (LACS)

• Pathology: Occlusion of small perforating arteries, often affecting the internal capsule, basal ganglia, or thalamus.
• Clinical Features: Absence of cortical signs such as dysphasia or apraxia; presents with distinct lacunar syndromes:
• Pure motor stroke (posterior limb of internal capsule)
• Pure sensory stroke (thalamus)
• Sensorimotor stroke (thalamus and posterior limb of internal capsule)
• Ataxic hemiparesis (variable sites)
• Dysarthria-clumsy hand syndrome (pons)
• Size: Typically <15 mm, seen in regions like the corona radiata, basal ganglia, thalamus, and pons.
• Prognosis: Less than 3% mortality within 30 days

Posterior Circulation Stroke (POCS)

• Symptoms: Can vary in severity; may include dizziness, vertigo, diplopia, nausea, vomiting, nystagmus, cerebellar signs, altered consciousness, and Horner's syndrome.
• Regions Affected: Brainstem, occipital lobes, and thalami, typically supplied by vertebral and basilar arteries.
• Notable Syndromes: "Top of the basilar" syndrome, often associated with bilateral infarction, can lead to serious complications.
• Signs: Cerebellar ataxia, bulbar symptoms (difficulty swallowing), and movement disorders like hemiballismus or chorea.
• Prognosis: Generally favorable, with variable outcomes based on severity and location.

Key Clinical Presentations of Stroke Types

• Total Anterior Circulation Stroke (TACS): Often presents with severe impairment, combining motor and sensory deficits, homonymous hemianopia, and cognitive dysfunction, which significantly affects activities of daily living.
• Partial Anterior Circulation Stroke (PACS): Presents with moderate impairments such as limited weakness or sensory loss, or isolated cortical signs, like language difficulties or visuospatial neglect.
• Lacunar Stroke (LACS): Primarily affects motor or sensory pathways, leading to pure motor or pure sensory deficits without cortical signs, allowing for greater recovery potential.
• Posterior Circulation Stroke (POCS): Presents with diverse symptoms related to brainstem, cerebellar, and occipital lobe dysfunction, including dizziness, vertigo, and visual field defects.

Management Considerations by Stroke Type

• TACS: Given the high risk of mortality, TACS management focuses on immediate stabilization, thrombolysis (if eligible), and close monitoring for complications such as cerebral edema.
• PACS: Management often includes thrombolysis, anticoagulation, and secondary prevention strategies, with rehabilitation targeting specific deficits such as motor recovery and cognitive support.
• LACS: Antiplatelet therapy and risk factor management (e.g., hypertension control) are crucial, alongside rehabilitation for motor deficits, with a typically favorable prognosis.
• POCS: Careful neurological assessment and imaging are essential due to variable presentations; management includes thrombolysis, anticoagulation, and support for cerebellar and brainstem dysfunction.

Prognosis Summary

• TACS: Higher mortality rate (approximately 40% within 30 days); survivors may experience significant long-term disability.
• PACS: Moderate prognosis with 10% 30-day mortality; long-term outcomes are influenced by the degree of cortical impairment.
• LACS: Generally favorable prognosis with less than 3% 30-day mortality; good recovery potential due to absence of cortical involvement.
• POCS: Variable prognosis; milder cases tend to have good outcomes, while more severe cases involving the brainstem or cerebellum may have significant complications.

References and Further Reading

• Stroke Association: Types of Stroke
• Classification and prognosis of stroke syndromes
• American Heart Association: Stroke Journal