# Stoke Pt's and their eyes



## el Murpharino (Feb 17, 2009)

Yesterday I brought in an unresponsive patient who's mother stated she had c/o headaches "all day" - of course I thought stroke....the pupils were equal and reactive, there was no fixed deviation of the eyes either way, and no facial droop.  The nurse at the hospital told me this "didn't matter" - which I was sort of taken aback by, but still thought stroke.  I understand that there are cranial nerves (in addition to other functions) that control eye movement and facial muscle function...but could a stroke pt. present with normal facial and eye function in presence of a CVA?  If so, I've never seen it in my 6 years of EMS, which I s'pose seems weird to me.  I await your response...........(blood sugar was 114, for those who care to know).  Pt was ALS'd appropirately, I'm just curious as to the eye/facial presentation as it relates to CVA's, not the treatment of the pt.  Thanks.

MURPH


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## vquintessence (Feb 17, 2009)

*20 questions!*

Was that what the hospital ultimately diagnosed?  Ischemic or hemmorhagic?

If not we need more to discern why RN felt so strongly:
Age and baseline mental status?
Vitals?
What was the respiration pattern?
Trismus present?
Was she truly unresponsive? (Not trying to be insulting, I've mispoken and described unresponsive before as someone non-verbal.  God, took a long time to live that one down...)
PMHx?

What about the hemmorhagic CVA pts you've probably seen where inappropriate/non verbal speech is the only outward sign/symptom?


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## redcrossemt (Feb 17, 2009)

el Murpharino said:


> could a stroke pt. present with normal facial and eye function in presence of a CVA?  If so, I've never seen it in my 6 years of EMS, which I s'pose seems weird to me.



Stroke patients can present in many ways....

Spend some time in the hospital and you will see it all the time. Sometimes it's just hemiparesis/hemiplegia, sometimes just slurred speech, sometimes just altered mental status, sometimes just a headache, sometimes all or some of the above.

With a sudden onset of severe headaches and now unresponsiveness, you would think hemorrhagic stroke. The symptoms, including if the pupils or gaze is effected, will depend on where the stroke is and how deep it is (intercerebral or subarrachnoid).

This is why so many people get head CT's... Not a lot to go on other than history and somewhat elusive symptoms with lots of causes.


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## el Murpharino (Feb 17, 2009)

vquintessence said:


> Was that what the hospital ultimately diagnosed?  Ischemic or hemmorhagic?
> 
> If not we need more to discern why RN felt so strongly:
> Age and baseline mental status?
> ...



by unresponsive I mean she didn't respond to a sternal rub, ear pinch, finger pinch, or any other painful stimuli, so yes, truly unresponsive..  53 y/o f, bp 98/80, resp 24 normal, open mouth and breathing (no trismus).

Again, this isn't a call review I feel 100% comfortable in my assessment and treatment of this patient - I'm just asking about the physiology behind why a patient in a CVA would present without any outward signs other than unresponsiveness...of course this may not have even been a CVA at all - the hospital hasn't followed up with me on this call.  

MURPH


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## jrm818 (Feb 17, 2009)

Function is localized in the brain.  Damage to specific areas of the brain produce specific deficits.  It is certianly possible for a stroke pt. to present without involvement of the nerves or areas of the brain responsible for pupilary reflexes or eye movements.  The reason eyes often display symptoms is due to the location of the stroke damage is commonly, but not always, near a structure responsible for some level of occular control.  For example, the oculomotor nerve passes near the posterior communicating artery in the circle of Willis - a common location for anyuerism because a small blood vessel joins a larger higher pressure artery, producing occulomotor symptoms.  we check the eyes because of the commonality of such symptoms.  Lack of such symptoms is ABSOLUTELY NOT a rule-out of some sort of CVA...the pneumbra of damage may just not infringe on any optic structures.


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## VentMedic (Feb 17, 2009)

CVAs come in many forms with several different etiologies that can initiate it. As well there are several differentials that must be done to be sure it is a CVA and not something like sepsis which can also have many of the same presentations.

Have you ever encountered Lock-in Syndrome? That is probably one of the most frightening forms of a CVA especially for the patient. It appears as if someone administered a paralytic even though the patient may still have normal respirations. The patient also may initially appear unconscious. I've seen it with trismus and without.


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## redcrossemt (Feb 17, 2009)

Does anyone know what hemorrhagic vs. ischemic strokes do the pupils and gaze? I know that the gaze is often towards the lesion in ischemic strokes and that pupils dilate on the side of the hemorrhage, right? 

I spent a few minutes googling and couldn't find much.

Would also love to know the pathophysiology behind it... Lack of blood supply to muscles/nerves?


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## jrm818 (Feb 17, 2009)

Deviation is due to the death of specific neurons...how they die likely won't make much difference.  Pressure on one side may cause increased spontaneous firing of a nerve which could confound this I guess, but I've never heard of any reliable rules for that sort of thing.

Pathophysiology of stroke is pretty complicated.  Ischemic strokes cause ischemia, but that leads to a cascade as the glial cells wall off the area of damage in a process called reactive gliosis.  Basically they sacrifice cells that are within the ischemic pneumbra in exchange for preventing the spread of damage.

Hemmohragic strokes can produce ischemia via compression or interruption of blood flow through a ruptured vessel, leading to downstream ischemia.  The buildup of blood also causes pressure on the brain...local pressure on a nerve can acutally cause nerve firing, too much pressure causes deformation of brain structures, interruption of communication, cell death, and possibly herniation.  Blood itself is not good for brain cells that are used to being bathed in ECF, not whole blood.  

The issue is loss of nerves, the muscles are in the eyes and probably not involved.

Oversimplifications obviously, but hopefully answer your question.


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## daedalus (Feb 17, 2009)

VentMedic said:


> CVAs come in many forms with several different etiologies that can initiate it. As well there are several differentials that must be done to be sure it is a CVA and not something like sepsis which can also have many of the same presentations.
> 
> Have you ever encountered Lock-in Syndrome? That is probably one of the most frightening forms of a CVA especially for the patient. It appears as if someone administered a paralytic even though the patient may still have normal respirations. The patient also may initially appear unconscious. I've seen it with trismus and without.



We had a patient we would bring to dialysis that had locked in syndrome after a big CVA. We always treated him like we would a normal person who was AOx4, and you could just see the pain in his eyes. He passed away a few months ago and I admit, was a bit relived.


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## remote_medic (Feb 17, 2009)

redcrossemt said:


> Stroke patients can present in many ways....
> 
> Spend some time in the hospital and you will see it all the time. Sometimes it's just hemiparesis/hemiplegia, sometimes just slurred speech, sometimes just altered mental status, sometimes just a headache, sometimes all or some of the above.
> 
> ...



If only we could get the patient's to read the textbooks so they'd know what symptoms to present with...would streamline the system dramatically...


That being said having suffered an ischemic stroke involving a 3 day ICU stay and associated follow up (going on 2 years ago) at age 27 I'm a bit sensitive to the symptoms and rapid treatment of any potential stroke like symptoms

Now my question for the OP...how can you claim normal eye movement or lack of facial droop in an unresponsive patient. I've yet to be able to notice facial droop in an unresponsive patient as both sides are equally "droopy" for lack of a better term.


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## yogakat (Feb 17, 2009)

new to site, but saw this and thought i'd put my thoughts in...

my husband suffered three ischemic strokes last fall at work (we got to see the mra's and mri's... three spots on the cerebellum)

he noticed the symptoms immediately...unable to walk straight, slurred speech, severe headache, profuse sweating, extreme weakness on the right side

HOWEVER, eye movements were fine and there was no facial drooping...while he was cooperative, responsive, talkative (tho slurred) and fairly alert in the ambulance and the ER, he has no memory of his time in the ER at all...he was in hospital 4 days

100% recovery


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## Ridryder911 (Feb 17, 2009)

That is why CVA's and other similar calls needs a good & thorough neuro examination per ALS provider. EOM's and a very good and thorough understanding of the cranial nerves and cerebral functions.

R/r


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## el Murpharino (Feb 18, 2009)

remote_medic said:


> Now my question for the OP...how can you claim normal eye movement or lack of facial droop in an unresponsive patient. I've yet to be able to notice facial droop in an unresponsive patient as both sides are equally "droopy" for lack of a better term.



I never claimed normal eye movement, just no fixed deviation one way or the other in addition to reactive and equal pupils.  I see what you're saying about the facial droop...


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## remote_medic (Feb 18, 2009)

el Murpharino said:


> I never claimed normal eye movement, just no fixed deviation one way or the other in addition to reactive and equal pupils....



You are correct, I misread...


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## chute43 (Feb 20, 2009)

A couple years ago we had two seperate cases of both diagnosed or misdiagnosed Bells palsy. One of the prehospital diagnostic test I picked up from that was, in the responsive pt with the facial droop. See if the pt can raise their eyebrows, one side at a time obviously. If I remember correctly, the stroke pt with most likely not have the ability to raise their eyebrow while the bells palsy pt can. Again if I remember correctly, it isnt like we get dispatched for bells palsy, and I havent seen a case since then. One was a actual pt, while the other was a semi-local paramedic.

kary

I know it isn't a true diagnostic tool, but the result in my opionion become as I often say " as note worthy"


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## BruceD (Feb 25, 2009)

chute43 said:


> A couple years ago we had two seperate cases of both diagnosed or misdiagnosed Bells palsy. One of the prehospital diagnostic test I picked up from that was, in the responsive pt with the facial droop. See if the pt can raise their eyebrows, one side at a time obviously. If I remember correctly, the stroke pt with most likely not have the ability to raise their eyebrow while the bells palsy pt can. Again if I remember correctly, it isnt like we get dispatched for bells palsy, and I havent seen a case since then. One was a actual pt, while the other was a semi-local paramedic.
> 
> kary
> 
> I know it isn't a true diagnostic tool, but the result in my opionion become as I often say " as note worthy"




Actually, be careful - in a CVA the ability to 'wrinkle the forehead' is often preserved, as there is a dual innervation to the frontalis muscles through CN VII.
In bell's palsy, often the patient can wrinkle one side of the forehead and not the other because it is believed to be affect the more distal portion of the nerves.


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## BruceD (Feb 25, 2009)

Strokes can present in many different ways.  It very much depends on the location of the infarct and the size of the infarct.  Neurologists will use this very information to help localize the origin of the damage, to know what may occur in the hours soon after onset, and to monitor progression of the problem.

There are certain typical presentations that many people have come to expect, such as drooping face, hemiparesis, dysarthria (slurred speech).

There are some not-so-common presentations as well, as a small example set, you could have a patient with sudden inability to write, new onset seizures, complete unresponsiveness with some preservation of conciousness (the dreaded locked-in syndrome due to pontine infarcts), inability to understand language - possibly a wernicke's, or even an ability to speak but the words are out of order (broca's).

As far as my understanding goes, there is no good way to differentiate a hemorrhagic stroke with an ischemic stroke without imaging.  However, the patients I've seen with ischemic CVAs have presented with much higher BPs than the OP's patient, usually with over 160's diastolic.

Be safe!
-B


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## jrm818 (Feb 25, 2009)

Don't disagree with anything you said, just a point of clarification.

Wernicke's aphasia is indeed a receptive aphasia, although the degree to which comprehension of speech is impaired is variable.  To a provider in the field, however, it may appear that someone with wernicke's is understanding you because they will appear to try to respond to questions and may even repeat some of what you said.  This might be recognized by asking them to follow simple commands, but the most prominent symptom will probably be that they speak with profuse, fluent (eg. they can produce speach, they have no motor disorder, though the speech may not be intelligible), grammatical, but nonsensical language  ("word salad") using inappropriate or even made-up words made of properly pronounced word fragments.  

Broca's patients _may_ be able to produce speech but with a loss of grammar, but the more typical presentation would be extreme word-searching and issues generating words.  They may speak in single (appropriate) words with long pauses between.  E.g Q: "what sort of health history do you have?"  A: uh....head......stroke......brain......years.....two
They may also have problems forming word.  Broca's can be thought of as a motor disorder - these patients have a problem generating the motor output necessary to generate speech as well as having grammatical problems.  E.g. broca's first patient with this sort of aphasia was called "Tan," as that was the only word he was able to produce.  

Side note: often these patients can sing even if they cannot speak - different areas control the motor output for singing (Ozzy osbourne is an OK example of this).  They can probably still understand speech, although they may have issues with word order (E.G. misinterpreting "the man bit the dog" as "the dog bit the man").  I don't know if there are any broca's patients who sing to communicate...would be interesting to see a patient who only sings to you.

There are some good videos on YouTube with examples of various forms of aphasia.  
In EMS you certianly don't need to be able to diagnose the various aphasias....speech science types go to school for a long time to do that...but it is important to be able to recognize the various presentations that are signs of a possible stroke.  I'd dare to say probably more common for these symptoms to overlap than to have a more "pure" type of aphasia.

For more - I like this set of descriptions...not so technical that an EMS provider would get lost.
http://brainmind.com/Aphasia33.html


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## BruceD (Feb 25, 2009)

jrm818 said:


> Don't disagree with anything you said, just a point of clarification.
> 
> http://brainmind.com/Aphasia33.html



Good clarification and I like that website.

The only thing I would disagree with (and it's a meaningless distinction for those providing emergency care) is about Broca's area.  It probably shouldn't be considered a motor disorder as Broca's is responsible for sequencing and syntax, the final speech is produced by muscles controlled by motor cortex adjacent to broca's area, not broca's itself.

Also, what you said is very true - it would be rare for a patient to present with a pure type of aphasia without other symptoms.

Be safe!
-B


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## chute43 (Feb 25, 2009)

BruceD said:


> Actually, be careful - in a CVA the ability to 'wrinkle the forehead' is often preserved, as there is a dual innervation to the frontalis muscles through CN VII.
> In bell's palsy, often the patient can wrinkle one side of the forehead and not the other because it is believed to be affect the more distal portion of the nerves.



That was why I said it was more of a note worthy thing and less of a diagnostic tool. Plus if you have the pt raise their eye brows and the pt can only raise one side, I believe that is very important information to gather. It doesnt change any therapy. Just using good assessment skills with documentation. I use it as part of my assessment for possible stroke pts, not to determine if they had a stroke but to make notes of the neuro deficit, incase there is a change in deficit later. Where I work the accepted standard is just facial droop, slurred speech, or unilateral weakness, which I dont feel like is enough information to give the receiving facility.

kary


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## jrm818 (Feb 25, 2009)

BruceD said:


> G
> The only thing I would disagree with (and it's a meaningless distinction for those providing emergency care) is about Broca's area.  It probably shouldn't be considered a motor disorder as Broca's is responsible for sequencing and syntax, the final speech is produced by muscles controlled by motor cortex adjacent to broca's area, not broca's itself.
> 
> -B



'Fraid I'm going to have to disagree with that.  While it is true that relatively recent evidence has implicated Broca's area in the comprehension of syntactical relationships, it is also certainly involved in the motor output of speech.  My take is that Broca's area probably encompasses multiple "areas" which are architecturally indistinguishable (the traditional way of delineating areas of the brain) but functionally distinct.  The lack of fluency in Broca's patients cannot be explained by grammar problems, but demonstrates an inability of the brain to generate and carry out the complex stereotyped motor programs necessary to produce speech.

The primary motor strip is far from the only structure in the nervous system involved in motor output.  There is remarkable complex interaction between the (I'm probably forgetting some) cerebellum _(coordination feedback to make sure the body is actually performing the action it wanted to)_, basal ganglia _(initiation of movement, among other roles)_, primary, supplementary, and premotor areas, the visual system including primary and secondary visual areas of cortex (_visually guided actions, mapping of environment)_ as well as subcortical tectum _(important for orienting reflex actions)_ and even the spinal cord which stores many complex motor patterns on its own in spinal pattern generators (the way this was demonstrated is pretty neat: cats with transected spinal cords, when supported above a treadmill, walk with their hind legs).


While the primary motor cortex is responsible for the direct output to the motor neurons (or spinal central pattern generators), Broca's area is required in order for the pattern of complex and coordinated oropharyngeal movements required to speak to be produced (it's like the programmer...the motor strip follows the program written by broca's area).  Similar to how the supplementary motor area coordinates complex and bilateral hand movements and sends the output to the primary motor strip to be executed.  

It's interesting that Broca's area also seems to have mirror neurons in it...just as the supplementary motor area does.  Mirror neurons are neurons which fire as if they are coordinating a specific action when that action is seen.  E.G. I see you raise your hand, the mirror neurons in my supp. motor. area will fire in the exact same way they would if I were to acutally raise my hand in imitation.  It's a sort of practice execution of the program, without acutally telling the motor strip to "GO."  Broca's does the same thing (which I think is also used as evidence that it is involved in speech comprehension).

Overall the research here is pretty complex, and a lot of it has been focusing on parceling out parts of the brain into smaller and smaller "subareas" each responsible for a different function (thank you occasionally mediocre fMRI studies for that), but as long as we talk about Broca's area as the area laid out by Broca (or Broadmanns 44 and 45), it will encompass an area of cortex which is important for motor output.  It's called non-fluent or expressive aphasia for a reason...while there is now appreciated to be a receptive aspect to the language dysfunction, the classical idea of Broca's as a motor problem is still valid, based on any evidence I've ever seen.

Fun discussion.  Like you said...largely irrelivent to the practice of EMS, but super interesting nonetheless.


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## Ridryder911 (Feb 25, 2009)

jrm818 said:


> Fun discussion.  Like you said...largely irrelivent to the practice of EMS, but super interesting nonetheless.



Not really, Advanced Stroke Life Support Course goes into very depth discussion of this, as they presume that all Paramedics should know that this as a minimum. Again, an in-depth knowledge of evaluating the nervous system should be a required minimal requirement.

R/r 911


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## BruceD (Feb 25, 2009)

Gonna have to read up on this! apparently more has been found since I last studied it.

Great discussion

-B


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## jrm818 (Feb 26, 2009)

Ridryder911 said:


> Not really, Advanced Stroke Life Support Course goes into very depth discussion of this, as they presume that all Paramedics should know that this as a minimum. Again, an in-depth knowledge of evaluating the nervous system should be a required minimal requirement.
> 
> R/r 911



Huh...I had no idea.  One of these days I'll have to finagle my schedule to sit in on that class.  If its really in depth I'm impressed...I imagined a very superficial course with maybe some discussion of how to administer more tests...like those seen in NIH stroke scale perhaps, but without too much neuro A&P.  I'm happy to be told I"m wrong.

That said, I wasn't really referring to the difference between Broca's and Wernicke's aphasia as "not relevent to EMS," but the more nitty gritty details of the exact nature of the processing done in Broca's area and its relationship to the SMA etc.  I'd be _very_ impressed if, for instance, mirror neurons were mentioned in the course.  they may well be, I don't know.  Unfortunately, from what I've seen, even paramedics tend to hit expressive vs. receptive aphasia and that's about it.  Basics..(in general) forget about it.  If the course at least give you some basic functional neuroanatomy I'd be very enthused.  

As I see it,  in the prehospital arena recognition of suspicious symptoms is the most important thing...neurologist specialists will (hopefully) be making the definitive diagnosis and doing specific interpretation of symptoms.

In the same vein, depth is relative.  I've spent almost three years on this stuff, and I've just scratched the surface compared to the experts in the field.  Heck the whole field has just scratched the surface of the brain..I don't know that any human can clam they have an in depth understanding of more than one or two subfields when dealing with the CNS...the field is just moving too fast to keep up at more than a somewhat superficial level.  I guarantee that something I said in my post above is outdated...and if it isn't today, by next month it will be.  To me that's what this stuff so intriguing.


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## jrm818 (Feb 26, 2009)

BruceD said:


> Gonna have to read up on this! apparently more has been found since I last studied it.
> 
> Great discussion
> 
> -B



Ha...more is always being discovered..and fast!  More has been discovered since I posted that, I'd be willing to bet.

I will say that I've always heard of Broca's as traditionally being thought of as a primarily motor disorder.  The identification of its role in syntax and processing is historically a more new idea.  I'm far from up on the new ideas, and acutally I can imagine that there could be new evidence that Broca's acutally plays little direct role in motor programming.  However, from what I remember, there is evidence of a topographic organization in the area which maps onto the muscles needed to produce speech...or something like that.  I remember being pretty convinced that Broca's was more similar than different to the supp. motor area.  

I'd be interested if you find out that I'm completely wrong.  Sure wouldn't be the first time..


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