Basal ganglia stroke

Basal Ganglia Stroke

Muhammad Asim RanaMBBS, MRCP, EDIC, SF-CCM, FRCPE

What are Basal Ganglia

• The basal ganglia or basal nuclei are group of subcortical nuclei located at the base of the forebrain.

• They are significantly united with the cerebral cortex, thalamus, and brainstem.

• The basal ganglia play a major role in voluntary motor functions, procedural learning, routines or habits, and eye movements.

• They also have contributions in cognition and emotions

Parts of Basal Ganglia

Caudate Nucleus

• This is where the complex or association loop of the basal ganglia traverses as it receives input from the association areas of the brain to transmit the information to the prefrontal cortex.

Putamen• This is where the motor

loop of the basal ganglia traverses as it receives input from the sensorimotor cortex to transmit the information to the premotor area.

Globus Pallidus

• Also known as pallidum or paleostriatum, it is the principal output structure of the basal ganglia.

Subthalamic Nucleus

• It is a structure surrounded by the substantia nigra, thalamus, and internal capsules which has a role on action selection.

Substantia Nigra

• Its name is derived from a Latin term meaning black substance. It is where dopamine resides. Dopamine is rich in neuromelanin which is rich in dark pigments, hence its name.

Getting Complex

Putamen + Globus Pallidus Lentiform Nucleus

Caudate Nucleus + Putamen Striatum or Neostriatum

Neostriatum + Paleostriatum Corpus Striatum

Functions of the Basal Ganglia

• The basal ganglia allow you to automatically perform a learned motor behavior.

• From your motor memory, basal ganglia facilitates in preparing for motor action.

• It controls and modifies your movements.• It is one of the brain structures that maintain

posture.• Basal ganglia play a role in memory retrieval

Stroke Definition

• Medically termed cerebrovascular disease or cerebrovascular accident (CVA), stroke is referred to any pathologic disturbance in the blood vessels of the brain causing some parts of it to be deprived of blood and oxygen, resulting to neurologic deficits and possibly death.

• It may be ischemic or hemorrhagic.

Risk Factors of Basal Ganglia Stroke

• Hypertension occurs in 90% of the cases.• Moyamoya disease• Chronic alcoholism• Use of cocaine

Signs and Symptoms of Ganglia Stroke

• Cerebrovascular disease of the basal ganglia often shows motor dysfunctions. The severity of signs and symptoms depends on how extensive the damage is and which parts of the basal ganglia are specifically affected.

Limitation in Motor Activities

• Ataxia or inability to coordinate muscles• Muscle weakness and rigidity• Involuntary tremors• Facial asymmetry• Pocketing happens when the mouth or throat

is affected. This means the foods are only chewed or held on one side of the mouth.

Impaired Sensation

• The patient will not be able to normally feel stimuli as he had before the stroke. He may not be able to feel touch, pain, temperature, or pressure in a certain area of his body. He may not even know which body part is being touched.

Speech Problems• Nonfluent Aphasia (basal ganglia stroke)

The patient has a problem with speaking his mind. What is in his mind is not completely what comes out of his mouth. There are missing words and incomplete sentences. He finds it difficult to speak.

• Fluent AphasiaThe patient speaks fluently and in complete sentences. The problem here is the words itself. His sentences are jumbled words that have no meaning altogether. What the patient wants to say is completely different from what comes out of his mouth. The statements do not make sense at all.

• Global AphasiaThe patient cannot speak nor understand words.

Changes in the Eyes

• Trouble looking upwards or sidewards• Loss of visual field in some areas• Pupils are asymmetrical in size

Personality Changes

• Depression• Inappropriate affect• Inappropriate emotions• Rage• Frustration• Nervousness• Avolition or lack of motivation

Right Basal Ganglia Stroke

• Anosognosia – is a state wherein the patient is not aware or

unable to perceive the severity of his deficit. This is frequent among patients who had right-sided hemispheric stroke, affecting the right middle cerebral artery, which supplies parts of the basal ganglia.

• Left-side neglect – happens in patients who had basal ganglia stroke

on the right side of his brain. – The patient will unconsciously neglect or ignore

anything that is on his left side. – He only pays attention on what’s on the right side

of his body. – He may even have trouble moving his body parts

to the left.

• Infarction and haemorrhage of the right anterior choroidal and lenticulostriate arteries put the basal ganglia and internal capsule into the picture.

• There will be – visuospatial hemineglect, – constructional apraxia, – motor impersistence, and – anosognosia.

Left Basal Ganglia Stroke

• Apathy– meaning lack of interest or concern as manifested

by inactivity, occurs after the occurrence of lesion on the left basal ganglia.

– Infarction of left anterior choroidal artery may cause impairment in memory.

– Infarction of right anterior choroidal artery does not cause impairment in memory

Prognosis of Basal Ganglia Stroke

• Approximately 33% of all stroke cases are deadly. Prognosis depends on the underlying cause, how extensive it is, how soon it was medically treated, size and location of the lesion, degree of deficit, and age of the patient.

• The chance of death for patients with hemorrhagic stroke is 70% while for ischemic stroke, mortality is lower which is 25%. However, reoccurrence of ischemic stroke is 5-15% every year

• Patients who had stroke confined to the basal ganglia have smaller lesions but slower initial recovery time compared to those who had stroke on the cerebral cortex.

• Although the recovery was gradual during early rehabilitation stage, it significantly progresses towards the end.

• Compared to patients who had stroke on cerebral cortex, those who had stroke on basal ganglia had a greater overall recovery.

• The earlier the stroke was recognized and treated, the better the prognosis.

• The greater the Glasgow coma scale (GCS) score of the patient, the better the prognosis.

References• Basal Ganglia accessed on http://en.wikipedia.org/wiki/Basal_ganglia• Afifi AK & Bergman RA, Functional Neuroanatomy: Text and Atlas 2nd edition,

McGraw-Hill 2005• Caplan LR, Stroke Syndromes 3rd edition, Cambridge University Press, 2012, p 509• Greenstein B & Greenstein A, Color Atlas of Neuroscience, Thieme 2000 , p 186• Ropper AH & Samuels MA, Adams & Victor’s Principles of Neurology 9th edition,

McGraw-Hill Companies Inc. 2009• Basal Ganglia Stroke accessed on

https://patienteducation.osumc.edu/Documents/BasalGangliaStroke.pdf• Godefroy O, The Behavioral and Cognitive Neurology of Stroke, Cambridge University

Press 2013, pp 37-38• Schaller B, State-of-the-Art Imaging in Stroke, Nova Publishers 2007, p 80• Lindsay KW et al, Neurology and Neurosurgery Illustrated 3rd edition, Churchill

Livingstone 1997, pp 236-237• Barnes MP et al, Recovery after Stroke, Cambridge University Press 2005, p 162