STROKE SYNDROMESprepared by dr.siruhan

Circle of Willis

•Anterior circulation-MCA, ACA, and Anterior choroidalartery

•Posterior circulation-Vertebral artery, Basilar artery and Posterior cerebral artery

Large vessel stroke syndromes (anterior circulation)– assuming left hemispheric dominance

Vascular territory Signs and Symptoms

Internal Carotid Artery - Combined ACA + MCA- Ipsilateral monocular visual loss ( amurosis) secondary

to CRAO

Left ACA - Right leg numbness and weakness- Transcortical motor aphasia- Ideomotor apraxia

Right ACA - Let leg numbess and weakness- Motor neglect- Possibly ideomotor apraxia

Left MCA - Right face/arm > leg numbness and weakness- Aphasia- Left gaze preference

Right MCA - Left face/arm > leg numbness and weakness- Left hemispatial neglect- Right gaze preference- Agraphesthesia / astereoagnosia

• Gerstmann syndrome• Acalculia• Right – left confusion• Finger agnosia• Ideomotor apraxia• Agraphia

• Dominant parietal lobe lesions, involving inferior parietal lobule

Graphical Aphasia box

• Motor/Broca aphasia – localized to posterior inferior frontal lobe

• Sensory/Wernicke’s aphasia – posterior superior temporal/inferior parietal

Lacunar syndromes;

Syndrome Signs/Symptoms Localization Vascular supply

Pure motor Contralesionalhemiparesis

- Internal capsule – posterior limb

- Corona radiata- Basis pontis

-Lenticulostriatebranches of the MCA or-perforating arteries from basilar artery

Pure sensory Contralesionalhemisensory loss

- VPL nucleus of thalamus

- Lenticulostriatebranches of MCA

- Small thalamoperforators of PCA

Sensorimotor Contralesionalweakness and numbess

- Thalamus and adjacent posterior limb of internal capsule

- Lenticulostriatebranches of MCA

Lacunar syndromes…contn.

Syndrome Signs/Symptoms Localization Vascular supply

Dysarthia-clumsy hand Slurred speech and weakness of contralateral hand (fine motor)

- Basis pontis ( between rostral 1/3rd and caudal 2/3rd )

- Basillar artery perforators

Ataxia- hemiparesis ContralesionalHemiparesis and ataxia out of proportion to weakness

- Internal capsule-posterior limb

- Basis pontis

- Lenticulostritaebranches of MCA

- Perforating arteries of basilar artery

Hemiballismus/Hemichorea

Contralesional limb flailing / dyskinesis

- Subthalamic nucleus - Perforating arteries ofanterior choroidal or PCOM

• Lacunar strokes present with fluctuating symptoms – “ capsular warning syndrome”

•Often thromolysis withheld due to “ rapidly improving symptoms”

OCSP – Oxfordshire community stroke project classification

•TAC – Total anterior circulation stroke• LAC – lacunar stroke•PAC – Partial anterior circulation stroke•POC- Posterior circulation stroke

I – Infarct ; S – syndrome ; H - hemorhage

TAC ( Total anterior circulation)

•Combination of•New, higher cerebral dysfunction ( eg.dysphasia)•Homonymous visual field defect• Ipsilateral motor or sensory deficit of atleast two areas

out of face, arm and leg.

PAC – Partial Anterior Circulation

•No drowsiness

•2 of 3 criteria of TAC

•OR Higher cerebral dysfunction alone

•OR Motor/Sensory deficit more restricted than those defined by LAC (eg. confined to one limb)

POC – Posterior circulationAny of;

• Affecting brainstem / cerebellar or occipital

• Ipsilateral CN palsy with contralateral motor/sensory signs

• B/L motor and/or sensory deficit

• Disorders of conjugate eye movement

• Cerebellar dysfunction without ipsilateral long tract signs

• Isolated homonymous visual field defect

Anterior circulation- Middle cerebral Artery

M1 segment(proximal)-

•deep penetrating or lenticulostriate branches

•Supply - Internal capsule, caudate nuclues, putamen and outer pallidus

M2 Segment

•M2(distal)- superior and inferior divisions-

• the entire superolateral surface of frontal and parietal lobe except frontal pole, strip along the superomedial frontal and parietal cortex, occipital lobe convolutions and medial temporal cortex

M2 segment

Complete MCA syndrome

•Contralateral hemiplegia

•Contralateral hemianaesthesia

•Contralateral homonymous hemianopia

•Gaze preference to the ipsilateral side

• If dominant hemisphere involved-Global aphasia

• If non dominant hemisphere involved- Hemispatialneglect, anasognosia and constructional apraxia

Partial syndromes

•M1 syndrome-occlusion of lenticulostriate branches-•If ischemia of internal capsule produces pure motor or sensorymotor stroke contralateral to the side of lesion•If ischemia of putamen, pallidus-predominantly parkinsonian features

M2 syndromes

•If superior division involved•Brachial syndrome- weakness of hand and arm•Frontal opercular syndrome-Brocas aphasia

with facial weakness with or without arm weakness•proximal part of the superior division involved-

clinical features of motor weakness, sensory disturbances and brocas aphasia

M2 syndrome

•If inferior division of M2 involved-• If dominant hemisphere- Wernickes aphasia

without weakness with contralateralhomonymous superior quadrantanopia• If non dominant hemisphere- Hemispatial

neglect , spatial agonosia without weakness

Anterior Cerebral artery

•A1 segment- from internal carotid to anterior communicating artery-branches to anterior limb of internal capsule, anteroinferior caudate, anterior hypothalamus•A2 segment-distal to anterior communicating artery- supplies frontal pole, entire medial part of cerebral hemispheres

Precommunal A1 segment

Post communal A2 segment

A1 segment

•A1 segment occlusion rarely produces clinical syndrome because collateral flow through anterior communicating artery and collaterals from MCA and PCA

A2 syndrome

•Motor area for leg and foot-c/l paralysis of foot and leg•Sensory area for foot and leg-c/l cortical sensory loss of foot and leg•Sensorimotor area in paracentral lobule-urinary incontinence•Medial surface of posterior frontal lobe-c/l grasp and suckling reflex•Cingulate gyrus and the medial inferior portions of frontal, parietal and temporal lobes-abulia

Anterior choroidal artery

•Supplies posterior limb of internal capsule, retrolentiform and sublentiform parts

•Complete syndrome rare due to collaterals from MCA, PCA, and ICA

•Syndrome comprises

•c/l hemiplegia

•c/l hemianaesthesia

•c/l homonymous hemianopia

Posterior circulation

Posterior circulation

•Cerebellum•Medulla•Pons•Midbrain•Thalamus•Subthalamus•Hippocampus•Medial part of temporal lobe•Occipital lobe

Stroke within the Posterior Circulation

• Posterior Cerebral Artery• result from atheroma formation or emboli that lodge at the top of the basilar

artery

• May also be caused by dissection of the vertebral artery or fibromusculardysplasia

Posterior Cerebral Artery

• P1 syndrome : midbrain, subthalamic, and thalamic signs, which are due to disease of the proximal P1 segment of the PCA or its penetrating branches

• P2 syndrome: cortical temporal and occipital lobe signs, due to occlusion of the P2 segment distal to the junction of the PCA with the posterior communicating artery.

Posterior Cerebral Artery• P1 Syndromes

Syndrome Clinical features Localization

Claude’s syndrome 3rd nerve palsy + contralateral ataxia

Rednucleus / cerebral peduncle

Weber’s syndrome 3rd nerve palsy + hemiplegia

Medial mid brain / cerebral peduncle

Benedikt’s syndrome 3rd Nerve palsy + hemiplegia + Ataxia

Rednucleus / Medial mid brain

Subthalamic nucleus Contralateral hemiballismus

thalamic Déjerine-Roussysyndrome

contralateral hemisensory loss and agonizing pain

thalamus

Posterior Cerebral Artery - P2 Syndromes

• Occulsion of the PCA causes infarction of the medial temporal and occipital lobes

• Contralateral homonymous hemianopia with macula sparing is the usual manifestation

• Acute disturbance in memory (hippocampus)

• peduncular hallucinosis - visual hallucinations of brightly colored scenes and objects

• Infarction in the distal PCAs produces cortical blindness (blindness with preserved pupillary light reflex)

• Anton's syndrome – unaware of blindness and in denial

Cerebellar stroke syndromes

Territory Signs and symptoms

Extracerebellarstructures

Extracerebellarsigns and symptoms

Superior cerebellar artery

Ipsilesional limb and gait ataxia

Midbrain, Thalamus, occipital lobes

Top of the basilar syndrome

Posterior Inferior Cerebellar artery

Ipsilesional limb and gait ataxia

Dorsolateral medulla Wallenberg’s syndrome

Anterior inferior Cerebellar artery

Vertigo ipsilesionaldeafness

Lateral pons Contralateral facial weakness, numbness and hearing loss

Lateral medullary syndrome(Wallenburgs)Modality Localization Symptoms

Vestibulocerebellar - Vestibular nuclei and connections- Inferior Cerebellar peduncle ( Restiform

body)

- Dizziness and imbalance- Tendency to fall to side of lesion- Hypotonia ipsilateral side- Diplopoia/ osscilospia- Nystagmus- ocular tilt reaction- Limb ataxia

Sensory - Spinal nucleus of CN V

- Spinothalamic tract

- Loss of pain and temperature sensation in ipsilateral face

- Loss of pain and temperature contraletral trunk

Bulbar muscle weakness

- Nucleus ambiguous (CN 9 and 10) - ipsilateral palate, pharynx, and larynx

Autonomic - Descending sympathetic fibers- Dorsomotor nucleus of vagus

- Ipsilateral Horner’s syndrome- Autonomic signs – labile BP/

tachycardia / sweating /arrythmias

Respiratory - Ventrolateral medullary tegmentum and the medullary reticular zone. (Respiratory centres)

- Failure of automatic respirations

Medial medullary syndrome (Dejerinesyndrome)

Motor symptoms - Pyramidal tract - Contraletral hemiparesis- Up to 50% facial weakness

contraletral

Sensory symptoms - Medial lemniscus - Paresthesias ( most often no clinical signs)

- Proprioception / vibration -rarely may be lost in the contraletral foot

12th nerve paralysis –least common feature

- Hypoglossal nucleus - Tongue paresis- Dysarthria – especially lingual

consonants

Hemimedullary infarction –• Involve both lateral and medial medulla• Lateral medullary syndrome + contralateral hemiparesis

Basilar Artery

• Arise at the junction of paired vertebral arteries.

•Begins at medullopontine junction, ends at junction of pons and midbrain

•Main blood supply of pons

Blood supply of pons

A) Large paired median arteries. B) Paramedian arteries lying slightly laterally. C) Arteries that branch at a right angle from the long circumferential artery

• Pontine syndromes – caused by occlusion of deep or circumferential pontine penetrating arteries• Dorsal portion or tegmentum - VI th nerve palsy

• Horizontal gaze palsy and dysarthria

• Pupils constricted as a result of involvement of descending sympathetic pupillodilator fibres.

• Hemiplegia or quadriplegia often present

• INO – involvement of MLF

• Locked – in Syndrome

• ventral pons (basis pontis) infarction with intact tegmentum

• All motor and sensory tracts involved

• Intact vertical gaze and spared consciousness – intact reticular activating system and vertical gaze centers.

• Top of basilar syndrome

• superior most part of basilar artery occlusion

• Involves – Thalamus, Midbrain, occipital lobes, cerebellum (Superior cerebellar artery)

• Visual, occulomotor, behavioral features,

Lateral Pontine Syndrome (Marie-Foix Syndrome)

• Blood vessels –• Basilar artery; Long circumferential branches

• Anterior inferior cerebellar artery

Tracts Manifestation Side

Cerebellar – Middle cerebellar peduncle

Ataxia – arm and leg Ipsilateral

Corticospinal tracts Hemiparesis contralateral

Spinothalamic tract Hemisensory loss Contraletral

Ventral Pontine Syndrome (Raymond syndrome)

• Blood vessels –• Basilar artery: Paramedian branches

Tracts Manifestation Side

CN VI Lateral gaze palsy Ipsilateral

Corticospinal tracts Hemiparesis contralateral

Ventral Pontine Syndrome (Millard-Gubler Syndrome)

• Blood vessels –• Basilar artery; Long circumferential branches

• Basilar artery: Paramedian branches

Tracts Manifestation Side

CN VII Facial palsy Ipsilateral

CN VI Lateral gaze palsy Ipsilateral

Corticospinal tracts (basis pontis)

Hemiparesis contralateral

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