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LOCALISING A STROKE
WE ALREADY HAVE A BRIEF IDEA OF ARTERIAL SUPPLY TO THE BRAIN
THE SUPPLY IS DIVIDED INTO ZONES OF CIRCULATION ANTERIOR TERRITORY
POSTERIOR TERRITORY
VERTEBRO-BASILAR TERRITORY
WHAT CAN GO WRONG These systems of circulation supply
specific regions of the brain Therefore if there is a interruption to the
specific blood supply, characteristic symptoms are experienced.
This is particularly useful in the clinical scene to locate exactly the position of a lesion or the offending supply.
ANTERIOR TERRITORY
Interior Carotid Artery
Middle Cerebral Artery
Anterior Cerebral Artery
POSTERIOR TERRITORY Posterior Cerebral Artery
Vertebral arteries
Basilar Artery
ANTERIOR
POSTERIOR
1
2
3
4
ANTERIOR CEREBRAL ARTERY Frontal lobe behavioural abnormalities
Loss of motivation Disinhibition
Grasp reflex
Leg Weakness
Leg loss of sensation
Contralateral neglect
MIDDLE CEREBRAL ARTERY Contralateral
hemiplegia
Contralateral hemiparesis
Contralateral hemisensory loss
Contralateral Hemianopia
Dysphasia
Visual/sensory neglect/inattention
Visual Field deficit
In deep supply (Lenticulostriate arteries): Pure Motor and/or Sensory loss, Dysarthria, Dyspahasia
POSTERIOR CEREBRAL ARTERY Contralateral
homonymous hemianopia.
Contralateral hemiparesis
Contralateral hemisensory loss.
Alexia without agraphia.
Dysphasia
Dysphagia
Dysarthria
Cerebellar ataxia
Cortical blindness
Impaired consciousness
Locked-in syndrome
‘Long tract’ motor & sensory signs
VERTEBRO-BASILAR SYSTEM Cranial nerve
abnormalities
Dysdiadokokinesia
Tremor,
Cerebellar ataxia
Vertigo
Locked-in syndrome
Nausea and vomiting
Nystagmus
Impaired consciousness
Respiratory arrest
Autonomic instability
Contralateral sensory and motor loss
Dysarthria
Dysphagia
‘Long tract’ motor & sensory signs
BAMFORD CLASSIFICATION OF STROKE1. Total Anterior Circulation Stroke –
TACS
2. Partial Anterior Circulation Stroke – PACS
3. Lacunar Stroke - LACS
4. Posterior Circulation Stroke – POCS
TOTAL ANTERIOR CIRCULATION STROKEAll of:1. New higher cerebral dysfunction in the
affected hemisphere (e.g. Dysphasia, inattention, neglect, dyspraxia , Visual field defect)
2. Contralateral hemiplegia and hemiparesis. Motor and / or sensory deficit of at least two areas out of face, arm and leg.
3. Contralateral hemianopia
*If drowsy with unilateral weakness, last two factors are assumed
PARTIAL ANTERIOR CIRCULATION STROKEAny of: No Drowsiness 2 out of 3 criteria of TACSOR• Isolated Higher cerebral dysfunction
alone (eg dysphasia)OR• Motor/sensory deficit more restricted
than those classified as LAC (eg confined to one limb)(Monoplaegia)
LACUNAR STROKE SYNDROMESNO visual field defectNO disturbance of language or other higher cortical functionNO evidence of brainstem dysfunction
Types:1. Pure Motor Stroke(most common). Complete or incomplete
weakness of 1 side, involving the whole of 2 of 3 of the body areas of face, arm and leg).
2. Pure Sensory Stroke. Sensory symptoms and/or signs, same distribution as above.
3. Ataxic Hemiparesis (inc. dysarthria-clumsy hand) . Hemiparesis with ipsilateral cerebellar ataxia
4. Sensorimotor Stroke. Combination of the above. Includes dysarthria (“clumsy hand syndrome”) and dysphasia
POSTERIOR CIRCULATION STROKE
Any of Dysfunctions of the brainstem, cerebellar
or occipital lobes(cortical blindness) Ipsilateral cranial nerve palsy with
contralateral motor and / or sensory deficit Bilateral motor and / or sensory deficit. Disorder of conjugate eye movement Isolated homonymous visual field defect Cerebellar dysfunction without ipsilateral
long tract signs (ataxia)
REFERENCES Robin Smithuis. Brain Ischemia - Vascular
territories. The Radiology Assistant, 24-11-2008[online]. http://www.radiologyassistant.nl/en/484b8328cb6b2. Accessed 04/05/2012
Iain Wilkinson and Graham Lennox. Essential Neurology© 2005 by Blackwell Publishing Ltd.
BLUMENFELD, H. Neuroanatomy Through Clinical Cases 1st edition. © 2002 by Sinauer Associates.
Seminar: Stroke by Dr Paul Worth. 3rd May 2012. 1100hrs CD ANNEX 0.01 Norwich Medical School.
