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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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