Stroke Syndromes



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Stroke Syndromes

 


Main symptom:
Hemiparesis (faciobrachiocrural weakness)


 

Associated symptoms


Anatomy & vascular territory

• Cortical sensory loss, global aphasia or spatial neglect, hemianopsia, contralateral gaze palsy

 


• Middle cerebral artery (entire territory) syndrome

• Hemisensory loss, transcortical motor or sensory aphasia

• Middle cerebral artery (deep territory)

 

• Watershed infarct (between superficial and deep middle cerebral artery territory)



 

• Sensory loss (face and hand), conduction aphasia, apraxia, Gerstmann syndrome, constructional apraxia

 


• Perisylvian, superficial middle cerebral artery territory

• Hemisensory loss, gaze palsy, spatial neglect, or expressive aphasia

 


• Middle cerebral artery, superior division (superficial territory)

• Ipsilateral 3rd nerve palsy (Weber syndrome)

+/- Supranuclear vertical gaze palsy

+/- Sensory deficit

 


• Posterior cerebral artery--paramedian midbrain perforators

 


• Ipsilateral 6th nerve palsy

+/- 7th nerve palsy (Millard-Gubler syndrome), internuclear ophthalmoplegia, horizontal gaze palsy, one-and-a-half syndrome

 


• Basilar artery--paramedian pontine perforators

• Ipsilateral 12th nerve palsy, contralateral loss of position and vibratory sense (medial medullary syndrome--Dejerine syndrome)

 

• Ipsilateral ataxia



+ Contralateral hemiparesis

 

• Ipsilateral ataxic hemiparesis



 

• Vertebral artery, anterior spinal artery--paramedian medullary perforators

 



Facio-brachial weakness


 


Associated symptoms



Anatomy & vascular territory

• Cognitive and behavioral abnormalities (abulia, agitation, hyperactivity, neglect)

• Middle cerebral artery complete or lateral lenticulostriate territory

 

• Anterior cerebral artery proximal perforating branches from Heubner artery territory--caudate infarcts



 


Crural weakness

 


Associated symptoms


Anatomy & vascular territory

• Homolateral ataxia

 

• Anterior cerebral artery distal territory



• Noncortical sensory loss

+/- Transcortical motor aphasia or mutism, mood disturbances

 


• Superficial borderzone territory between anterior and middle cerebral artery

• Sensory loss, shoulder weakness, gegenhalten, left hand apraxia, alien hand sign, grasp reflex, transient urinary incontinence, abulia, akinetic mutism

 


• Anterior cerebral artery complete territory


Brachial weakness

 

Associated symptoms


Anatomy & vascular territory

• Cortical sensory loss, disturbance of volitional saccadic eye movements

• Borderzone territory between anterior and middle cerebral artery

 

• Middle cerebral artery superficial territory: cortical infarct



 

Bilateral weakness - hemiparesis

 

Associated symptoms


Anatomy & vascular territory

+/- Sensory loss

Internal carotid artery territory:

• Bilateral hemispheric

 

Anterior spinal artery territory:



• Bilateral medullary pyramids

• Spinal cord infarction

 


• Locked-in syndrome

+/- Supranuclear vertical gaze palsy



Basilar artery territory:

• Bilateral paramedian pontine or mesencephalic

 


Bilateral weakness - brachial weakness


 

Associated symptoms

Anatomy & vascular territory


 

• Bilateral anterior watershed infarctions (man-in-a-barrel syndrome)

 


• Vertigo, distal amyotrophy

• Anterior spinal artery watershed (“snake-eyes” infarction) (Pullicino 1994)

 


Bilateral weakness - paraplegia

 

Associated symptoms


Anatomy & vascular territory

• Akinetic mutism, abulia, grasp, urinary incontinence

 


• Anterior cerebral artery bilateral

• Sensory level, urinary incontinence

 


• Anterior spinal artery infarction

Bilateral weakness - pseudobulbar palsy

 

Associated symptoms


Anatomy & vascular territory

• Facio-pharyngo-glosso-masticatory diplegia with automatic-voluntary dissociation, spasmodic laughing or crying

 


• Middle cerebral artery bilateral opercular branches

+ Pyramidal signs, intellectual impairment

• Anterior choroidal artery: bilateral perforating branches

 


+ Pyramidal or cerebellar signs, lack of dementia

 


• Basilar artery paramedian branches

Sensory strokes

 

Associated symptoms


Anatomy & vascular territory

• Loss of position sense, impairment of 2-point discrimination, somatotopagnosia, agraphesthesia, astereognosis

+/- Hemiparesis, hemianopsia, aphasia or hemineglect pseudothalamic parietal sensory syndrome

 

• Faciobrachiocrural elementary sensory loss



 

• Middle cerebral artery--parietal branches

• Restricted acral sensory syndrome: cheiro(hand)-oral, cheiro-pedal, cheiro-oral-pedal syndrome

• Middle cerebral artery

 

•Thalamogeniculate pedicle



 

• Basilar artery: deep perforating or medullary arteries

 

• Small strokes in lateral thalamus, pontine tegmentum, corona radiata, parietal cortex, midbrain.



 

• Hemianesthesia, transient hemiparesis, hemiataxia, thalamic astasia, choreoathetoid movements, thalamic hand, paroxysmal pain

+/- Hemianopsia

(Dejerine-Roussy syndrome)

 


• Thalamogeniculate territory, proximal posterior cerebral artery


Cerebellar ataxia - limb ataxia, gait imbalance

 

Associated symptoms


Anatomy & vascular territory

+/- Lateropulsion, vertigo, nausea and vomiting, nystagmus, ocular tilt reaction, dysphonia and dysphagia, (nucleus ambiguous: IX, X, XI), ipsilateral facial thermalgesia (5th cranial nerve), Horner syndrome, contralateral thermalgesia of trunk and limbs (Wallenberg syndrome)

 


• Vertebral artery brainstem branches from vertebral artery occlusion

Contralateral analgesia or thermalgesia

+/- Vertigo, nausea, vomiting, horizontal nystagmus, dysarthria, Horner syndrome, 4th nerve palsy

 

+ 3rd nerve palsy



 

+ Hemichoreoathetosis (Benedikt syndrome)

 


• Superior cerebellar artery: cerebellar + midbrain tegmentum infarction territory

Cerebellar ataxia

 

Associated symptoms


Anatomy & vascular territory

+/- Supranuclear vertical gaze palsy

 

+ Defective convergence or convergence-retraction nystagmus



 

• Basilar or posterior cerebral artery--P1--paramedian perforators

+ Light-near dissociation (Parinaud syndrome)

 


• Dorsal rostral midbrain syndrome

• Vertigo, tinnitus, ipsilateral hearing loss, dysarthria, Horner syndrome, peripheral 7th nerve palsy, facial hypesthesia, contralateral thermalgesia of the limbs and trunk

 


• Anterior inferior cerebellar artery--pontocerebellar infarction

Ataxic hemiparesis

 

Associated symptoms


Anatomy & vascular territory

+/- Sensory symptoms

+/- Dysarthria (dysarthria- clumsy-hand syndrome)



• Thalamogeniculate or basilar artery or middle cerebral artery--lacunar infarctions in pons, thalamus, internal capsule, medulla

 


+ Aphasia

• Middle cerebral artery-parainsular

 


Visual symptoms - monocular blindness (amaurosis fugax)

 

Associated symptoms


Anatomy & vascular territory

+/- Contralateral variable motor and hemisensory deficit

 


• Internal carotid artery territory ischemia

Visual symptoms - visual-field defects

                            - sectoranopia



 

Associated symptoms


Anatomy & vascular territory

• Wedge-shaped defect straddling the horizontal median, pointing towards fixation

 


• Posterior choroidal artery - lateral geniculate body infarction

• Sector defects adjacent to the vertical meridian, sparing the zone around the horizontal meridian

 


• Anterior choroidal artery--lateral geniculate body infarction

Visual symptoms - quadrantanopia (inferior noncongruent)

 

Associated symptoms


Anatomy & vascular territory

+ Optic ataxia, difficulty judging size, distance, movement

 


• Anterior, middle, or posterior cerebral artery--watershed infarction

+/- Cortical hypesthesia, aphasia (anomia, transcortical sensory, receptive)

• Middle or posterior cerebral artery superficial watershed, middle cerebral artery (parietal optic radiations)

 



Visual symptoms - quadrantanopia (inferior congruent)

 

Associated symptoms


Anatomy & vascular territory

 

• Posterior cerebral artery--upper bank calcarine fissure

 



Visual symptoms - quadrantanopia (superior noncongruent)

 

Associated symptoms


Anatomy & vascular territory

 

• Middle cerebral artery inferior division (temporal optic radiations)

 


Visual symptoms - quadrantanopia (superior congruent)

 

Associated symptoms


Anatomy & vascular territory

 

• Posterior cerebral artery--lower bank calcarine fissure

 



Visual symptoms - hemianopsia

 

Associated symptoms


Anatomy & vascular territory

• Isolated, +/- hemiparesis, hemisensory loss, ataxia

 


• Anterior choroidal artery territory

+ Hemiparesis, sensory loss, aphasia or neglect

• Middle cerebral artery--optic radiation infarction

 

 • Left middle cerebral artery



 

• Alexia without agraphia

• Posterior cerebral artery territory (occipital, mediotemporal and callosal branches)

 


+ Cortical blindness (if bilateral- Anton syndrome), release hallucinations, agitated delirium or confusion,

visual and color agnosia,

prosopagnosia

 + Simultanagnosia, ocular ataxia, ocular apraxia (Balint syndrome)



• Posterior cerebral artery bilateral (lower bank of calcarine fissure)

 

• Middle or posterior cerebral artery watershed (upper bank of calcarine fissure)



 

• Posterior cerebral artery territory stroke

 


Visual symptoms - visual hallucinations

 

Associated symptoms


Anatomy & vascular territory

• In the hemianoptic field, transient or persistent, simple or complex, nonstereotyped

 


• Posterior cerebral artery territory stroke

• Complex, detailed,

+ inversion of the sleep-wake cycle (peduncular hallucinosis)

 


• Basilar artery or posterior cerebral artery, paramedian perforators

Encephalopathic symptoms

 

Associated symptoms


Anatomy & vascular territory

• Agitated delirium, abnormal behavior

 


• Posterior or middle cerebral artery or basilar artery: paramedian midbrain and thalamus, hippocampus, fusiform and lingual gyri (top-of-the-basilar

 


• Cognitive impairment-decline in mentation

• Posterior cerebral artery: occipital plus splenial or parahippocampal infarct (Park et al 2009)

 

• Pontine infarction



 

• Middle cerebral artery territory—right temporal, inferior frontal, and parietal lobe infarction


 

• Abulia, manic behavior

• Medial frontal lobe, caudate nucleus (anterior cerebral artery territory)



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