School of Medicine - LSU Health New Orleans
Stroke Syndromes
|Main symptom: |
| |
|Hemiparesis (faciobrachiocrural weakness) |
| |Associated symptoms |Anatomy & vascular territory |
| |• Cortical sensory loss, global aphasia or spatial neglect, |• Middle cerebral artery (entire territory) syndrome |
| |hemianopsia, contralateral gaze palsy | |
| | | |
| |• 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, |• Perisylvian, superficial middle cerebral artery territory |
| |Gerstmann syndrome, constructional apraxia | |
| | | |
| |• Hemisensory loss, gaze palsy, spatial neglect, or expressive |• Middle cerebral artery, superior division (superficial |
| |aphasia |territory) |
| | | |
| |• Ipsilateral 3rd nerve palsy (Weber syndrome) |• Posterior cerebral artery--paramedian midbrain perforators[pic] |
| |+/- Supranuclear vertical gaze palsy | |
| |+/- Sensory deficit | |
| | | |
| |• Ipsilateral 6th nerve palsy |• Basilar artery--paramedian pontine perforators |
| |+/- 7th nerve palsy (Millard-Gubler syndrome), internuclear | |
| |ophthalmoplegia, horizontal gaze palsy, one-and-a-half syndrome | |
| | | |
| |• Ipsilateral 12th nerve palsy, contralateral loss of position |• Vertebral artery, anterior spinal artery--paramedian medullary |
| |and vibratory sense (medial medullary syndrome--Dejerine |perforators[pic] |
| |syndrome) | |
| | | |
| |• Ipsilateral ataxia | |
| |+ Contralateral hemiparesis | |
| | | |
| |• Ipsilateral ataxic hemiparesis | |
| | | |
| |
|Facio-brachial weakness |
| | | |
| |Associated symptoms |Anatomy & vascular territory |
| |• Cognitive and behavioral abnormalities (abulia, agitation, |• Middle cerebral artery complete or lateral lenticulostriate |
| |hyperactivity, neglect) |territory |
| | | |
| | |• Anterior cerebral artery proximal perforating branches from |
| | |Heubner artery territory--caudate infarcts[pic] |
| | | |
| |
|Crural weakness |
| | | |
| |Associated symptoms |Anatomy & vascular territory |
| | | |
| |• Homolateral ataxia |• Anterior cerebral artery distal territory |
| | | |
| |• Noncortical sensory loss |• Superficial borderzone territory between anterior and middle |
| |+/- Transcortical motor aphasia or mutism, mood disturbances |cerebral artery |
| | | |
| |• Sensory loss, shoulder weakness, gegenhalten, left hand |• Anterior cerebral artery complete territory |
| |apraxia, alien hand sign, grasp reflex, transient urinary | |
| |incontinence, abulia, akinetic mutism | |
| | | |
| |
|Brachial weakness |
| |Associated symptoms |Anatomy & vascular territory |
| |• Cortical sensory loss, disturbance of volitional saccadic eye |• Borderzone territory between anterior and middle cerebral artery|
| |movements | |
| | |• 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 |Basilar artery territory: |
| |+/- Supranuclear vertical gaze palsy |• 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 |• Middle cerebral artery bilateral opercular branches |
| |automatic-voluntary dissociation, spasmodic laughing or crying | |
| | | |
| |+ 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, |• Middle cerebral artery--parietal branches |
| |somatotopagnosia, agraphesthesia, astereognosis | |
| |+/- Hemiparesis, hemianopsia, aphasia or hemineglect | |
| |pseudothalamic parietal sensory syndrome | |
| | | |
| |• Faciobrachiocrural elementary sensory loss | |
| | | |
| |• Restricted acral sensory syndrome: cheiro(hand)-oral, |• Middle cerebral artery |
| |cheiro-pedal, cheiro-oral-pedal syndrome | |
| | |•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 |• Thalamogeniculate territory, proximal posterior cerebral artery |
| |astasia, choreoathetoid movements, thalamic hand, paroxysmal | |
| |pain | |
| |+/- Hemianopsia | |
| |(Dejerine-Roussy syndrome) | |
| | | |
| |
|Cerebellar ataxia - limb ataxia, gait imbalance |
| |Associated symptoms |Anatomy & vascular territory |
| |+/- Lateropulsion, vertigo, nausea and vomiting, nystagmus, |• Vertebral artery brainstem branches from vertebral artery |
| |ocular tilt reaction, dysphonia and dysphagia, (nucleus |occlusion |
| |ambiguous: IX, X, XI), ipsilateral facial thermalgesia (5th | |
| |cranial nerve), Horner syndrome, contralateral thermalgesia of | |
| |trunk and limbs (Wallenberg syndrome) | |
| | | |
| |Contralateral analgesia or thermalgesia |• Superior cerebellar artery: cerebellar + midbrain tegmentum |
| |+/- Vertigo, nausea, vomiting, horizontal nystagmus, dysarthria,|infarction territory |
| |Horner syndrome, 4th nerve palsy | |
| | | |
| |+ 3rd nerve palsy | |
| | | |
| |+ Hemichoreoathetosis (Benedikt syndrome) | |
| | | |
|Cerebellar ataxia |
| |Associated symptoms |Anatomy & vascular territory |
| |+/- Supranuclear vertical gaze palsy |• Basilar or posterior cerebral artery--P1--paramedian perforators|
| | | |
| |+ Defective convergence or convergence-retraction nystagmus | |
| | | |
| |+ Light-near dissociation (Parinaud syndrome) |• Dorsal rostral midbrain syndrome |
| | | |
| |• Vertigo, tinnitus, ipsilateral hearing loss, dysarthria, |• Anterior inferior cerebellar artery--pontocerebellar infarction |
| |Horner syndrome, peripheral 7th nerve palsy, facial hypesthesia,| |
| |contralateral thermalgesia of the limbs and trunk | |
| | | |
|Ataxic hemiparesis |
| |Associated symptoms |Anatomy & vascular territory |
| |+/- Sensory symptoms |• Thalamogeniculate or basilar artery or middle cerebral |
| |+/- Dysarthria (dysarthria- clumsy-hand syndrome) |artery--lacunar infarctions in pons, thalamus, internal capsule, |
| | |medulla |
| | | |
| |+ Aphasia |• Middle cerebral artery-parainsular[pic] |
| | | |
|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|• Posterior choroidal artery - lateral geniculate body infarction |
| |towards fixation | |
| | | |
| |• Sector defects adjacent to the vertical meridian, sparing the |• Anterior choroidal artery--lateral geniculate body infarction |
| |zone around the horizontal meridian | |
| | | |
|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 |• Middle or posterior cerebral artery superficial watershed, |
| |sensory, receptive) |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 |• Posterior cerebral artery bilateral (lower bank of calcarine |
| |hallucinations, agitated delirium or confusion, |fissure) |
| |visual and color agnosia, | |
| |prosopagnosia |• Middle or posterior cerebral artery watershed (upper bank of |
| | + Simultanagnosia, ocular ataxia, ocular apraxia (Balint |calcarine fissure) |
| |syndrome) | |
| | |• Posterior cerebral artery territory stroke |
| | | |
|Visual symptoms - visual hallucinations |
| |Associated symptoms |Anatomy & vascular territory |
| |• In the hemianoptic field, transient or persistent, simple or |• Posterior cerebral artery territory stroke |
| |complex, nonstereotyped | |
| | | |
| |• Complex, detailed, |• Basilar artery or posterior cerebral artery, paramedian |
| |+ inversion of the sleep-wake cycle (peduncular hallucinosis) |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[pic] |
| | | |
| |• Abulia, manic behavior |• Medial frontal lobe, caudate nucleus (anterior cerebral artery |
| | |territory)[pic] |
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