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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