a not so detailed review of stroke syndrome - might come handy.

1. STROKE SYNDROMES
prepared by dr.siruhan

2. Circle of Willis
•Anterior circulation-
MCA, ACA, and
Anterior choroidal
artery
•Posterior circulation-
Vertebral artery,
Basilar artery and
Posterior cerebral
artery

4. 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

5. • Gerstmann syndrome
• Acalculia
• Right – left confusion
• Finger agnosia
• Ideomotor apraxia
• Agraphia
• Dominant parietal lobe
lesions, involving inferior
parietal lobule

6. Graphical Aphasia box

7. • Motor/Broca aphasia – localized to posterior inferior frontal lobe
• Sensory/Wernicke’s aphasia – posterior superior temporal/inferior
parietal

8. Lacunar syndromes;
Syndrome Signs/Symptoms Localization Vascular supply
Pure motor Contralesional
hemiparesis
- Internal capsule
– posterior limb
- Corona radiata
- Basis pontis
-Lenticulostriate
branches of the
MCA or
-perforating arteries
from basilar artery
Pure sensory Contralesional
hemisensory loss
- VPL nucleus of
thalamus
- Lenticulostriate
branches of MCA
- Small
thalamoperforat
ors of PCA
Sensorimotor Contralesional
weakness and
numbess
- Thalamus and
adjacent posterior
limb of internal
capsule
- Lenticulostriate
branches of MCA

9. 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 Contralesional
Hemiparesis and ataxia
out of proportion to
weakness
- Internal capsule-
posterior limb
- Basis pontis
- Lenticulostritae
branches of MCA
- Perforating arteries of
basilar artery
Hemiballismus/
Hemichorea
Contralesional limb
flailing / dyskinesis
- Subthalamic nucleus - Perforating arteries of
anterior choroidal or
PCOM

10. •Lacunar strokes present with fluctuating symptoms
– “ capsular warning syndrome”
•Often thromolysis withheld due to “ rapidly
improving symptoms”

11. 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

12. 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.

13. 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)

14. POC – Posterior circulation
Any 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

15. Anterior circulation- Middle cerebral Artery
M1 segment(proximal)-
•deep penetrating or lenticulostriate branches
•Supply - Internal capsule, caudate nuclues,
putamen and outer pallidus

16. 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

18. M2 segment

19. 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- Hemispatial
neglect, anasognosia and constructional apraxia

20. 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

21. 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

22. M2 syndrome
•If inferior division of M2 involved-
•If dominant hemisphere- Wernickes aphasia
without weakness with contralateral
homonymous superior quadrantanopia
•If non dominant hemisphere- Hemispatial
neglect , spatial agonosia without weakness

23. 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

24. Precommunal A1 segment

25. Post communal A2 segment

26. A1 segment
•A1 segment occlusion rarely produces clinical
syndrome because collateral flow through
anterior communicating artery and
collaterals from MCA and PCA

27. 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

28. 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

29. Posterior
circulation

30. Posterior circulation
•Cerebellum
•Medulla
•Pons
•Midbrain
•Thalamus
•Subthalamus
•Hippocampus
•Medial part of temporal lobe
•Occipital lobe

31. 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 fibromuscular
dysplasia

32. 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.

33. 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-Roussy
syndrome
contralateral
hemisensory loss and
agonizing pain
thalamus

35. 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

36. Cerebellar stroke syndromes
Territory Signs and
symptoms
Extracerebellar
structures
Extracerebellar
signs 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 ipsilesional
deafness
Lateral pons Contralateral facial
weakness,
numbness and
hearing loss

37. 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

39. Medial medullary syndrome (Dejerine
syndrome)
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

40. 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

42. 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

43. • 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,

44. 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

45. Ventral Pontine Syndrome (Raymond syndrome)
• Blood vessels –
• Basilar artery: Paramedian branches
Tracts Manifestation Side
CN VI Lateral gaze palsy Ipsilateral
Corticospinal tracts Hemiparesis contralateral

46. 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

48. THANK YOU