Stroke location and ACA and PCA syndromes from harrison's 20th edition

1. Localization of stroke
Dr. Mohammed firoz
Post graduate
Final year
Andhra medical College

2.  stroke, or cerebrovascular accident, is defined
as an acute onset of a neurologic deficit that is
due to a focal vascular cause.
 • Transient Ischemic Attack (TIA) or ‘mini
stroke’ is when those symptoms resolve in 24
hours (usually under 1hr) without evidence of
brain infarction on brain imaging.

3.  Stroke is classified into two major types:
 Brain ischemia due to thrombosis,
embolism, or systemic hypoperfusion (80%).
 Brain hemorrhage due to intracerebral
hemorrhage (ICH) or subarachnoid
hemorrhage (SAH)(20%).

4. Localization of stroke syndromes
Three steps
1.Clinical localization of the site of the lesion.
2.Identifying the vascular territory and the vessel
involved.
3.Correlating with the imaging findings

5.  Prerequisites
 1.Functional anatomy of brain.
 2.Blood supply to the different parts of brain

6.  Cortex functional anatomy

9. Frontal lobe dysfunction
 Emotions,judgement
 Memory,reasoning
 Abstract thinking
 Motor cortex
 Dominent
cortex(brocas area44)
 Non dominant side
 Frontal eye field (8)
 Social disinhibition,
Poor judgement,poor
memory, impaired
abstract
thinking,urinary
incontinence
 Weakness of opposite
 Non fluent aphasia(t)
 Lack of
prosody(expression)
 Contralateral
conjugate horizontal
gaze palsy

10. Parital lobe dysfunction
 Cortical sensations
 optic radiation
 Loss of tactile
localization,
 two point
discriminaton,
 Stereognosis,
 graphesthesia.
 Inferior
quadrantanopia

11. Parital lobe(Dominant) dysfunction
 Ability to perfom
learned motor
activity
 Calculation,writing
Gertsmans syndrome
 Idiomotor
apraxia.imagination
impaired ,can use
real time objects
 Ideational apraxia
Acalculia
Dysgraphia
Finger agnosia
Rt to Lt confusion

12. Parital lobe (non dominant)
 Visuospatial
integration
 Left hemi neglect
 Anosognosia-pt
deny existance of
left limbs
 Constructional and
dressing apraxia

13. Temporal lobe
 Memory
 Emotions (limbic area)
 Wernickes area
 Optic radiations
(visual field)
 Recent
memory(hypocamps)
 Memory of
fear(amygdala)
kluver bucy syndrome
 Emotional distruance
 Wernikes apahsia
without hemiplegia
 Superior
quadrantanopia

14. Occipital lobe
 Visual field areas.
 Occipito temporal
connections.
 Occipito parital
connections.
 Homonymous
hemianopia with
macular sparing
 Propspagnosia(ina
bility to identify
known faces).
 Asimultanagnosia.

15. Circle of willis

16. Anterior circulation
 Anterior cerebral artery Medial surface of the
cerebral hemisphere and internal capsule
 Middle cerebral artery -(M1) basal ganglia and
internal capsule, (M2)Lateral surface of the
hemisphere
 Post communicating artery – internal capsule
 Ant choroidal artery – internal capsule,
thalamus,LGB
 Ophthalmic artery – optic nerve and retina

17. Internal carotid artery
occlusion
 AMOUROSIS FUGAX
 only feature that distinguishes between
internal carotid artery syndrome and MCA
syndrome
 Sudden onset of transient monocular visual
loss
 Curtain pattern moving superior to inferiorly
 Spontaneous, unrelated to position usually
lasting for 1 to 5 minutes rarely beyond 30
mins

18. Blood supply

20.  Internal capsule

21. Internal capsule
 Anterior limb
 genu
 Posterior limb
 Retro&sub
lenticular
 Fronto ponto
cerebellar fibers
 Papez circuit
 Saccadic pathway
 Corticobulbar fiber
 Corticospinal,thalamic
radiations
 Visual and auditory
radiations.

22. Blood supply

23.  LESION AT LEVEL OF INTERNAL
CAPSULE:
 Dense hemiplegia (UL weekness=LL
weeknes)
 Hemisensory loss
 UMN type of facial palsy
 Homonymous hemianopia

24. Occlusion of lenticulostriate vessels leads to lacunar stroke(2mm
to 2cm) with in internal capsule

25. Posterior circulation
 Vertebral artery- medulla and
cerebellum
 Basilar artery pons and cerebellum
 Posterior cerebral artery midbrain,
thalamus, hippocampus, occipital
lobe, temporal lobe and cerebellum

26. Thalamus
 Supplied by deep branches
 of PCA.
 Contalateral hemiplegia.
 Sensory deficit.
 Aphasia, constructional apraxia.
 Homonymous visual defect,horners I/L.
 After Thalamic stroke Dejerine roussy syndrome-
C/l hemisensory loss,burning pain in affected
area

28. Mid brain

30. Mid brain
 Vertical gaze
 3rd &4th cranial
nerve nucleus
 Corticospinal tract
 Substantia nigra
 upward gaze palsy
 Convergence
retraction disorder
 Pupil and lid disorder
(parinaud syndrome)
 L/l 3rd &4th CN palsy
 C/l hemiplegia
 Parkinsons disease

31. P1 syndromes
Webers syndrome
Site: anterior cerebral peduncle ,3rd&7th cranial
nerves, corticospinal tract
Signs:I/L3rd CN palsy,C/L 7th CN palsy UMN,C/L
hemiplegia
Claude syndrome
site: superior cerebellar peduncle ,3rdC/N nucleus
Signs: I/L3rd CN palsy+C/L cerebellar ataxia
nothnagel syndrome
Site:tectum ,superior cerebellar peduncle
Signs:I/L 3rd CN palsy+ C/L cerebellar ataxia

32.  Benedikt syndrome
 Site: tegmentum of mid brain,red
nucleus,corticospinal tract,brachium
conjunctivum
 Signs: I/L 3rd CN palsy,C/L cerebellar
ataxia,tremors,C/L hemiplegia

33.  P2 syndromes
 Antons syndrome
 Site:B/L infract in Distal PCAs
 Sign:cortical blindness,pupillary light reflex
preserved,pt often unaware of blindness
 Balints syndrome
 Site:visual association areas(water shed area)
 Signs:optic ataxia,Asimultagnosia,Oculomotor
apraxia

34. Pons

35. pons
 Horizontal
gaze(pprf)
 5,6,7&8nerve nuclei
 Corticospinal tract
 Millard gubler
syndrome
Raymond-foville
syndrome
 Horizontal gaze
palsy
 I/L 6th&(LMN)7th
CN palsy
 C/L hemiplegia

36. Medulla
 Medial medulla
(posterior column,12th
CN, Cortico spinaltract)
 Lateral medulla
Spinal tract of 5thCN
spinothalamic tract,
vestibular nucleus,
inferior cerebellar
peduncle,sympathetic
tract
Dejerine syndrome
 Hemiesthesia
,hemiplegia,12thCN
palsy
Wallenberg syndrome
 I/L facial sensory
loss with C/L loss of
pain,temp,
nystagmus,vertigo,a
taxia,horners
syndrome

37. cerebellum
 Flocculonodular
lobe (archi
cerebellum)
 Vermis(paleo
cerebellum)
 Cerebellar
hemispheres(neo
cerebellum)
 Eye movement
control and gross
orientation in space
 Concerned with
gait and locomotion
 Concerned with
precise movements
of the extremities

38.  UL weakness>LLweakness=brachial
hemiplegia,MCA territory infract
 UL weakness<LLweakness=crural
hemiplegia,ACA territory infract
 ULweakness=LLweakness=densehemiplegia,
internal capsule infract
 I/L CN&C/L hemiplegia =crossed hemiplegia
 U/L one side &L/L opposite site=Cruciate
hemiplegia= at level of dicussation

39.  My reference Harrison 20th edition
 Uptodate