Stroke syndromes

1. STROKE SYNDROMES
Dr. Kamaldeep Kaur Sidhu

2. DEFINITION
 A cluster of signs and symtoms that is
produced due to occlusion of an artery
or due to haemmorhage in an artery
supplying a particular region of the
brain.
 They help to identify which part of
brain is injured in stroke therby help in
localisation of lesion.

3. CIRCLE OF WILLIS

4. Arterial supply of cerebral hemisphere : lateral
aspect

5. Arterial supply of cerebral hemisphere : medial
aspect

6. Arterial supply of cerebral hemisphere : inferior
aspect

7. Brodmann’s functional areas of Brain
• Cerebral cortex has been divided into
52 functional area by Brodmann (1909)
1.Motor areas
2.Sensory areas
3.Association areas

8. Brodmann’sfunctional areas on lateral surface
Brain

9. Brodmann’sfunctional areas on lateral surface
Brain

10. •Pharyngeal region
and tongue are
represented in the
lowermost part
followed by face,
hand, trunk and
thigh.
•Legs, feet and
perineum are
represented on the
medial surface of
the hemisphere in
the paracentral
lobule.

11. CLASSIFICATION
Stroke syndromes are divided into:
(1) large vessel stroke within the anterior
circulation，
(2) large-vessel stroke within the
posterior circulation,and
(3) small-vessel disease of either
vascular bed.

12. LARGE VESSEL STROKE
IN ANTERIOR
CIRCULATION

13. Anterior Cerebral Artery
1. A1 SEGMENT= HORIZONTAL PORTION b/w origin
and Ant Comm artery.
BRANCHES:
1. Inferior branches to optic nerve and chiasma
2. Superior branches to ant hypothalamus, septum pellucidum,
ant commisure, fornix,
3. medial lenticulostriate artery to anteroinferior portion of
corpus striatum.
2. A2 SEGMENT= INTERHEMISPHERIC PORTION
after the origin of Ant Comm artery .
BRANCHES:
1. Medial orbitofrontal artery.
2. Frontopolar artery.
3. Callosomarginal artery.
4. Pericallosal artery.
SUPPLY: anterior 2/3 of medial cerebral surface and
1cm of superomedial brain over convexity.

14. • Occlusion of the proximal ACA is usually well
tolerated because of collateral flow through
the anterior communicating artery and
collaterals through the MCA and PCA.
• The occlusion to ACA( distal to ant comm.
artery) may produce:
a) Contralateral hemiparesis and
hemianaesthesia (legs>arms), due to
involvement of upper parts of the primary
motor and sensory areas.
b) Urinary incontinence- d/t paracentral lobule.
c) Inability to identify objects i.e. Agnosia due
to involvement of sup parietal lobe.
d) Apathy and personality changes due to
involvement of a part of frontal lobe.

15. Anterior choroidal artery
• Branch of ICA
• Supplies post limb of internal capsule.
• Occlusion leads to Contralateral
hemiplegia, hemianaesthesia, and
homonymous hemianopia.

16. Middle cerebral artery
The Largest branch of ICA, arises lat to optic chiasma,
passes in horizontal and lateral direction to enter in sylvian
fissure and divides into 2 branches
SUPPLY:
– Lateral cerebrum
– Insular cortex
– Anterior and Lateral temporal lobes
• M1 SEGMENT:
– Origin to MCA bifurcation
Lateral lenticulostriate -supply the globus pallidus,
putamen, post limb of internal capsule, adjacent corona
radiata, and most of the caudate nucleus.
• M2 SEGMENT:
– Insular branches
• M3 SEGMENT:
– MCA branches beyond sylvian fissure

17. Middle cerebral artery occlusion
• Contralateral hemiplegia and hemianaesthesia,
involving mainly the face and the arms, due to
involvement of the most of the primary motor
area and sensory areas.
• Aphasia if left dominant hemisphere is
involved, due to involvement of motor and
sensory speech areas.
• Anosognosis,constructional apraxia, and hemi
neglect if non dominant hemisphere is
involved.
• Contralateral homonymous hemianopia, due to
involvement of optic radiation.
• Paralysis of conjugate gaze to the opposite
side due to involvement of frontal eye field.

18. • Partial syndromes due to incomplete
occlusion of a single branch include hand
or arm and hand weakness alone
(BRACHIAL SYNDROME) .

19. LARGE VESSEL STROKE
IN POSTERIOR
CIRCULATION

20. Posterior cerebral artery
• Arises from the bifurcation of basilar
artery.
• P1 and P2 segments:
• P1 is the proximal to junction of post
communicating artery and P2 is distal to
it.
• P1 supplies midbrain, thalamus and
subthalamus
• P2 supplies cortical temporal and
occipital lobe.

21. P1 syndrome
• A 3rd nerve palsy with contralateral ataxia: CLAUDE’S
SYNDROME d/t involvement of red nu.
• A 3rd nerve palsy with c/l hemiplegia: WEBER’S
SYNDROME d/t involvement of cerebral peduncle
• If subthalamic nucleus is involved, hemiballismus may
occur.
• Occlusion of the ARTERY OF PERCHERON produces
paresis of upward gaze and drowsiness and often abulia.
• Extensive infarction in the midbrain and sub- thalamus
occurring with bilateral proximal PCA occlusion presents
as coma， unreactive pupils,bilateral pyramidal signs and
decerebrate rigidity.
• Dejerine -Roussy syndrome d/t occlusion of thalamic
and thalamo geniculate arteries. The thalamic Dejérine-
Roussy syndrome consists of contralateral hemisensory
loss followed later by an agonizing, searing or burning
pain in the affected areas.

22. P2 syndrome
• C/l homonymous hemianopia with macula sparing is
the usual feature.
• Acute disturbances in memory d/t medial temporal
lobe and hippocampal involvement particularly if it
occurs in the dominant hemisphere..
• B/l infaction produces cortical blindness with
normal pupillary reaction. The patient is often
unaware of the blindness and often deny it(
ANTON’S SYNDROME)
• Rarely,only peripheral vision is lost and central
vision is spared,resulting in "gun-barrel" vision.
• Patients may experience persistence of a visual
image for several minutes despite gazing at
another scene (palinopsia) or an inability to
synthesize the whole of an image
(asimultanagnosia).

23. • Bilateral visual association area lesions
may result in Balint's syndrome,a
disorder of the orderly visual scanning
of the environment, usually resulting
from infarctions secondary to low flow
in the "watershed" between the distal
PCA and MCA territories,as occurs
after cardiac arrest.
• Occlusion of the posterior cerebral
artery can produce peduncular
hallucinosis (visual hallucinations of
brightly colored scenes and objects).

24. Vertebro-Basilar system
• The vertebral arteries originates from the
subclavian artery ,and ascend through the
transverse foramen of the upper six cervical
vertebra.
• At the upper margin of the Axis (C2) it moves
outward and upward to the transverse foramen
of the Atlas (C1). It then moves backwards
along the articular process of atlas into a deep
groove, passes beneath the atlanto-occipital
ligament and enters the foramen magnum. The
arteries then run forward and unite at the
caudal border of the pons to form the basilar
artery.

25. Segments of vertebral Artery
• V1- Extends from its origin to entrance
into 6th transverse vertebral foramen
• V2- traverses the vertebral foramine from
C6-C2
• V3- Passes through the transverse
foramina and circles around the arch of
the atlas it pierce the dura at the foramen
magnum
• V4- it courses upwards to join the basilar
artery. It is the only segment that gives
branches to supply the inferior surface of
cerebrum and cerebellum.

26. Branches of the vertebral artery
Cranial Part:
• Anterior spinal artery- Ant Cord syndrome
• Posterior spinal artery- Post cord
syndrome
• PICA- It is the largest branch.
Wallenberg syndrome
• Meningeal branches- supplies the
duramatter
• Medullary arteries- Supply dorso-lateral
medulla

27. Branches of the Basilar Artery
• Supply the base of the brain and
superior cerebellum
• Three groups of arteries:
1.Paramedian - Pontine branches- Medial
pontine syndrome
2.Short circumferential – lateral pontine
syndrome
3.Long circumferential -Superior
cerebellar artery and AICA

29. Medial inferior pontine syndrome (occlusion of
paramedian branch of basilar artery)
On side of lesion
• Paralysis of conjugate gaze to
side of lesion (preservation of
convergence): Center for
conjugate lateral gaze(PPRF)
• Nystagmus: Vestibular nucleus
• Ataxia of limbs and gait:middle
cerebellar peduncle
• Diplopia on lateral gaze:
Abducens nerve
On side opposite lesion
• Paralysis of face, arm, and leg:
Corticobulbar and corticospinal
tract in lower pons
• Impaired tactile and
proprioceptive sense over one-
half of the body: Medial
lemniscus

30. Lateral inferior pontine syndrome (occlusion of anterior
inferior cerebellar artery)
On side of lesion
• Horizontal and vertical nystagmus,
vertigo, nausea, vomiting, oscillopsia:
Vestibular nerve or nucleus
• Facial paralysis: Seventh nerve
• Paralysis of conjugate gaze to side
of lesion: Center for conjugate
lateral gaze
• Deafness, tinnitus: Auditory nerve
or cochlear nucleus
• Ataxia: Middle cerebellar peduncle
and cerebellar hemisphere
• Impaired sensation over face:
Descending tract and nucleus fifth
nerve
On side opposite lesion
• Impaired pain and thermal sense
over one-half the body (may include
face): Spinothalamic tract

31. Medial midpontine syndrome
(paramedian branch of midbasilar artery)
On side of lesion
• Ataxia of limbs and gait
(more prominent in
bilateral involvement):
Pontine nuclei
On side opposite lesion
• Paralysis of face, arm,
and leg: Corticobulbar
and corticospinal tract
• Variable impaired touch
and proprioception when
lesion extends
posteriorly: Medial
lemniscus

32. Lateral midpontine syndrome (short
circumferential artery)
On side of lesion
• Ataxia of limbs: Middle
cerebellar peduncle
• Paralysis of muscles of
mastication: Motor fibers
or nucleus of fifth nerve
• Impaired sensation over
side of face: Sensory
fibers or nucleus of fifth
nerve
On side opposite lesion
• Impaired pain and thermal
sense on limbs and trunk:
Spinothalamic tract

33. Medial superior pontine syndrome (paramedian
branches of upper basilar artery)
On side of lesion
• Cerebellar ataxia (probably):
Superior and/or middle
cerebellar peduncle
• Internuclear ophthalmoplegia:
Medial longitudinal fasciculus
• Myoclonic syndrome, of palate,
pharynx, vocal cords,
respiratory apparatus, face,
oculomotor apparatus, etc.: —
central tegmental bundle.
On side opposite lesion
• Paralysis of face, arm, and leg:
Corticobulbar and
corticospinal tract
• Rarely touch, vibration, and
position are
affected(arm>leg): Medial
lemniscus

34. Lateral superior pontine syndrome (syndrome of
superior cerebellar artery)
On side of lesion
• Ataxia of limbs and gait, falling to side of
lesion: Middle and superior cerebellar
peduncles, superior surface of
cerebellum, dentate nucleus
• Dizziness, nausea, vomiting; horizontal
nystagmus: Vestibular nucleus
• Paresis of conjugate gaze (ipsilateral):
Pontine contralateral gaze
• Miosis, ptosis, decreased sweating over
face (Horner's syndrome): Descending
sympathetic fibers
On side opposite lesion
• Impaired pain and thermal sense on face,
limbs, and trunk: Spinothalamic tract
• Impaired touch, vibration, and position
sense, more in leg than arm : Medial
lemniscus (lateral portion)

35. Medial Midbrain Syndrome
(paramedian branches of upper basilar and proximal PCA)
On side of lesion
• Eye "down and out"
secondary to unopposed
action of fourth and
sixth cranial nerves, with
dilated and unresponsive
pupil: Third nerve fibers.
On side opposite lesion
Paralysis of face,arm, and
leg: Corticobulbar and
corticospinal tract
descending in crus
cerebri

36. Lateral midbrain syndrome
(small penetrating arteries arising from PCA)
On side of lesion
• Eye "down and out“
secondary to unopposed
action of fourth and
sixth cranial nerves，
with dilated and
unresponsive pupil :Third
nerve fibers and/or third
nerve nucleus.
On side opposite lesion
• Hemiataxia,
hyperkinesias, tremor:
Red
nucleus,dentotorubrothali
c pathway.

37. Medial medullary syndrome (occlusion of
vertebral artery or of branch of vertebral or lower
basilar artery)
On side of lesion
• Paralysis with atrophy of
one-half half the tongue:
Ipsilateral twelfth nerve.
On side opposite lesion
• Paralysis of arm and leg
,sparing face; impaired
tactile and proprioceptive
sense over one-h a l f the
body: Contralateral
pyramidal tract and
medial lemniscus.

38. Lateral medullary syndrome (occlusion of any of five
vessels may be responsible – vertebral, posterior inferior
cerebellar, superior, middle or inferior lateral medullary arteries)
On side of lesion
• Pain , numbness, impaired sensation over one-half
the face: Descending tract σnd nucleus fifth nerve.
• Ataxia of limbs, fall onto side of lesion: Uncertain-
restiform , body, cerebellar hemisphere, cerebellar
fibers, spinocerebellar tract.
• Nystagmus,diplopia,oscillopsia,vertigo,nausea,vomiti
ng :Vestibular nucleus.
• Horner's syndrome (miosis, ptosis,decreased
sweating): Descending sympathetic tract.
• Dysphagia, hoarseness, paralysis of palate,
paralysis of vocal cord，diminished gag reflex:
Issuing fibers 9th and 10th cranial nerves.
• Loss of taste :Nucleus and tractus solitarius.
• Numbness of ipsilateral arm, trunk or leg: Cuneate
and gracile nυclei.
• Weahness of lower half of face: Genuflected upper
motor neuron fibers to ipsilateral facial nucleus.
On side opposite lesion
• Impaired pain and thermal sense over half the
body sometimes face: Spinothalamic tract.

39. THANKS!!!!