The middle cerebral artery is the largest branch of the internal carotid artery and supllies the largest area of the cerebral cortex Supplying the motor and sensory cortices, also supplies the areas of the cortex pertaining to the comprehension Wernicke’s area and expresion brocca’s area (left hemisphere)

1. Clinical
syndromes of
vascular
disease of the
nervous system
Aditya Johan .R, M.Fis

2. Middle cerebral artery occlusion
o The middle cerebral artery is the largest branch of the
internal carotid artery and supllies the largest area of the
cerebral cortex
o Supplying the motor and sensory cortices, also supplies
the areas of the cortex pertaining to the comprehension
Wernicke’s area and expresion brocca’s area (left
hemisphere)

3. Anterior cerebral artery
occlusion
o Occlusion proximal to the anterior communicating artery is normal well
tolerated because of adequate cross-flow and thus few symptoms result
o Occlusion distal to the anterior communicating artery causes contralateral
weakness and cortical sensory loss in the leg
o Incontinence is often present
o It is often involved secondary to occlusion more proximally in the internal
carotid

4. Posterior cerebral artery
occlusion
o The posterior cerebral arteries are the terminal branches
of the basiler artery
o In addition to cortical branches to the temporal lobe and
occipital and visual cortices, there are perforating
branches that supply the midbrain and thalamus

5. Posterior cerebral artery
occlusion
o Proximal occlusion : midbrain syndrome (weber’s syndrome) third nerve palsy
and contralateral hemiplegia, chorea or hemiballismus, hemisensory
disturbance
o Cortical vessel occlusion : homonymous hemianopia with macular sparing
o Bilateral occlusion : anton’s syndrome (cortical blindness)

6. Lacunar infarction
o A lacunar stroke occurs when one of the arteries that provide blood to the
brain's deep structures is blocked
o Approximately 25% of ischaemic strokes are due to infarction of the internal
capsule
o This originate from the origin of the middle cerebral artery and supply parts
of the internal capsule, basal ganglia and thalamus

7. Internal capsule stroke
o The internal capsule is one of the subcortical structures of the
brain
o Subcortical structures: internal capsule, caudate, putamen,
globus pallidus, thalamus, brainstem
o The anterior limb of the internal capsule separates the caudate
nucleus and lenticular nucleus
o The posterior limb separates the thalamus and lenticular nucleus

8. Types of fiber internal capsule
o Anterior limb: frontopontine fibers (frontal cortex to pons),
thalamocortical fibers (thalamus to frontal lobe)
o Genu (angle): corticobulbar fibers (cortex to brainstem)
o Posterior limb: corticospinal fibers (cortex to spine), thalamo
cortical fibers to parietal lobe (general sensory)

9. Internal capsule

10. Blood supply of internal capsule
o Anterior limb: mainly fed by the lenticulostriate
branches of middle cerebral artery(MCA), less often
branches of anterior cerebral artery (ACA)
o Genu: lenticulostriate branches of MCA
o Posterior limb: lenticulostriate branches of MCA &
anterior choroidal artery (AChA) of internal carotid
artery

11. Symptoms and sign
Weakness of the face, arm, and/or leg (pure motor stroke) :
o Known as one of the classic types of lacunar infarcts, a pure motor stroke is the
result of an infarct in the internal capsule
o Upper motor neuron signs : hyperreflexia, Babinski sign, Hoffman present,
clonus, spasticity
Mixed sensorimotor stroke :
o Since both motor and sensory fibers are carried in the internal capsule, a stroke
to the posterior limb of the internal capsule (where motor fibers for the arm,
trunk and legs and sensory fibers are located) can lead to contralateral
weakness and contralateral sensory loss

12. Brainstem stroke
o Multiple patterns of deficit can arise depending on the exact location of the
lesion with respect to the long tracts
o Medial medullary syndrome : corticospinal tract, medial lemniscus (dorsum
column), hypoglossal nucleus (CN XII)
o Lateral medullary syndrome : vestibular nuclei (nystagmus, nausea, vomiting
and vertigo), inferior cerebellar peduncle (dystaxia, dysmetria,
dysdiadochokinesia), nucleus ambiguus (dysphagia, dysphonia)

13. Brainstem stroke clinical feature
o UMN hemiparesis or tetraparesis (corticospinal tracts)
o Hemisensory or bilateral sensory impairment (medial lemniscus, spinothalamic
tract)
o Diplopia (C.N 3, 4 at midbrain, CN 6 at pons)
o Facial sensory loss (CN 5)
o LMN facial weakness (CN 7)
o Dysphagia, dysarthria (CN 9 and 10 at medulla)
o Ataxia (cerebellum and cerebral connection)
o Horner’s syndrome (meiosis, ptosis, disturbed sweating) : sympathetic fiber in
lateral brainstem
o Altered consciousness (reticular formation)

14. Brainstem stroke
o Locked in syndrome : bilateral infarction in the ventral pons, with or without
medullary involvement, the patient is conscious (intact brainstem reticular
formation) but is mute and paralysed, patient can often move their eyes
because of sparing CN 3 and 4 in the brainstem
o Weber’s syndrome : caused by lesion in one half of the midbrain, resulting an
ipsilateral third nerve palsy (CN 3) and contralateral hemiplegia (descending
pyramidal tract above decussation)

15. Subarachnoid and intracerebral
haemorage
o Subarachnoid haemorage : usually comes from a berry aneurysm arising from
one of the arteries at the base of the brain, around circle of willis
o Intracerebral haemorage : tends to occur in the internal capsule or the pons,
because of the rupture of long thin penetrating arteries
o Both haemorages cause a sudden rise in intracranial pressure, with headache,
vomiting and decrease conscious level, which may followed by the development
of papilloedema

16. Subarachnoid haemorage
o The bleeding irritates the meninges, this causes the
characteristic sudden severe headache and neck
stiffness
o Often a brief loss of consciousness at the moment of
the bleed

17. Intracerebral haemorage
o In the region of internal capsule will cause sudden severe motor, sensory and
visual problems on the contralateral side of the body (hemiplegia,
hemianesthesia and homonymous hemianopia)
o In the pons , sudden loss of motor and sensory function in all four limbs,
associated with disordered brainstem function, accounts for the extremely high
mortality of haemorage in this area

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