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Posterior circulation stroke syndromes
Differentiating features between anterior and posterior
circulation stroke
Clinical features Posterior circulation Anterio...
ANATOMY
• Comprises of:
(Tracing from Below Upwards of VertebroBasilar System)
1) Paired vertebral arteries
2) Basilar artery
3) P...
VERTEBROBASILAR SYSTEM - Branches
• Vertebral Artery
• Anterior spinal artery
• Posterior spinal artery
• Posterior inferi...
CIRCLE OF WILLIS – a note
CIRCLE OF WILLIS – a note
Posterior circulation
Lateral view
DISCUSSION
Posterior Cerebral Artery:- (PCA)
• Terminal branch of the basilar artery
• Paired
• At the interpeduncular fossa
• Branch...
• 75% cases: from bifurcation of basilar artery
• 20% cases: One PCA arises from ipsilateral ICA via
posterior communicati...
• The artery of Percheron is a rare variant of the posterior
cerebral circulation.
• The term is used to refer to a solita...
• Supplies posterior cranial fossa structures:
– Medial area of occipital lobe
– Inferior temporal lobe
– Midbrain
– Thala...
• Causes:
– Atheroma/Emboli @ Basilar
– Dissection @ Vertebral
– Fibromuscular dysplasia
• Two syndromes
– P 1 Syndrome
– ...
• Area infarcted:
– Ipsilateral subthalamus
– Medial thalamus
– Ipsilateral cerebral peduncle
– Midbrain
• Weber’s/Claude’...
• B/L Prox PCA occlusion: Extensive infarction:
– Coma, Unreactive pupils, b/l pyramidal signs, decerebrate rigidity
• Pen...
• Infarction of:
– Medial temporal and occipital lobes
• Contralateral homonymous hemianopia with macular
sparing
• Occasi...
• Anton’s blindness
• Gun barrel vision
• Balint’s syndrome
• Palinopsia
• Asimultanagnosia
• Embolic occulsion of top of ...
MID BRAIN
Weber syndrome-occlusion of
perforating branch of posterior cerebral
artery
Clinical features
1.Ipsilateral
a.3rd nerve pa...
Benedikt syndrome-occlusion of
perforating branch of posterior cerebral
Clinical features
1.Ipsilateral
a.3rd nerve palsy
...
Thalamus-occlusion of thalamo
geniculate branches of posterior
cerebral artery
Contralateral
1.Sensory loss
2.Spontaneous ...
Occipital lobe-optic pathway and visual
reflexes
Occipital lobe-occlusion of left
calcarine artery
Clinical features
1.Right Hemianopia
Occipital lobe-occlusion of both
calcarine arteries
Clinical features
1.Bilateral hemianopia-
cortical blindness (light
re...
Left occipital lobe with corpus
callosum infarction
Left
Clinical features
1.Right hemianopia
2.Alexia without
agraphia
• Commences as the union of
both vertebral arteries
• Terminates by dividing into
two Posterior cerebral
arteries.
• Branc...
• Three groups:
– Paramedian, 7-10 in number, supply a wedge of pons on
either side of midline
– Short circumferential, 5-...
Structures
supplied by
BASILAR
• Complete basilar occlusion
– Constellation of bilateral long tract signs (sensory & motor)
with signs of cranial nerve &...
Basilar artery occlusion
Clinical features
1.Paralysis of all four limbs
2.Bulbar paralysis
3.Eye movements
abnormalities
...
• Severe ipsilateral cerebellar ataxia
• Nausea & vomitings
• Dysarthria
• Contralateral loss of pain & temperature over e...
Pons-Lower
Medial pontine syndrome – occlusion
of paramedian branch of basilar artery
A.IPSILATERAL
1.Gaze paresis
2.Cerebellar signs...
Lateral pontine syndrome-occlusion of
anterior inferior cerebellar artery
A.IPSILATERAL
1.LMN VIIth nerve palsy
2.Gaze pal...
Vertebral
artery
• Commences as a branch of the subclavian on left and
brachiocephalic on right and terminates by joining to form
the basil...
• Branches:
– Anterior spinal artery
– Posterior spinal artery
– Posterior inferior cerebellar artery
VERTEBRAL… contd
• Largest branch of vertebral artery
• One of the three major supplies of the cerebellum
• Also supplies the lateral medul...
• Posterior meningeal branch
• Arises from opposite the formen magnum
• Supplies Falx cerebri
MENINGEAL BRANCHES OF VERTEB...
• Predilection for V1 and V4
• Usually lesion of one vertebral does not cause TIAs.
• TIAs occur if one is atretic and oth...
• Atheromatous disease is rare.
• Fibromuscular dysplasia, dissection  common here
• Rarely due to encroachment from oste...
• Subclavian occluded proximal to
origin of vertebral.
• Leads of reversal in the direction of
blood flow in the ipsilater...
Medulla
Lateral medullary syndrome
(Wallenberg Syndrome – PICA occlusion)
A. IPSILATERAL
1.Xth cranial nerve palsy
2.Cerebellar si...
Medial medullary syndrome –
Anterior Spinal Artery occlusion
A.IPSILATERAL
1.XIIth nerve palsy
B.CONTRALATERAL
1.Hemiplegi...
• Can lead to sudden respiratory arrest
• Due to raised ICP in the posterior fossa
• Symptoms:
– Drowsiness
– Babinski sig...
THANK YOU
Dr.Karthik Raghavan
Postgraduate MD (Int. Med)
SRM Medical College & Hospital
Posterior circulation stroke Syndromes
Posterior circulation stroke Syndromes
Posterior circulation stroke Syndromes
Posterior circulation stroke Syndromes
Posterior circulation stroke Syndromes
Posterior circulation stroke Syndromes
Posterior circulation stroke Syndromes
Posterior circulation stroke Syndromes
Posterior circulation stroke Syndromes
Posterior circulation stroke Syndromes
Posterior circulation stroke Syndromes
Posterior circulation stroke Syndromes
Posterior circulation stroke Syndromes
Posterior circulation stroke Syndromes
Posterior circulation stroke Syndromes
Posterior circulation stroke Syndromes
Posterior circulation stroke Syndromes
Posterior circulation stroke Syndromes
Posterior circulation stroke Syndromes
Posterior circulation stroke Syndromes
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Posterior circulation stroke Syndromes

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Types of Posterior Circulation Stroke's

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Posterior circulation stroke Syndromes

  1. 1. Posterior circulation stroke syndromes
  2. 2. Differentiating features between anterior and posterior circulation stroke Clinical features Posterior circulation Anterior circulation A.History 1.Vertigo Present Absent 2.Unsteadiness Present Absent B.Physical findings 1.Crossed hemiplegia Present Absent 2.Bilateral deficits Present Absent 3.Cerebellar signs Present Absent 4.Ocular findings(LMN/INO/Gaze deviation to paralysed side) Present Absent 5.Dissociated sensory loss Present Absent 6.Sensory loss over V1 and V2 Present Absent 7.Horners syndrome Present Absent
  3. 3. ANATOMY
  4. 4. • Comprises of: (Tracing from Below Upwards of VertebroBasilar System) 1) Paired vertebral arteries 2) Basilar artery 3) Paired posterior cerebral arteries • Vertebrals join to form basilar at the pontomedullary junction • Basilar divides into two posterior cerebrals in the interpeduncular fossa. • These 3 give rise to long & short circumferential branches and to smaller deep penetrating branches. • Supply: Cerebellum, Medulla, Pons, midbrain, subthalamus, thalamus, hippocampus and medial temporal & occipital lobes POSTERIOR CIRCULATION
  5. 5. VERTEBROBASILAR SYSTEM - Branches • Vertebral Artery • Anterior spinal artery • Posterior spinal artery • Posterior inferior cerebellar artery • Basilar artery • Superior cerebellar artery • Pontine arteries • Anterior inferior cerebellar artery • Posterior cerebral artery • Central - Thalamoperforate arteries & Thalamogeniculate arteries • Choroidal arteries • Callosal • Cortical branches
  6. 6. CIRCLE OF WILLIS – a note
  7. 7. CIRCLE OF WILLIS – a note
  8. 8. Posterior circulation Lateral view
  9. 9. DISCUSSION
  10. 10. Posterior Cerebral Artery:- (PCA) • Terminal branch of the basilar artery • Paired • At the interpeduncular fossa • Branches: • P 1 segment: Proximal PCA prior to junction of PCA with posterior communicating (=Precommunal segment) • Penetrating branches of P1:Thalamogeneculate, Percheron, posterior choroidal) • P 2 segment: Distal PCA (distal to junction of PCA and posterior communicating) PCA
  11. 11. • 75% cases: from bifurcation of basilar artery • 20% cases: One PCA arises from ipsilateral ICA via posterior communicating artery • 5% cases: BOTH PCAs originate from respective ipsilateral ICAs. The P1 segment (precommunal) of the true PCA is atretic in such cases. PCA - ORIGINS
  12. 12. • The artery of Percheron is a rare variant of the posterior cerebral circulation. • The term is used to refer to a solitary arterial trunk that branches from one of the proximal segments of either posterior cerebral artery. • It supplies blood to the paramedian thalami and the rostral midbrain bilaterally. • Percheron infarct: bilateral thalamic and mesencephalic infarctions ; clinically, often obtunded, comatose, or agitated, with associated hemiplegia or hemisensory loss PERCHERON???
  13. 13. • Supplies posterior cranial fossa structures: – Medial area of occipital lobe – Inferior temporal lobe – Midbrain – Thalamus • Lesion causes: – Visual agnosia – Hemianopsia – Alexia – Loss of smell POSTERIOR CEREBRAL ARTERY (PCA)
  14. 14. • Causes: – Atheroma/Emboli @ Basilar – Dissection @ Vertebral – Fibromuscular dysplasia • Two syndromes – P 1 Syndrome – P 2 Syndrome PCA Syndromes:
  15. 15. • Area infarcted: – Ipsilateral subthalamus – Medial thalamus – Ipsilateral cerebral peduncle – Midbrain • Weber’s/Claude’s syndrome can occur • Contralateral hemiballismus +/- • Art. of Percheron occlusion: Upward gaze paresis, drowsiness, abulia P 1 syndrome:
  16. 16. • B/L Prox PCA occlusion: Extensive infarction: – Coma, Unreactive pupils, b/l pyramidal signs, decerebrate rigidity • Penetrating branches of thalamic and thalamogeniculate arteries if occluded: – Less extensive syndromes • Thalamic Dejerine-Roussy syndrome: – Contralateral hemisensory loss – Followed by agonising, searing, burning pain – Persistent, poor response to analgesics – Anticonvulsants (Carbamazepine, gabapentin) & TCAs used. P 1 syndrome… contd:
  17. 17. • Infarction of: – Medial temporal and occipital lobes • Contralateral homonymous hemianopia with macular sparing • Occasional only the upper quadrant is involved. • Dominant medial temporal lobe and hippocampal lesions: Acute disturbances in memory – usually recovers • Alexia without Agraphia • Visual agnosia • Amnestic aphasia • Peduncular hallucinosis P 2 syndrome
  18. 18. • Anton’s blindness • Gun barrel vision • Balint’s syndrome • Palinopsia • Asimultanagnosia • Embolic occulsion of top of basilar: – HALLMARK is sudden onset of bilateral signs, including ptosis, pupillary asymmetry or lack of reaction to light, somnolence. P 2 syndrome… contd:
  19. 19. MID BRAIN
  20. 20. Weber syndrome-occlusion of perforating branch of posterior cerebral artery Clinical features 1.Ipsilateral a.3rd nerve palsy 2.Contralateral a.hemiplegia
  21. 21. Benedikt syndrome-occlusion of perforating branch of posterior cerebral Clinical features 1.Ipsilateral a.3rd nerve palsy 2.Contralateral a.cerebellar ataxia
  22. 22. Thalamus-occlusion of thalamo geniculate branches of posterior cerebral artery Contralateral 1.Sensory loss 2.Spontaneous pain 3.Choreo athetosis 4.Ataxic tremor 5.Mild hemiparesisTHALAMUS
  23. 23. Occipital lobe-optic pathway and visual reflexes
  24. 24. Occipital lobe-occlusion of left calcarine artery Clinical features 1.Right Hemianopia
  25. 25. Occipital lobe-occlusion of both calcarine arteries Clinical features 1.Bilateral hemianopia- cortical blindness (light reflex preserved)
  26. 26. Left occipital lobe with corpus callosum infarction Left Clinical features 1.Right hemianopia 2.Alexia without agraphia
  27. 27. • Commences as the union of both vertebral arteries • Terminates by dividing into two Posterior cerebral arteries. • Branches: – AICA – Pontine arteries – Superior cerebellar artery – PCA BASILAR ARTERY
  28. 28. • Three groups: – Paramedian, 7-10 in number, supply a wedge of pons on either side of midline – Short circumferential, 5-7, supply lateral 2/3rd of Pons, middle & superior cerebellar peduncles. – Bilateral long circumferentials (curve around pons to supply cerebellum): • Superior cerebellar art • Anterior inferior cerebellar art Basilar artery – Branches
  29. 29. Structures supplied by BASILAR
  30. 30. • Complete basilar occlusion – Constellation of bilateral long tract signs (sensory & motor) with signs of cranial nerve & cerebellar dysfunction. • “Locked-in” state: – Preserved consciousness with quadriplegia & cranial nerve signs. Basilar syndromes
  31. 31. Basilar artery occlusion Clinical features 1.Paralysis of all four limbs 2.Bulbar paralysis 3.Eye movements abnormalities 4.Nystagmus 5.Coma Note: The neurological deficit is variable depending upon the ischemia – modifying factors.
  32. 32. • Severe ipsilateral cerebellar ataxia • Nausea & vomitings • Dysarthria • Contralateral loss of pain & temperature over extremities, body & face. • Partial deafness, ataxic tremor of ipsilateral UL, Horner’s syndrome & Palatal myoclonus rare Superior cerebellar artery occlusion
  33. 33. Pons-Lower
  34. 34. Medial pontine syndrome – occlusion of paramedian branch of basilar artery A.IPSILATERAL 1.Gaze paresis 2.Cerebellar signs B.CONTRALATERAL 1.Hemiparesis 2.Hemianaesthesia
  35. 35. Lateral pontine syndrome-occlusion of anterior inferior cerebellar artery A.IPSILATERAL 1.LMN VIIth nerve palsy 2.Gaze palsy 3.Deafness,tinnitus 4.Cerebellar signs B.CONTRALATERAL 1.Impairment of pain and temperature on the body
  36. 36. Vertebral artery
  37. 37. • Commences as a branch of the subclavian on left and brachiocephalic on right and terminates by joining to form the basilar artery • Four parts: – V-1: Preforaminal- origin to entrance into C5 or C6 foramen – V-2: Foraminal- vertebral foramina C6 to C2 – V-3: C2 to dura- passes through transverse foramen and circles around the arch of the atlas to pierce the atlas at the formen magnum – V-4: Intradural-courses upwards and joins other to form basilar. Gives branches that supply BS & cerebellum. VERTEBRAL ARTERY
  38. 38. • Branches: – Anterior spinal artery – Posterior spinal artery – Posterior inferior cerebellar artery VERTEBRAL… contd
  39. 39. • Largest branch of vertebral artery • One of the three major supplies of the cerebellum • Also supplies the lateral medulla • Wallenberg syndrome (=LMS) PICA
  40. 40. • Posterior meningeal branch • Arises from opposite the formen magnum • Supplies Falx cerebri MENINGEAL BRANCHES OF VERTEBRAL a.
  41. 41. • Predilection for V1 and V4 • Usually lesion of one vertebral does not cause TIAs. • TIAs occur if one is atretic and other is developing occlusion. • Symptoms: – Syncope – Vertigo – Alternating hemiplegia – ‘Sets the stage for thrombosis’ • Stenosis proximal to origin of PICA can threaten lateral medulla & posterior inferior surface of cerebellum. ATHEROTHROMBOTIC LESIONS – V1 & V4
  42. 42. • Atheromatous disease is rare. • Fibromuscular dysplasia, dissection  common here • Rarely due to encroachment from osteophytic spurs within vertebral foramina LESIONS OF V2 & V3
  43. 43. • Subclavian occluded proximal to origin of vertebral. • Leads of reversal in the direction of blood flow in the ipsilateral vertebral artery. • Exercise of ipsilateral arm may increase demand on vertebral flow, leading to posterior circulation TIAs. “SUBCLAVIAN STEAL”
  44. 44. Medulla
  45. 45. Lateral medullary syndrome (Wallenberg Syndrome – PICA occlusion) A. IPSILATERAL 1.Xth cranial nerve palsy 2.Cerebellar signs 3.Horner’s syndrome 4.Impaired pain, temperature and touch on the upper half of face B. CONTRA LATERAL 1.Impaired pain and temperature over the body
  46. 46. Medial medullary syndrome – Anterior Spinal Artery occlusion A.IPSILATERAL 1.XIIth nerve palsy B.CONTRALATERAL 1.Hemiplegia – sparing the face 2.Hemianaesthesia sparing the face.
  47. 47. • Can lead to sudden respiratory arrest • Due to raised ICP in the posterior fossa • Symptoms: – Drowsiness – Babinski signs – Dysarthria – Bifacial weakness maybe absent, or present only briefly, before respiratory arrest ensues. – Gait unsteadiness, headache, dizziness, nausea and vomiting maybe the only early symptoms and signs and should arouse suspicion. • D/D: Viral labrynthitis (Headache, neck stiffness & unilateral dysmetria favor stroke) CEREBELLAR INFARCTION
  48. 48. THANK YOU Dr.Karthik Raghavan Postgraduate MD (Int. Med) SRM Medical College & Hospital

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