Details of posterior circulation stroke syndromes for neurology and neurosurgery residents

1. POSTERIOR CIRCULATION
STROKE SYNDROMES
DR SAMEEP KOSHTI

2. (Dejerine’s anterior bulbar
syndrome,
pyramidhypoglossal
syndrome,
alternating hypoglossal
hemiplegia)

9. WEBER SYNDROME
• by occlusion of a branch of the posterior cerebral artery involving
• the oculomotor nerve
• Ipsilateral 3rd nerve palsy
• the crus cerebri :
• Corticospinal tract
• Contralateral paralysis of the arm and leg.
• Corticobulbar tract
• contralateral paralysis of the lower part of the face, the tongue,

10. CLAUDE SYNDROME
• due to involvement of the
• superior cerebellar peduncle
• TREMOR AND
• CONTRALATERAL CEREBELLAR ATAXIA,ASYNERGY,DYSDIADOCHOKINESIS
• ipsilateral third nerve palsy
• Partial

11. BENEDIKT SYNDROME
V 1.0 Snell
• involves the
• medial lemniscus :
• contralateral hemianesthesia
• red nucleus:
• involuntary movements of the limbs of the opposite side.

13. BENEDICT SYNDROME 2.0
DeJong’s
• the lesion is more extensive,
• involving both the tegmentum and the peduncle,
• causing
• Contralateral hemiparesis with
• tremor and contralateral ataxia of the involved limbs;
• Benedikt’s is essentially
• Weber’s + Claude’s
• Because the fascicles of cranial nerve (CN) III are scattered in their course
through the midbrain,
• the third nerve palsy in any of these syndromes may be partial.

14. NOTHNAGEL SYNDROME
• it is more a variant of Parinaud’s syndrome :
• Affect Tectum of Midbrain
• unilateral or bilateral third nerve palsy and
• Contralateral ataxia accompanied by
• vertical gaze deficits and
• other neurologic signs.

15. PERINAUD SYNDROME
• also known as dorsal midbrain syndrome, vertical gaze palsy, and sunset sign,
• is an inability to move the eyes up and down.
• It is caused by compression of the vertical gaze center at the rostral interstitial
nucleus of medial longitudinal fasciculus (riMLF).

16. • Parinaud's syndrome is a cluster of abnormalities of eye movement and pupil dysfunction, characterized by:
• (P U N E Sunset)
1. Paralysis of upwards gaze: Downward gaze is usually preserved. This vertical palsy is supranuclear, so doll's head maneuver should elevate
the eyes, but eventually all upward gaze mechanisms fail.
2. Pseudo-Argyll Robertson pupils: Accommodative paresis ensues, and pupils become mid-dilated and show light-near dissociation.
3. Convergence-retraction nystagmus: Attempts at upward gaze often produce this phenomenon. On fast up-gaze, the eyes pull in and the
globes retract. The easiest way to bring out this reaction is to ask the patient to follow down-going stripes on an optokinetic drum.
4. Eyelid retraction (Collier's sign) Due to Dorsal Midbrain compression
5. Conjugate down gaze in the primary position: "setting-sun sign". Neurosurgeons see this sign most commonly in patients with
failed hydrocephalus shunts.
• It is also commonly associated with bilateral papilledema.
• It has less commonly been associated with
• spasm of accommodation on attempted upward gaze,
• pseudoabducens palsy (also known as thalamic esotropia) or slower movements of the abducting eye than the adducting eye during horizontal saccades,
• see-saw nystagmus and
• associated ocular motility deficits including skew deviation,
• oculomotor nerve palsy: Ptosis Due to Infiltration of dorsal Midbrain ,
• trochlear nerve palsy and
• internuclear ophthalmoplegia.

17. • Argyll Robertson Pupils:
• A lesion in pretectal midbrain area
• would involve efferent pupillary fibres on the dorsal aspect of the Edinger-Westphal nucleus (associated
with the response to light)
• while sparing the fibres associated with the response to near, which lie slightly more ventrally.

19. Medial inferior pontine (Foville Syndrome)
• Structures:
• PRRF;
• CN VI nucleus or fibers;
• MCP;
• CST;
• ML
• Deficit
• Ipsilateral CN VI or horizontal gaze palsy;
• Ipsilateral ataxia.
• Paresis and impaired lemniscal sensation of contralateral limbs
• Lesion:
• Due to occlusion of paramedian perforating vessel.

20. Lateral superior
pontine (SCA syndrome/Mills’ syndrome)
• Structures:
• SCP and MCP;
• LST;
• lateral part of ML;
• superior cerebellar hemisphere
• Deficit:
• Ipsilateral ataxia;
• Horner’s syndrome;
• Skew deviation.
• Contralateral impairment of pain temperature and lemniscal sensation.
• Vertigo;
• dysarthria;
• lateropulsion to side of lesion
• Lesion:
• Due to occlusion of superior cerebellar or distal basilar artery.

21. Lateral inferior pontine (AICA syndrome)
• Structures:
• CN VII nucleus or fibers;
• CN VIII nuclei;
• MCP;
• ICP;
• CST;
• principal and spinal nucleus of CN V;
• LST:
• ST;
• flocculus and inferior surface of cerebellar hemisphere
• Deficit:
• Ipsilateral
• cerebellar ataxia;
• loss of pain and temperature sensation and
• diminished light touch sensation; of face;
• impaired taste sensation;
• central Horner’s syndrome;
• deafness;
• peripheral type of facial palsy.
• Loss of pain and temperature sensation of contralateral limbs.
• Lesion:
• Due to occlusion of anterior inferior cerebellar artery