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Stroke syndromes
1. The document describes various large vessel stroke syndromes involving the anterior and posterior circulations. Anterior circulation strokes can affect the internal carotid, anterior cerebral, or middle cerebral artery territories and cause symptoms like weakness or sensory loss on one side of the body. 2. Posterior circulation strokes involving the vertebral, basilar, or posterior cerebral arteries can cause visual field defects, memory problems, or lateral medullary syndrome with dizziness and sensory loss on one side of the face and trunk. 3. Small deep strokes in the pons, internal capsule, or thalamus can cause pure motor, sensory, or sensorimotor deficits localized to one side of the body.
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Stroke syndromes
- 1. STROKE SYNDROMES prepared bydr.siruhan
- 2. Circle of Willis •Anteriorcirculation- MCA, ACA, and Anterior choroidal artery •Posterior circulation- Vertebral artery, Basilar artery and Posterior cerebral artery
- 4. Large vessel strokesyndromes (anterior circulation)– assuming left hemispheric dominance Vascular territory Signs and Symptoms Internal Carotid Artery - Combined ACA + MCA - Ipsilateral monocular visual loss ( amurosis) secondary to CRAO Left ACA - Right leg numbness and weakness - Transcortical motor aphasia - Ideomotor apraxia Right ACA - Let leg numbess and weakness - Motor neglect - Possibly ideomotor apraxia Left MCA - Right face/arm > leg numbness and weakness - Aphasia - Left gaze preference Right MCA - Left face/arm > leg numbness and weakness - Left hemispatial neglect - Right gaze preference - Agraphesthesia / astereoagnosia
- 5. • Gerstmann syndrome •Acalculia • Right – left confusion • Finger agnosia • Ideomotor apraxia • Agraphia • Dominant parietal lobe lesions, involving inferior parietal lobule
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- 7. • Motor/Broca aphasia– localized to posterior inferior frontal lobe • Sensory/Wernicke’s aphasia – posterior superior temporal/inferior parietal
- 8. Lacunar syndromes; Syndrome Signs/SymptomsLocalization Vascular supply Pure motor Contralesional hemiparesis - Internal capsule – posterior limb - Corona radiata - Basis pontis -Lenticulostriate branches of the MCA or -perforating arteries from basilar artery Pure sensory Contralesional hemisensory loss - VPL nucleus of thalamus - Lenticulostriate branches of MCA - Small thalamoperforat ors of PCA Sensorimotor Contralesional weakness and numbess - Thalamus and adjacent posterior limb of internal capsule - Lenticulostriate branches of MCA
- 9. Lacunar syndromes…contn. Syndrome Signs/SymptomsLocalization Vascular supply Dysarthia-clumsy hand Slurred speech and weakness of contralateral hand (fine motor) - Basis pontis ( between rostral 1/3rd and caudal 2/3rd ) - Basillar artery perforators Ataxia- hemiparesis Contralesional Hemiparesis and ataxia out of proportion to weakness - Internal capsule- posterior limb - Basis pontis - Lenticulostritae branches of MCA - Perforating arteries of basilar artery Hemiballismus/ Hemichorea Contralesional limb flailing / dyskinesis - Subthalamic nucleus - Perforating arteries of anterior choroidal or PCOM
- 10. •Lacunar strokes presentwith fluctuating symptoms – “ capsular warning syndrome” •Often thromolysis withheld due to “ rapidly improving symptoms”
- 11. OCSP – Oxfordshirecommunity stroke project classification •TAC – Total anterior circulation stroke •LAC – lacunar stroke •PAC – Partial anterior circulation stroke •POC- Posterior circulation stroke I – Infarct ; S – syndrome ; H - hemorhage
- 12. TAC ( Totalanterior circulation) •Combination of •New, higher cerebral dysfunction ( eg.dysphasia) •Homonymous visual field defect •Ipsilateral motor or sensory deficit of atleast two areas out of face, arm and leg.
- 13. PAC – PartialAnterior Circulation •No drowsiness •2 of 3 criteria of TAC •OR Higher cerebral dysfunction alone •OR Motor/Sensory deficit more restricted than those defined by LAC (eg. confined to one limb)
- 14. POC – Posteriorcirculation Any of; • Affecting brainstem / cerebellar or occipital • Ipsilateral CN palsy with contralateral motor/sensory signs • B/L motor and/or sensory deficit • Disorders of conjugate eye movement • Cerebellar dysfunction without ipsilateral long tract signs • Isolated homonymous visual field defect
- 15. Anterior circulation- Middlecerebral Artery M1 segment(proximal)- •deep penetrating or lenticulostriate branches •Supply - Internal capsule, caudate nuclues, putamen and outer pallidus
- 16. M2 Segment •M2(distal)- superiorand inferior divisions- •the entire superolateral surface of frontal and parietal lobe except frontal pole, strip along the superomedial frontal and parietal cortex, occipital lobe convolutions and medial temporal cortex
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- 19. Complete MCA syndrome •Contralateralhemiplegia •Contralateral hemianaesthesia •Contralateral homonymous hemianopia •Gaze preference to the ipsilateral side •If dominant hemisphere involved-Global aphasia •If non dominant hemisphere involved- Hemispatial neglect, anasognosia and constructional apraxia
- 20. Partial syndromes •M1 syndrome-occlusionof lenticulostriate branches- •If ischemia of internal capsule produces pure motor or sensorymotor stroke contralateral to the side of lesion •If ischemia of putamen, pallidus- predominantly parkinsonian features
- 21. M2 syndromes •If superiordivision involved •Brachial syndrome- weakness of hand and arm •Frontal opercular syndrome-Brocas aphasia with facial weakness with or without arm weakness •proximal part of the superior division involved- clinical features of motor weakness, sensory disturbances and brocas aphasia
- 22. M2 syndrome •If inferiordivision of M2 involved- •If dominant hemisphere- Wernickes aphasia without weakness with contralateral homonymous superior quadrantanopia •If non dominant hemisphere- Hemispatial neglect , spatial agonosia without weakness
- 23. Anterior Cerebral artery •A1segment- from internal carotid to anterior communicating artery- branches to anterior limb of internal capsule, anteroinferior caudate, anterior hypothalamus •A2 segment-distal to anterior communicating artery- supplies frontal pole, entire medial part of cerebral hemispheres
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- 25. Post communal A2segment
- 26. A1 segment •A1 segmentocclusion rarely produces clinical syndrome because collateral flow through anterior communicating artery and collaterals from MCA and PCA
- 27. A2 syndrome •Motor areafor leg and foot-c/l paralysis of foot and leg •Sensory area for foot and leg-c/l cortical sensory loss of foot and leg •Sensorimotor area in paracentral lobule- urinary incontinence •Medial surface of posterior frontal lobe-c/l grasp and suckling reflex •Cingulate gyrus and the medial inferior portions of frontal, parietal and temporal lobes-abulia
- 28. Anterior choroidal artery •Suppliesposterior limb of internal capsule, retrolentiform and sublentiform parts •Complete syndrome rare due to collaterals from MCA, PCA, and ICA •Syndrome comprises •c/l hemiplegia •c/l hemianaesthesia •c/l homonymous hemianopia
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- 30. Posterior circulation •Cerebellum •Medulla •Pons •Midbrain •Thalamus •Subthalamus •Hippocampus •Medial partof temporal lobe •Occipital lobe
- 31. Stroke within thePosterior Circulation • Posterior Cerebral Artery • result from atheroma formation or emboli that lodge at the top of the basilar artery • May also be caused by dissection of the vertebral artery or fibromuscular dysplasia
- 32. Posterior Cerebral Artery •P1 syndrome : midbrain, subthalamic, and thalamic signs, which are due to disease of the proximal P1 segment of the PCA or its penetrating branches • P2 syndrome: cortical temporal and occipital lobe signs, due to occlusion of the P2 segment distal to the junction of the PCA with the posterior communicating artery.
- 33. Posterior Cerebral Artery •P1 Syndromes Syndrome Clinical features Localization Claude’s syndrome 3rd nerve palsy + contralateral ataxia Rednucleus / cerebral peduncle Weber’s syndrome 3rd nerve palsy + hemiplegia Medial mid brain / cerebral peduncle Benedikt’s syndrome 3rd Nerve palsy + hemiplegia + Ataxia Rednucleus / Medial mid brain Subthalamic nucleus Contralateral hemiballismus thalamic Déjerine-Roussy syndrome contralateral hemisensory loss and agonizing pain thalamus
- 35. Posterior Cerebral Artery- P2 Syndromes • Occulsion of the PCA causes infarction of the medial temporal and occipital lobes • Contralateral homonymous hemianopia with macula sparing is the usual manifestation • Acute disturbance in memory (hippocampus) • peduncular hallucinosis - visual hallucinations of brightly colored scenes and objects • Infarction in the distal PCAs produces cortical blindness (blindness with preserved pupillary light reflex) • Anton's syndrome – unaware of blindness and in denial
- 36. Cerebellar stroke syndromes TerritorySigns and symptoms Extracerebellar structures Extracerebellar signs and symptoms Superior cerebellar artery Ipsilesional limb and gait ataxia Midbrain, Thalamus, occipital lobes Top of the basilar syndrome Posterior Inferior Cerebellar artery Ipsilesional limb and gait ataxia Dorsolateral medulla Wallenberg’s syndrome Anterior inferior Cerebellar artery Vertigo ipsilesional deafness Lateral pons Contralateral facial weakness, numbness and hearing loss
- 37. Lateral medullary syndrome(Wallenburgs) ModalityLocalization Symptoms Vestibulocerebellar - Vestibular nuclei and connections - Inferior Cerebellar peduncle ( Restiform body) - Dizziness and imbalance - Tendency to fall to side of lesion - Hypotonia ipsilateral side - Diplopoia/ osscilospia - Nystagmus - ocular tilt reaction - Limb ataxia Sensory - Spinal nucleus of CN V - Spinothalamic tract - Loss of pain and temperature sensation in ipsilateral face - Loss of pain and temperature contraletral trunk Bulbar muscle weakness - Nucleus ambiguous (CN 9 and 10) - ipsilateral palate, pharynx, and larynx Autonomic - Descending sympathetic fibers - Dorsomotor nucleus of vagus - Ipsilateral Horner’s syndrome - Autonomic signs – labile BP/ tachycardia / sweating /arrythmias Respiratory - Ventrolateral medullary tegmentum and the medullary reticular zone. (Respiratory centres) - Failure of automatic respirations
- 39. Medial medullary syndrome(Dejerine syndrome) Motor symptoms - Pyramidal tract - Contraletral hemiparesis - Up to 50% facial weakness contraletral Sensory symptoms - Medial lemniscus - Paresthesias ( most often no clinical signs) - Proprioception / vibration - rarely may be lost in the contraletral foot 12th nerve paralysis – least common feature - Hypoglossal nucleus - Tongue paresis - Dysarthria – especially lingual consonants Hemimedullary infarction – • Involve both lateral and medial medulla • Lateral medullary syndrome + contralateral hemiparesis
- 40. Basilar Artery • Ariseat the junction of paired vertebral arteries. •Begins at medullopontine junction, ends at junction of pons and midbrain •Main blood supply of pons
- 42. Blood supply ofpons A) Large paired median arteries. B) Paramedian arteries lying slightly laterally. C) Arteries that branch at a right angle from the long circumferential artery
- 43. • Pontine syndromes– caused by occlusion of deep or circumferential pontine penetrating arteries • Dorsal portion or tegmentum - VI th nerve palsy • Horizontal gaze palsy and dysarthria • Pupils constricted as a result of involvement of descending sympathetic pupillodilator fibres. • Hemiplegia or quadriplegia often present • INO – involvement of MLF • Locked – in Syndrome • ventral pons (basis pontis) infarction with intact tegmentum • All motor and sensory tracts involved • Intact vertical gaze and spared consciousness – intact reticular activating system and vertical gaze centers. • Top of basilar syndrome • superior most part of basilar artery occlusion • Involves – Thalamus, Midbrain, occipital lobes, cerebellum (Superior cerebellar artery) • Visual, occulomotor, behavioral features,
- 44. Lateral Pontine Syndrome(Marie-Foix Syndrome) • Blood vessels – • Basilar artery; Long circumferential branches • Anterior inferior cerebellar artery Tracts Manifestation Side Cerebellar – Middle cerebellar peduncle Ataxia – arm and leg Ipsilateral Corticospinal tracts Hemiparesis contralateral Spinothalamic tract Hemisensory loss Contraletral
- 45. Ventral Pontine Syndrome(Raymond syndrome) • Blood vessels – • Basilar artery: Paramedian branches Tracts Manifestation Side CN VI Lateral gaze palsy Ipsilateral Corticospinal tracts Hemiparesis contralateral
- 46. Ventral Pontine Syndrome(Millard-Gubler Syndrome) • Blood vessels – • Basilar artery; Long circumferential branches • Basilar artery: Paramedian branches Tracts Manifestation Side CN VII Facial palsy Ipsilateral CN VI Lateral gaze palsy Ipsilateral Corticospinal tracts (basis pontis) Hemiparesis contralateral
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