Stroke Syndromes

1. MCA & ACA
Syndromes
Patrick M. Yalung, MD, MBA, FPNA
November 16, 2021

2. Pre-Test

3. Pre-Test
1. Identify Artery involved:
a. Lateral Lenticulostriate
b. Recurrent Artery of Heubner
c. MCA, leptomeningeal branch
d. MCA, superior division
e. MCA, parasylvian

4. Pre-Test
2. Identify Artery involved:
a. Lateral Lenticulostriate
b. Recurrent Artery of Heubner
c. MCA, leptomeningeal branch
d. MCA, superior division
e. MCA, parasylvian

5. Pre-Test
3. Identify Artery involved:
a. Lateral Lenticulostriate
b. Recurrent Artery of Heubner
c. MCA, leptomeningeal branch
d. MCA, superior division
e. MCA, parasylvian
Clue: Foix-Chavany-Marie Syndrome

6. Pre-Test
4. Identify Artery involved:
a. Lateral Lenticulostriate
b. Recurrent Artery of Heubner
c. MCA, leptomeningeal branch
d. MCA, superior division
e. MCA, parasylvian

7. Pre-Test
5. Identify Artery involved:
a. Lateral Lenticulostriate
b. Recurrent Artery of Heubner
c. MCA, leptomeningeal branch
d. MCA, superior division
e. MCA, parasylvian

8. References:
1. Park, H., Jeong, Y. S., Lee, S. H., Jang, S. H., Kwon, D. H.,
Hong, J.-H., Sohn, S.-I., & Yoo, J. (2021). Clinical
prognosis of isolated anterior cerebral artery territory
infarction: a retrospective study. In BMC Neurology
(Vol. 21, Issue 1). Springer Science and Business Media
LLC.
2. Odier, C., & Michel, P. (2019). Common Stroke
Syndromes. In Textbook of Stroke Medicine (pp. 169–
181). Cambridge University Press.
3. Heiss, W.-D. (2015). Malignant MCA Infarction:
Pathophysiology and Imaging for Early Diagnosis and
Management Decisions. In Cerebrovascular Diseases
(Vol. 41, Issues 1–2, pp. 1–7). S. Karger AG.
4. Harrigan, M. R., & Deveikis, J. P. (2012). Essential
Neurovascular Anatomy. In Handbook of
Cerebrovascular Disease and Neurointerventional
Technique (pp. 3–98). Humana Press.
5. González Delgado, M., & Bogousslavsky, J. (2012).
Superficial Middle Cerebral Artery Territory Infarction.
In Frontiers of Neurology and Neuroscience (pp. 111–
114). KARGER.

9. Middle Cerebral Artery
(MCA)
• Supplies most of the temporal lobe,
anterolateral frontal lobe,
and parietal lobe
Harrigan, M. R., & Deveikis, J. P. (2012). Essential Neurovascular Anatomy. In Handbook of Cerebrovascular Disease and Neurointerventional Technique (pp. 3–98). Humana Press.

10. Middle Cerebral Artery
(MCA)
Harrigan, M. R., & Deveikis, J. P. (2012). Essential Neurovascular Anatomy. In Handbook of Cerebrovascular Disease and Neurointerventional Technique (pp. 3–98). Humana Press.

11. Middle Cerebral Artery
(MCA)
• 4 segments:
o M1 (Sphenoidal/Horizontal)—
ICA to bifurcation (or trifurcation)
o M2 (Insular)—MCA bifurcation to
circular sulcus of the insula
o M3 (Opercular)—circular sulcus
to superficial aspect of the
sylvian fissure
o M4 (Cortical)—cortical branches
Harrigan, M. R., & Deveikis, J. P. (2012). Essential Neurovascular Anatomy. In Handbook of Cerebrovascular Disease and Neurointerventional Technique (pp. 3–98). Humana Press.

12. M1 Sphenoidal/Horizontal
• from ICA, travels laterally,
parallel to the sphenoid wing
• 16 mm in length
• usually twice the size of the A1
• terminates into the M2
segments:
o bifurcates (71%)
o trifurcates (20%)
o four branches (9%)
Harrigan, M. R., & Deveikis, J. P. (2012). Essential Neurovascular Anatomy. In Handbook of Cerebrovascular Disease and Neurointerventional Technique (pp. 3–98). Humana Press.

13. M1 Sphenoidal/Horizontal
• Branches:
1. Lateral lenticulostriate
2. Anterior temporal artery
Harrigan, M. R., & Deveikis, J. P. (2012). Essential Neurovascular Anatomy. In Handbook of Cerebrovascular Disease and Neurointerventional Technique (pp. 3–98). Humana Press.

14. Lateral Lenticulostriate
• 80% arise from superior aspect
of M1 segment
• average 10 in number
• enter the anterior perforated
substance to supply the
anterior commissure, internal
capsule, caudate nucleus,
putamen, globus pallidus, and
substantia innominata
Harrigan, M. R., & Deveikis, J. P. (2012). Essential Neurovascular Anatomy. In Handbook of Cerebrovascular Disease and Neurointerventional Technique (pp. 3–98). Humana Press.

15. Anterior Temporal
• arises near the midpoint of the M1
segment
• Less commonly, it arises from the
inferior division of M2 or as part of
an M1 trifurcation
• travels anteriorly and inferiorly over
the temporal tip and does not enter
the sylvian
• supplies the anterior temporal lobe
Harrigan, M. R., & Deveikis, J. P. (2012). Essential Neurovascular Anatomy. In Handbook of Cerebrovascular Disease and Neurointerventional Technique (pp. 3–98). Humana Press.

16. M2 Insular
• from the main division point of
the M1
• over the insula within the sylvian
fissure, and terminate at the
circular sulcus of the insula
• divisions are equal in size (18%)
• superior division dominant
(28%)
• inferior division dominant (32%)
Harrigan, M. R., & Deveikis, J. P. (2012). Essential Neurovascular Anatomy. In Handbook of Cerebrovascular Disease and Neurointerventional Technique (pp. 3–98). Humana Press.

17. M2 Insular
• cortical area supplied
o superior division—
orbitofrontal area to the
posterior parietal area
o inferior division—temporal
pole to the angular area
• 6-8 arteries at the point of
transition into the M3 segments
Harrigan, M. R., & Deveikis, J. P. (2012). Essential Neurovascular Anatomy. In Handbook of Cerebrovascular Disease and Neurointerventional Technique (pp. 3–98). Humana Press.

18. M3 Opercular
• begin at the circular sulcus
• end at the surface of the
sylvian fissure
• give rise to the 8 stem arteries
which in turn give rise to 1-5
the cortical branches
Harrigan, M. R., & Deveikis, J. P. (2012). Essential Neurovascular Anatomy. In Handbook of Cerebrovascular Disease and Neurointerventional Technique (pp. 3–98). Humana Press.

19. M4 Cortical
• begin at the surface of the
sylvian fissure and extend over
the surface of the cerebral
hemisphere
• smallest arise from the
anterior; largest ones emerge
from posterior sylvian fissure
• 12 subdivision system—
actually exist as several
branches (up to 5) from a
single stem artery
Harrigan, M. R., & Deveikis, J. P. (2012). Essential Neurovascular Anatomy. In Handbook of Cerebrovascular Disease and Neurointerventional Technique (pp. 3–98). Humana Press.

20. M4 Cortical
Superior division
o Lateral Orbitofrontal
o Prefrontal
o Precentral
o Central
Inferior division
o Temporopolar
o Temporo-occipital
o Angular
o Anterior Temporal
o Middle Temporal
o Posterior Temporal
Dominant division
o Anterior Parietal
o Posterior Parietal
Harrigan, M. R., & Deveikis, J. P. (2012). Essential Neurovascular Anatomy. In Handbook of Cerebrovascular Disease and Neurointerventional Technique (pp. 3–98). Humana Press.

21. MCA Territory Infarction
• 2/3 of all ischemic stroke occurs
in the MCA territory
• can be subtle or devastating
clinical syndrome, depending on
site of occlusion, the extent of
ischemia, etiology, and collateral
arterial network
• Involves—frontal, temporal,
parietal, basal ganglia
Odier, C., & Michel, P. (2019). Common Stroke Syndromes. In Textbook of Stroke Medicine (pp. 169–181). Cambridge University Press.

22. MCA Territory Infarction
• Large infarcts—involvement of
2 of the 3 MCA territories
(deep, superior, and inferior
divisions)
• Malignant MCA stroke—
complete or near complete
MCA territory infarction with
ensuing mass effect from brain
edema
Odier, C., & Michel, P. (2019). Common Stroke Syndromes. In Textbook of Stroke Medicine (pp. 169–181). Cambridge University Press.

23. MCA Territory Infarction
Left hemisphere Right hemisphere
• Right hemiparesis—Variable
involvement of face, arm, leg
• Right-sided sensory loss—pattern
similar to motor deficit, usually
involves all modalities, decreased
stereognosis, agraphesthesia, left-
right confusion
• Right homonymous hemianopia
• Dysarthria
• Aphasia, fluent and non-fluent
• Alexia, Agraphia, Acalculia, Apraxia
• Left hemiparesis
• Left-sided sensory loss
• Left homonymous hemianopia
• Dysarthria
• Neglect of the left side of
environment
• Anosognosia
• Asomatognosia
• Loss of prosody of speech
• Flat affect
Odier, C., & Michel, P. (2019). Common Stroke Syndromes. In Textbook of Stroke Medicine (pp. 169–181). Cambridge University Press.

24. MCA Superior Division
Infarction
• one of the most common
locations of embolic stroke,
either from proximal arterial
source or from the heart
• contralateral hemiparesis—face,
arm > leg
• contralateral hemisensory loss
MRI T2 FLAIR—prominent bright signal affecting the left frontal
lobe above the Sylvian fissure
Odier, C., & Michel, P. (2019). Common Stroke Syndromes. In Textbook of Stroke Medicine (pp. 169–181). Cambridge University Press.

25. MCA Superior Division
Infarction
• contralateral visual field deficit
predominantly affecting the
lower fields (pie on the floor)
• gaze preference to the ipsilateral
side
• Left-sided infarct—expressive
(Broca’s) aphasia
• Right-sided infarct—neglect
Odier, C., & Michel, P. (2019). Common Stroke Syndromes. In Textbook of Stroke Medicine (pp. 169–181). Cambridge University Press.

26. MCA Inferior Division
Infarction
• less commonly affected by
emboli than the superior
division
• do NOT cause any weakness
or sensory loss
• misdiagnosed initially as
primary psychiatric disorder Cranial CT scan—3 days post ictus; large lesion in the left temporal
and posterior parietal lobes
Odier, C., & Michel, P. (2019). Common Stroke Syndromes. In Textbook of Stroke Medicine (pp. 169–181). Cambridge University Press.

27. MCA Inferior Division
Infarction
• contralateral visual field deficit
predominantly affecting the upper
fields (pie in the sky)
• Left-sided infarct—receptive
(Wernicke's) aphasia
• Right-sided infarct—neglect,
constructional and clothing
dyspraxia, spatial disorientation,
behavioral changes, impairment of
visuospatial skills
Odier, C., & Michel, P. (2019). Common Stroke Syndromes. In Textbook of Stroke Medicine (pp. 169–181). Cambridge University Press.

28. MCA Proximal Segment
Infarction
• affect the:
o superior division
o inferior divisions
o lenticulostriates
• contralateral hemiplegia—face,
arm, and leg
o leg is plegic as well due to
involvement of
lenticulostriates which supply
the internal capsule Cranial CT scan—3 days post ictus; hypodensity involving
distribution of entire MCA as well as deeper basal ganglia
Odier, C., & Michel, P. (2019). Common Stroke Syndromes. In Textbook of Stroke Medicine (pp. 169–181). Cambridge University Press.

29. MCA Proximal Segment
Infarction
• contralateral hemisensory loss
• contralateral visual field deficit
• ipsilateral conjugated eye and
head deviation
• Awake or with mild
drowsiness/agitation
Odier, C., & Michel, P. (2019). Common Stroke Syndromes. In Textbook of Stroke Medicine (pp. 169–181). Cambridge University Press.

30. MCA Proximal Segment
Infarction
• Left-sided infarct—global
aphasia, ideomotor apraxia
• Right-sided infarct—neglect
syndrome, anosognosia,
asomatognosia, impairment of
visuospatial skills
Odier, C., & Michel, P. (2019). Common Stroke Syndromes. In Textbook of Stroke Medicine (pp. 169–181). Cambridge University Press.

31. Malignant MCA Infarction
• annual incidence 10–20 per 100,000
• females > men
• younger patients are more
susceptible
• brain edema  high ICP 
herniation
• deterioration typically within
48–72 hours
• death in up to 80% within the first
week
Odier, C., & Michel, P. (2019). Common Stroke Syndromes. In Textbook of Stroke Medicine (pp. 169–181). Cambridge University Press.

32. Malignant MCA Infarction
• new cortical symptoms may occur
because of infarction of ACA or PCA
which become compressed against
interhemispheric falx and cerebellar
tentorium
• Uncal herniation  ipsilateral fixed
mydriasis and ipsilateral corticospinal
signs (Kernohan’s notch
phenomenon)
• bilateral ptosis, headache, vomiting,
papilledema, decreasing sensorium
Odier, C., & Michel, P. (2019). Common Stroke Syndromes. In Textbook of Stroke Medicine (pp. 169–181). Cambridge University Press.

33. Superficial/Parasylvian
MCA Infarction
• Affects distal MCA, at the
bifurcation, sparing the
lenticulostriate arteries
• Contralateral weakness of face
and arm
• Contralateral hemisensory loss on
face and arm
• Contralateral homonymous
hemianopia or a quadrantanopsia
Odier, C., & Michel, P. (2019). Common Stroke Syndromes. In Textbook of Stroke Medicine (pp. 169–181). Cambridge University Press.
González Delgado, M., & Bogousslavsky, J. (2012). Superficial Middle Cerebral Artery Territory Infarction. In Frontiers of Neurology and Neuroscience (pp. 111–114). KARGER.

34. Superficial/Parasylvian
MCA Infarction
• Deviation of the head and the
eyes is more transitory
• Cognitive deficit less pronounced
or rapidly improving
• Left-sided infarct—conduction
aphasia, apraxia, Gerstmann
syndrome
• Right-sided infarct—
constructional apraxia
Odier, C., & Michel, P. (2019). Common Stroke Syndromes. In Textbook of Stroke Medicine (pp. 169–181). Cambridge University Press.
González Delgado, M., & Bogousslavsky, J. (2012). Superficial Middle Cerebral Artery Territory Infarction. In Frontiers of Neurology and Neuroscience (pp. 111–114). KARGER.

35. Superficial/Parasylvian
MCA Infarction
• Opercular Syndrome (Foix-
Chavany-Marie Syndrome)
o pseudobulbar palsy with
bilateral insular lesions
o dysarthria, dysphagia and
dysphonia due to disruption
of cortical inputs to CN V, VII
and IX from the insular
cortex
Odier, C., & Michel, P. (2019). Common Stroke Syndromes. In Textbook of Stroke Medicine (pp. 169–181). Cambridge University Press.
González Delgado, M., & Bogousslavsky, J. (2012). Superficial Middle Cerebral Artery Territory Infarction. In Frontiers of Neurology and Neuroscience (pp. 111–114). KARGER.

36. Lenticulostriate Infarction
• Can have severe deficits with
small lesion
• Cortical signs are absent or
minor due to interruption of
subcortical–cortical pathways
• Hemiparesis
• Hemihypesthesia
• Dysarthria
• Abnormal movements
Odier, C., & Michel, P. (2019). Common Stroke Syndromes. In Textbook of Stroke Medicine (pp. 169–181). Cambridge University Press.

37. Leptomeningeal Branch
Infarction
• Involvement of M3 or M4
branches
• produce highly circumscribed
infarcts accompanied by specific
neurological deficits
• most of the time related to
embolism Cranial CT scan—3 days post ictus
wedge shaped infarct in distribution of MCA branch
involving the right posterior frontal area
Odier, C., & Michel, P. (2019). Common Stroke Syndromes. In Textbook of Stroke Medicine (pp. 169–181). Cambridge University Press.

38. Leptomeningeal Branch
Infarction
• Involvement of M3 or M4
branches
• produce highly circumscribed
infarcts accompanied by specific
neurological deficits
• most of the time related to
embolism
Odier, C., & Michel, P. (2019). Common Stroke Syndromes. In Textbook of Stroke Medicine (pp. 169–181). Cambridge University Press.
MRI T2 FLAIR
Hyperintensity in the distribution of MCA branch
involving left inferior frontal area which resulted in
expressive aphasia

39. Anterior Cerebral Artery
(ACA)
Harrigan, M. R., & Deveikis, J. P. (2012). Essential Neurovascular Anatomy. In Handbook of Cerebrovascular Disease and Neurointerventional Technique (pp. 3–98). Humana Press.
• Medial and superior parts of frontal,
anterior parietal lobes

40. Anterior Cerebral Artery
(ACA)
• 3 segments:
o A1 (Pre-communicating/
Horizontal)—from ICA to
Acomm
o A2 (Post-communicating/
Vertical)—from Acomm to
origins of the pericallosal and
supramarginal arteries
o A3 (Cortical)—distal branches
Harrigan, M. R., & Deveikis, J. P. (2012). Essential Neurovascular Anatomy. In Handbook of Cerebrovascular Disease and Neurointerventional Technique (pp. 3–98). Humana Press.

41. A1 Pre-Communicating/Horizontal
Harrigan, M. R., & Deveikis, J. P. (2012). Essential Neurovascular Anatomy. In Handbook of Cerebrovascular Disease and Neurointerventional Technique (pp. 3–98). Humana Press.
• extends from the ICA
bifurcation to its junction with
Acomm within or inferior to the
interhemispheric fissure
• superior to optic chiasm inferior
to the anterior perforated
substance
• 4.0 mm in length

42. A1 Pre-Communicating/Horizontal
Harrigan, M. R., & Deveikis, J. P. (2012). Essential Neurovascular Anatomy. In Handbook of Cerebrovascular Disease and Neurointerventional Technique (pp. 3–98). Humana Press.
• asymmetric in up to 80%
• Right A1 tends to be longer, more
tortuous, and narrow
• 10% are hypoplastic
• 1-2% are absent on one side

43. Acomm Complex
Harrigan, M. R., & Deveikis, J. P. (2012). Essential Neurovascular Anatomy. In Handbook of Cerebrovascular Disease and Neurointerventional Technique (pp. 3–98). Humana Press.
• highly variable
• four main patterns:
o single or duplicated Acomm
forms a bridge between the
ACAs
o A large branch arises from
the Acomm
o Acomm is not present—ACAs
join together directly
o Azygos ACA

44. A1 and Acomm Branches
Harrigan, M. R., & Deveikis, J. P. (2012). Essential Neurovascular Anatomy. In Handbook of Cerebrovascular Disease and Neurointerventional Technique (pp. 3–98). Humana Press.
• A1 Perforating Branches
1. Superior branches—Medial
Lenticulostriate
2. Inferior branches
• Acomm Perforating Branches
• Recurrent artery of Heubner

45. A1 Perforating Branches
Harrigan, M. R., & Deveikis, J. P. (2012). Essential Neurovascular Anatomy. In Handbook of Cerebrovascular Disease and Neurointerventional Technique (pp. 3–98). Humana Press.
• Superior branches—Medial
Lenticulostriate
o 2–15 branches
o supply the anterior
hypothalamus, septum
pellucidum, anterior
commissure, fornix, and anterior
striatum
• Inferior branches
o supply the optic chiasm and
optic nerves

46. Acomm Perforating Branches
Harrigan, M. R., & Deveikis, J. P. (2012). Essential Neurovascular Anatomy. In Handbook of Cerebrovascular Disease and Neurointerventional Technique (pp. 3–98). Humana Press.
Najera, E., Alves Belo, J. T., Truong, H. Q., Gardner, P. A., & Fernandez-Miranda, J. C. (2018). Surgical Anatomy of the Subcallosal Artery: Implications for Transcranial and Endoscopic Endonasal Surgery in the Suprachiasmatic
Region. In Operative Neurosurgery (Vol. 17, Issue 1, pp. 79–87). Oxford University Press (OUP). https://doi.org/10.1093/ons/opy276
• Subcallosal
o single, largest
o supplies the septum pellucidum, columns of the fornix,
corpus callosum and lamina terminalis
• Hypothalamic
o smaller and multiple
• Chiasmatic
o present only in 20%

47. A2 Post-Communicating/Vertical
Harrigan, M. R., & Deveikis, J. P. (2012). Essential Neurovascular Anatomy. In Handbook of Cerebrovascular Disease and Neurointerventional Technique (pp. 3–98). Humana Press.
• travels in a vertical direction to its
division into the pericallosal and
callosomarginal arteries
• anterior to the genu of corpus
callosum
• 43 mm
• travel in the interhemispheric
fissure
• right A2 is more often (72%)
anterior to the left A2

48. A2 Branches
Harrigan, M. R., & Deveikis, J. P. (2012). Essential Neurovascular Anatomy. In Handbook of Cerebrovascular Disease and Neurointerventional Technique (pp. 3–98). Humana Press.
• A2 Perforators
• Recurrent artery of Heubner
• Orbitofrontal Artery
• Frontopolar Artery

49. A2 Perforators
Harrigan, M. R., & Deveikis, J. P. (2012). Essential Neurovascular Anatomy. In Handbook of Cerebrovascular Disease and Neurointerventional Technique (pp. 3–98). Humana Press.
• along the first 5 mm of the
segment
• penetrate the gyrus rectus and
olfactory sulcus

50. Recurrent Artery of Heubner
Harrigan, M. R., & Deveikis, J. P. (2012). Essential Neurovascular Anatomy. In Handbook of Cerebrovascular Disease and Neurointerventional Technique (pp. 3–98). Humana Press.
• a large lenticulostriate artery
• doubles back and runs in the
opposite direction to the A1
segment to enter the lateral
anterior perforated substance
lateral to the ICA bifurcation

51. Recurrent Artery of Heubner
Harrigan, M. R., & Deveikis, J. P. (2012). Essential Neurovascular Anatomy. In Handbook of Cerebrovascular Disease and Neurointerventional Technique (pp. 3–98). Humana Press.
• arise from:
o A2 branch (57-78%)
o A1 (17-45%)
o ACA-Acomm junction (35%)

52. Recurrent Artery of Heubner
Harrigan, M. R., & Deveikis, J. P. (2012). Essential Neurovascular Anatomy. In Handbook of Cerebrovascular Disease and Neurointerventional Technique (pp. 3–98). Humana Press.
• Supplies head of the caudate
nucleus, genu and anterior limb of
the internal capsule, anterior third
of the putamen

53. Orbitofrontal Artery
Harrigan, M. R., & Deveikis, J. P. (2012). Essential Neurovascular Anatomy. In Handbook of Cerebrovascular Disease and Neurointerventional Technique (pp. 3–98). Humana Press.
• First cortical branch of the
A2 segment
• 2-3 vessels
• runs close to the midline in
an anterior direction to the
gyrus rectus, olfactory bulb,
and medial aspect of the
inferior frontal lobe

54. Frontopolar Artery
Harrigan, M. R., & Deveikis, J. P. (2012). Essential Neurovascular Anatomy. In Handbook of Cerebrovascular Disease and Neurointerventional Technique (pp. 3–98). Humana Press.
• may also appear as a group of
vessels
• arises from distal A2
segment, below the corpus
callosum
• travels anteriorly and
superiorly towards the frontal
pole

55. A3 Cortical
Harrigan, M. R., & Deveikis, J. P. (2012). Essential Neurovascular Anatomy. In Handbook of Cerebrovascular Disease and Neurointerventional Technique (pp. 3–98). Humana Press.
• include all the ACA branches
distal to the origin of the
pericallosal and
callosomarginal arteries
• around the genu
• A4, A5 segments—over the
corpus callosum

56. A3 Cortical
Harrigan, M. R., & Deveikis, J. P. (2012). Essential Neurovascular Anatomy. In Handbook of Cerebrovascular Disease and Neurointerventional Technique (pp. 3–98). Humana Press.
(1) Orbitofrontal artery; (2) frontopolar artery; (3) anterior internal
frontal artery; (4) middle internal frontal artery; (5) posterior internal
frontal artery; (6) paracentral artery; (7) superior parietal artery;
(8) inferior parietal artery; (9) callosomarginal artery;
(10) pericallosal artery
• Branches:
1. Pericallosal artery
2. Callosomarginal artery
3. Internal frontal branches
o Anterior internal frontal
o Middle internal frontal
o Posterior internal frontal
4. Paracentral artery
5. Parietal arteries
o Superior parietal
o Inferior parietal

57. Pericallosal Artery
Harrigan, M. R., & Deveikis, J. P. (2012). Essential Neurovascular Anatomy. In Handbook of Cerebrovascular Disease and Neurointerventional Technique (pp. 3–98). Humana Press.
• main trunk of the ACA
• anastomose with the
splenial artery of the
PCA

58. Callosomarginal Artery
Harrigan, M. R., & Deveikis, J. P. (2012). Essential Neurovascular Anatomy. In Handbook of Cerebrovascular Disease and Neurointerventional Technique (pp. 3–98). Humana Press.
• second largest distal
branch of the ACA
• travels superiorly over the
cingulate gyrus to run in a
posterior direction within
the cingulate sulcus
• absent in 18%

59. Internal Frontal Branches
Harrigan, M. R., & Deveikis, J. P. (2012). Essential Neurovascular Anatomy. In Handbook of Cerebrovascular Disease and Neurointerventional Technique (pp. 3–98). Humana Press.
• identified according to which
part of the superior frontal
gyrus they supply
• may arise from the
pericallosal or the
callosomarginal artery
o Anterior internal frontal
(3)
o Middle internal frontal
(4)
o Posterior internal frontal
(5)

60. Paracental Artery
Harrigan, M. R., & Deveikis, J. P. (2012). Essential Neurovascular Anatomy. In Handbook of Cerebrovascular Disease and Neurointerventional Technique (pp. 3–98). Humana Press.
• arises from pericallosal or
callosomarginal artery
midway between the genu
and splenium of the
corpus callosum
• supply the paracentral
lobule

61. Parietal Arteries
Harrigan, M. R., & Deveikis, J. P. (2012). Essential Neurovascular Anatomy. In Handbook of Cerebrovascular Disease and Neurointerventional Technique (pp. 3–98). Humana Press.
• final and most distal
branches
• supply medial aspect of the
hemisphere above the
corpus callosum and most of
the precuneus
• anastomose with the parieto-
occipital branch of PCA
• divided into:
o Superior parietal artery
(7)
o Inferior parietal artery

62. ACA Territory Infarction
Park, H., Jeong, Y. S., Lee, S. H., Jang, S. H., Kwon, D. H., Hong, J.-H., Sohn, S.-I., & Yoo, J. (2021). Clinical prognosis of isolated anterior cerebral artery territory infarction: a retrospective study. In BMC Neurology (Vol. 21, Issue 1).
Springer Science and Business Media LLC.
• Isolated ACA territory infarction is
a rare phenomenon
• 0.5–3 % of all cerebral infarctions
• diameter of the A1 segment is
only approximately half that of the
MCA

63. ACA Syndrome
Park, H., Jeong, Y. S., Lee, S. H., Jang, S. H., Kwon, D. H., Hong, J.-H., Sohn, S.-I., & Yoo, J. (2021). Clinical prognosis of isolated anterior cerebral artery territory infarction: a retrospective study. In BMC Neurology (Vol. 21, Issue 1).
Springer Science and Business Media LLC.
• clinical presentation:
o weakness lower limb > upper
limb
o hemisensory loss affecting
contralateral leg
o hemineglect
o transcortical motor aphasia

64. ACA Syndrome
Park, H., Jeong, Y. S., Lee, S. H., Jang, S. H., Kwon, D. H., Hong, J.-H., Sohn, S.-I., & Yoo, J. (2021). Clinical prognosis of isolated anterior cerebral artery territory infarction: a retrospective study. In BMC Neurology (Vol. 21, Issue 1).
Springer Science and Business Media LLC.
• Isolated infarction in territory of
recurrent artery of Heubner
o restricted diffusion in caudate
nucleus, anterior limb of the
internal capsule, and anterior
aspect of the putamen and
globus pallidus
o can be clinically silent
o hemiparesis most prominent in
face and upper extremity

65. ACA Syndrome
Park, H., Jeong, Y. S., Lee, S. H., Jang, S. H., Kwon, D. H., Hong, J.-H., Sohn, S.-I., & Yoo, J. (2021). Clinical prognosis of isolated anterior cerebral artery territory infarction: a retrospective study. In BMC Neurology (Vol. 21, Issue 1).
Springer Science and Business Media LLC.
• clinical presentation:
o Sphincter dysfunction
o Anterograde amnesia
o Grasping
o Abulia, Akinetic mutism

66. ACA Syndrome
Park, H., Jeong, Y. S., Lee, S. H., Jang, S. H., Kwon, D. H., Hong, J.-H., Sohn, S.-I., & Yoo, J. (2021). Clinical prognosis of isolated anterior cerebral artery territory infarction: a retrospective study. In BMC Neurology (Vol. 21, Issue 1).
Springer Science and Business Media LLC.
• clinical presentation:
o callosal disconnection
syndrome—interruption of
connection from the right
hemisphere to the cognitive
center in the left hemisphere
hence ideomotor apraxia,
agraphia, tactile anomia alien-
hand syndrome of left hand

67. Thank you!

68. Answers to
Pre-Test

69. Pre-Test
1. Identify Artery involved:
a. Lateral Lenticulostriate
b. Recurrent Artery of Heubner
c. MCA, leptomeningeal branch
d. MCA, superior division
e. MCA, parasylvian

70. Pre-Test
1. Identify Artery involved:
a. Lateral Lenticulostriate
b. Recurrent Artery of Heubner
c. MCA, leptomeningeal branch
d. MCA, superior division
e. MCA, parasylvian

71. Pre-Test
2. Identify Artery involved:
a. Lateral Lenticulostriate
b. Recurrent Artery of Heubner
c. MCA, leptomeningeal branch
d. MCA, superior division
e. MCA, parasylvian

72. Pre-Test
2. Identify Artery involved:
a. Lateral Lenticulostriate
b. Recurrent Artery of Heubner
c. MCA, leptomeningeal branch
d. MCA, superior division
e. MCA, parasylvian

73. Pre-Test
3. Identify Artery involved:
a. Lateral Lenticulostriate
b. Recurrent Artery of Heubner
c. MCA, leptomeningeal branch
d. MCA, superior division
e. MCA, parasylvian
Clue: Foix-Chavany-Marie Syndrome

74. Pre-Test
3. Identify Artery involved:
a. Lateral Lenticulostriate
b. Recurrent Artery of Heubner
c. MCA, leptomeningeal branch
d. MCA, superior division
e. MCA, parasylvian
Clue: Foix-Chavany-Marie Syndrome

75. Pre-Test
4. Identify Artery involved:
a. Lateral Lenticulostriate
b. Recurrent Artery of Heubner
c. MCA, leptomeningeal branch
d. MCA, superior division
e. MCA, parasylvian

76. Pre-Test
4. Identify Artery involved:
a. Lateral Lenticulostriate
b. Recurrent Artery of Heubner
c. MCA, leptomeningeal branch
d. MCA, superior division
e. MCA, parasylvian

77. Pre-Test
5. Identify Artery involved:
a. Lateral Lenticulostriate
b. Recurrent Artery of Heubner
c. MCA, leptomeningeal branch
d. MCA, superior division
e. MCA, parasylvian

78. Pre-Test
5. Identify Artery involved:
a. Lateral Lenticulostriate
b. Recurrent Artery of Heubner
c. MCA, leptomeningeal branch
d. MCA, superior division
e. MCA, parasylvian