Clinical stroke syndromes
- 2. Cluster of signs and symptoms produced due to the occlusion of an artery(due to an atherothrombotic lesion or an emboli or dissection ) supplying a particular region of the brain
- 3. Large vessel stroke within the anterior circulation Large vessel stroke within the posterior circulation Small vessel disease of either vascular bed
- 4. Anterior circulation- MCA, ACA, and Anterior choroidal artery Posterior circulation-Vertebral artery, Basilar artery and Posterior cerebral artery
- 6. Due to occlusion of Internal carotid artery and its branches-Middle cerebral artery, Anterior cerebral artery and Anterior choroidal artery
- 7. M1 segment(proximal)- deep penetrating or lenticulostriate branches– Internal capsule, caudate nuclues, putamen and outer pallidus
- 8. M2(distal)- superior and 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
- 11. Contralateral hemiplegia & hemianaesthesia–Somatic motor area for face and arm and the fibres descending from the leg area to enter the corona radiata & corresponding somatic sensory system. Contralateral homonymous hemianopia –Optic radiation deep to second temporal convolution Motor aphasia - Motor speech area of the dominant hemisphere Conduction aphasia- Central speech area (parietal operculum)
- 12. Central aphasia, word deafness, anomia, jargon speech, sensory agraphia, acalculia, alexia, finger agnosia, right-left confusion- Central, suprasylvian speech area and parietooccipital cortex of the dominant hemisphere Gaze preference to the ipsilateral side If dominant hemisphere involved-Global aphasia If non dominant hemisphere involved- Hemispatial neglect, anasognosia and constructional apraxia
- 13. Occlusion of lenticulostriate branches: Lacunar stroke within the internal capsule produces pure motor or sensory- motor stroke contralateral to the side of lesion; alternatively, the contralateral hand may become ataxic and dysarthria will be prominent (Clumsy hand syndrome, dysarthria lacunar syndrome) Lacunar infarct of putamen, globus pallidus- predominantly parkinsonian features
- 14. If superior division of M1 involved: Brachial syndrome- weakness of hand and arm Frontal opercular syndrome-Broca’s aphasia with facial weakness with or without arm weakness Proximal part of the superior division involved- clinical features of motor weakness, sensory disturbances and broca’s aphasia
- 15. If inferior division of M2 involved: If dominant hemisphere- Wernicke’s aphasia without weakness with contralateral homonymous superior quadrantanopia If non dominant hemisphere- Hemineglect , spatial agonosia without weakness
- 16. A1 segment- from internal carotid to anterior communicating artery- branches to anterior limb of internal capsule, inferior part of caudate, anterior hypothalamus A2 segment- distal to anterior communicating artery- supplies frontal pole, entire medial part of cerebral hemispheres
- 19. A1 segment occlusion rarely produces clinical syndrome because collateral flow through anterior communicating artery and collaterals from MCA and PCA
- 20. -c/l paralysis of foot and leg, paresis of arm -c/l cortical sensory loss of foot and leg -urinary incontinence -Sensorimotor area in paracentral lobule -c/l grasp and suckling reflex -abulia, slowness, delay -gait apraxia If both A2 segments arise from a single anterior cerebral stem(c/l A1 segment atresia),it may affect both hemispheres- Profound abulia, b/l pyramidal signs, paraparesis or quadriparesis and urinary incontinence
- 21. Supplies posterior limb of internal capsule, white matter posterolaterally Complete syndrome rare due to collaterals from MCA, PCA, and ICA Syndrome comprises c/l hemiplegia c/l hemianaesthesia c/l homonymous hemianopia Anterior choroidal strokes are usually due to insitu thrombosis of the vessel.
- 22. • Internal carotid artery: The cortex supplied by the MCA territory is affected most often. When the origins of both the ACA and MCA are occluded at the top of the carotid artery, abulia or stupor occurs with hemiplegia, hemianesthesia, and aphasia or anosognosia. When the PCA arises from the internal carotid artery (a configuration called a fetal posterior cerebral artery), it may also become occluded and give rise to symptoms referable to its peripheral territory The internal carotid artery also perfuses the optic nerve and retina via the ophthalmic artery. In ~25% of symptomatic internal carotid disease, recurrent transient monocular blindness (amaurosis fugax) warns of the lesion-typically describe a horizontal shade that sweeps down or up across the field of vision • Common carotid artery: Jaw claudication may result from low flow in the external carotid branches
- 23. Paired Vertebral arteries Basilar artery Paired Posterior cerebral arteries Small penetrating branches and short and long circumferential branches
- 25. Supplies Cerebellum Medulla Pons Midbrain Thalamus Subthalamus Hippocampus Medial part of temporal lobe Occipital lobe P2
- 26. Inferior Aspect of the brain
- 27. P1 segment-Precommunal- Midbrain, thalamic and subthalamic P2 segment-Temporal and occipital cortex
- 28. Due to the involvement of ipsilateral subthalamus, cerebral peduncles and midbrain
- 29. Claude’s- 3rd nerve palsy with c/l ataxia- Red nuclues Weber’s- 3rd nerve palsy with c/l hemiplegia- Cerebral peduncle Subthalamus-c/l hemiballismus Thalamus- Thalamic ‘Dejerine Roussy syndrome’ - c/l hemisensory loss followed later by agonising,searing or burning pain in the affected areas. Occlusion of the artery of Percheron produces paresis of upward gaze and drowsiness and often abulia. Extensive infarction in the midbrain and subthalamus occurring with bilateral proximal PCA occlusion presents as coma, unreactive pupils, bilateral pyramidal signs, and decerebrate rigidity. `
- 30. Infarction of medial temporal and occipital lobes Occipital lobe-c/l homonymous hemianopia with macular sparing, if visual association area spared, patient aware of visual defect Medial temporal lobe- Memory impairement Visual agnosia for faces, objects, mathematical symbols, and colors and anomia with paraphasic errors (amnestic aphasia) may also occur Visual hallucinations of brightly coloured scenes and objects.
- 31. Antons syndrome- bilateral occlusion in distal PCAs – bilateral occipital lobe infarction- cortical blindness and patient often unaware and even deny it. Rarely, only peripheral vision is lost and central vision is spared-’gun-barrel’ vision Balints syndrome- bilateral visual association areas- disorder of orderly visual scanning of the environment, resulting from infarctions secondary to low flow in watershed between distal PCA and MCA-palinopsia and asimultagnosia
- 32. Paramedian branches of upper basilar and proximal posterior cerebral arteries Eye “down and out” secondary to unopposed action of fourth and sixth cranial nerves, with dilated and unresponsive pupil: Third nerve fibers c/l Paralysis of face, arm, and leg: Corticobulbar and corticospinal tract descending in crus cerebri.
- 33. Syndrome of small penetrating arteries arising from posterior cerebral artery Eye “down and out” secondary to unopposed action of fourth and sixth cranial nerves, with dilated and unresponsive pupil: Third nerve fibers Hemiataxia, hyperkinesias, tremor: Red nucleus, dentatorubrothalamic pathway
- 35. V1 and V4- prone for atherothrombosis If occlusion is proximal to origin of vertebral artery, reversal of blood flow- subclavian steal syndrome
- 36. Caused due to occlusion of V4 segment or PICA Pain, numbness and abnormal sensation over one half of face -Descending tract and nucleus of trigeminal nerve Vertigo, nausea, vomiting and diplopia -Vestibular nucleus Dysphagia, hoarseness, palatal paralysis - Issuing fibres of 9th and 10th nerve nucleus Ataxia of limbs -Restiform body, and cerebellar hemispheres Horner’s syndrome -Descending sympathetic tract c/l loss of pain and temperature - Spinothalamic tract
- 37. Infarction of pyramid- c/l hemiplegia of arm and leg, sparing face If medial lemniscus-c/l loss of tactile and proprioceptive sense If hypoglossal nerve nucleus involved- ipsilateral LMN hypoglossal nerve palsy – atrophy of half of tongue.
- 39. Paramedian- wedge of pons in midline Short circumerential- lateral two thirds of pons and middle and superior cerebellar peduncles Long circumferential(Superior and anterior inferior cerebellar),supply cerebellar hemispheres.
- 40. Occlusion of basilar artery- b/l brainstem signs Occlusion of basilar branch artery- unilateral motor, sensory and cranial nerves
- 41. • Complete basilar artery occlusion (Locked in state)- b/l long tract(sensory/motor) with cranial nerve and cerebellar dysfunction- preserved consciousness, quadriplegia and cranial nerve signs • TIAs in the proximal basilar distribution may produce vertigo “swimming,” “swaying,” “moving,” “unsteadiness,” or “light-headedness. Other symptoms that warn of basilar thrombosis include diplopia, dysarthria, facial or circumoral numbness, and hemisensory symptoms. In general, symptoms of basilar branch TIAs affect one side of the brainstem, whereas symptoms of basilar artery TIAs usually affect both sides
- 42. TOP OF BASILAR SYNDROME: Embolic occlusion of the top of the basilar artery can produce any or all of the central or peripheral PCA territory symptoms. The hallmark is the sudden onset of bilateral signs, including ptosis, pupillary asymmetry or lack of reaction to light, and somnolence.
- 43. Anterior inferior cerebellar artery- lateral part of inferior pons and anterior part of inferior cerebellar hemispheres Cerebellum- Ataxia of limb and gait 7th nerve nuclues- Facial weakness 8th nerve nucleus- Deafness, tinnitus, vertigo, nausea, vomiting Spinothalamic tract- c/l loss of pain and temperature
- 44. Paralysis of conjugate gaze to side of lesion (preservation of convergence): Center for conjugate lateral gaze Nystagmus: Vestibular nucleus Ataxia of limbs and gait: Likely middle cerebellar peduncle Diplopia on lateral gaze: Abducens nerve c/l Paralysis of face, arm, and leg: Corticobulbar and corticospinal tract in lower pons Impaired tactile and proprioceptive sense over c/l side of the body: Medial lemniscus
- 46. Short Circumferential artery-lateral two-thirds of the pons and middle and superior cerebellar peduncles Ataxia of limbs -Middle cerebellar peduncle Paralysis of muscles of mastication -Motor fibers or nucleus of fifth nerve Impaired sensation over side of face -Sensory fibers or nucleus of fifth nerve c/l Impaired pain and thermal sense on limbs and trunk -Spinothalamic tract
- 47. Ataxia of limbs and gait : Pontine nuclei c/l Paralysis of face, arm, and leg: Corticobulbar and corticospinal tract Variable impaired touch and proprioception on c/l side: Medial lemniscus
- 49. Superior cerebellar artery- lateral part of superior pons and superior surface of cerebellar hemispheres Superior and middle cerebellar peduncles and superior cerebellar hemisphere -Ataxia of limb and gait Vestibular nucleus -dizziness, nausea and vomiting Spinothalamic tract -c/l loss of pain and temperature
- 50. Cerebellar ataxia :Superior and/or middle cerebellar peduncle Internuclear ophthalmoplegia: Medial longitudinal fasciculus c/l Paralysis of face, arm, and leg: Corticobulbar and corticospinal tract. Rarely touch, vibration, and position are affected on c/l side: Medial lemniscus
- 52. Reference: Harrison’s Principles Of Internal Medicine 19e