Stroke Syndromes & Eponyms Wajih

Important Perforating arteries

Alexia without Agraphia Site of Lesion Left cerebral hemisphere, splenium of corpus callosum Culprit Vessel Posterior cerebral artery, collosal branch Description Alexia, right homonymous hemianopia, can write but not read ones own written statement!

Anton Syndrome Site of lesion Culprit Vessel Description Bilateral occipital lobes Culprit Vessel Bilateral PCA, top of the basilar Description Bilateral visual loss but patient denies blindness

Gerstmann Syndrome Site of Lesion Culprit Vessel Description Dominant parietal lobe Culprit Vessel MCA M3 branches Description Agraphia, acalculia, right-left confusion, finger agnosia, may have ideomotor apraxia

Ataxic HemiparAesis Site of Lesion Culprit Vessel Description Most commonly corona radiata or anterior limb of internal capsule. Pons can also be involved. Posterior limb of internal capsule, lentiform nucleus and thalamus can also be seen. Culprit Vessel Many vessels can produce the same phenotype so is not localising. Perforating branches of MCA, ACA or perforating branches of basilar artery. Description 18% of lacunar infarctions. Crural predominant weakness, out of proportion homolateral ataxia.

Pure Motor Hemiparesis Site of Lesion Genu or posterior limb of internal capsule, corona radiata, pons, medullary pyramid. Culprit Vessel Usually perforating branches of MCA, can be perforating branches of basilar artery, or anterior spinal artery. Description Most common (50-75%). Paralysis of face, arm and leg on one side, no sensory signs, visual field defect, dysphasia or apraxia. Face can be spared and transient numbness or subjective heaviness of the affected limbs at the onset.

Pure Sensory Stroke Site of Lesion Culprit Vessel Description Posteroventral thalamus, can be sensory cortex, or centrum semiovale (thalamocortical pathways) Culprit Vessel Thalamic branches of PCA. Small branches of MCA Description Less common, 6-7%. Half of the body feels numb, with some pareasthesia. Thalamic Pain Syndrome (Dejerine-Roussy Syndrome), the above with hemi-body dysaesthesia/pain. Can develop hours to months later. Some times difficult to treat.

Sensorimotor Stroke Site of Lesion Culprit Vessel Description Relatively larger lesions in the area of internal capsule, caudate, putamen, thalamus. Some times thalamus and internal capsule are supplied by MCA and can have stroke together. Can happen in lateral pons. Culprit Vessel Perforators of MCA. Description 20%. Hemi-body motor and sensory deficit.

Dysarthria-Clumsy Hand Syndrome Site of Lesion Internal capsule, junction of capsule and corona radiata, could also occur in upper paramedian pons and also in putamen. Culprit Vessel Perforators of MCA or basilar artery Description Facial weakness, severe dysarthria, and dysphagia, with mild hand weakness and clumsiness. Occasionally, some weakness of the arm or leg is present.

hemichorea-hemiballism or dystonia Site of Lesion Contralateral subthalamic, putamin, globus pallidus or posterolateral thalamus Culprit Vessel Perforators of MCA or PCA Description Rare

Balint Syndrome Site of Lesion Culprit Vessel Description Bilateral parieto-occipital areas (watershed area between MCA and PCA) Culprit Vessel Bilatral PCA branches Description Rare. Triad of Occular apraxia- loss of voluntary fixation but not reflex eye movements, Optic ataxia – poor visual-motor coordination reaching the shown object with hand, Asimultagnosia – inability to perceive the visual field as a whole.

Scheme of Arterial supply to brain stem

P1 arterial strokes of Mid Brain Claude Weber Medial longitudinal fasiculus

Weber Syndrome Site of Lesion Culprit Vessel Description Mid brain, cerebral peduncles and 3rd nerve fibers Culprit Vessel Perforators of PCA P1 part Description Ipsilateral 3rd nerve palsy and contralateral hemiparaesis. If red nucleus is also involved then there will be additional contralateral tremor and ataxia (Benedikt Syndrome).

Claude Syndrome Site of Lesion Culprit Vessel Description Mid brain tegmentum, damage occurs to red nucleus, occulomotor nucleus, dentato rubral fibres Culprit Vessel PCA P1 branches Description Ispilateral 3rd nerve palsy and contralateral cerebellar ataxia. Very rare Nothnagels Syndrome is infarction of superior cerebellar peduncle and adjoining midbrain. Ipsilateral 3rd nerve palsy and ipsilateral ataxia. Some times this term is used for bilateral mid brain lesion causing bilateral 3rd nerve palsy and global ataxia. Midbrain has three parts, cerebral peduncles, tegmentum from substantia nigra to central aqueduct, tectum posterior to aqueduct. It has colliculi

Perinaud Syndrome Site of Lesion Culprit Vessel Description Dorsal midbrain lesion (posterior to aqueduct) Culprit Vessel Description Very rare due to ischemia. Can be seen with pineal tumours. Paralysis of upgaze, pseudo-Argyll Robertson pupils (constrict on accommodation but not with light, AR pupils are miotic but psuedo AR pupils are not miotic), Convergence retraction nystagmus (attempted upgaze causes globe retraction and convergence) Lid retraction Conjugate downgaze in primary position (setting sun) Setting sun is also seen with raised intracranial hypertension

Artery of Percheron Stroke Rare anatomical variant of paramedian arteries. Triad: drowsiness, vertical gaze palsy, & amnesia sometimes with confabulation Drowsiness & amnesia: bilateral paramedian thalamus lesion. Vertical gaze palsies: mid brain. If more mid brain is involved: 3rd nerve palsy, hemiplegia, ataxia, and tremor

“Top of the basilar” syndrome Site of Lesion mid brain, thalamus, bilateral occipital lobes Culprit Vessel bifurcation of basilar Description 50% will experience TIA for several days to weeks (hemi, tetra or facial paresis; dysarthria; vertigo; headache; visual symptoms; altered consciousness) impaired consciousness or hypersomnolence, vertical gaze palsy, 3rd & 4th palsy, visual field defects, INO, visual agnosia, amnesia.

Pons Superior Pons Mid Pons Inferior Pons Millard PPRF Superior Pons Mid Pons Inferior Pons Basilar artery Branches:(1) paramedian, 7–10, supply a wedge around midline (2) short circumferential, 5–7 , supply lateral 2/3 pons & mid & sup cerebellar peduncles(3) bilateral long circumferential (superior cerebellar and anterior inferior cerebellar arteries), run around pons to supply the cerebellum.

Various Pontine Syndromes Sup. Pons Syndrome Mid Pons Syndrome Inf Pons Syndrome med ipsil. hemi-ataxia, INO, palatal & pharyngeal myoclonus; contr. hemiplegia (face), sometimes hemisensory loss ipsil. hemi-ataxia; contr. hemiparesis (face), contr. deviation of the eyes &variably impaired sensation nystagmus ipsil. conjugate gaze paralysis, hemi-ataxia; contr. hemiparesis (face), impaired touch & proprioception lat nystagmus, dizziness & vomiting; Ipsil. hemi-ataxia, conjugate gaze paresis & sometimes skew deviation of the eyes, Horner's; contr. hemisensory loss ipsi. hemi-ataxia, masticatory paralysis, hemi facial sensory loss; contr. NONE nystagmus, vertigo, ipsil. hemi-facial paralysis, conjugate gaze paralysis, deafness, tinnitus, hemi-ataxia, facial hemisensory loss; contr. body hemisenosry loss Skew deviation each eye pointing in opposite direction

Raymond Syndrome Site of Lesion Culprit Vessel Description Upper ventral pons (superior to facial nucleus) Culprit Vessel Paramedian branches of basilar artery Description Ispilateral abducens nerve palsy and contralateral hemiplegia (face). (limited form of medial Mid Pontine syndrome)

Millard-Gubler Syndrome Site of Lesion Ventral lower paramedian Pons Culprit Vessel Paramedian branches of basilar artery Description Ipsilatearl 7th and 6th nerves palsy and contralateral hemiparaesis. ‘crossed hemiplegia’ (extended form of lateral inferior pontine syndrome)

Foville Syndrome Site of Lesion Culprit Vessel Description Dorsal medial lower pons Culprit Vessel Paramedian or short circumferential branches of basilar art Description Contralateral body Weakness Ipsilateral facial Weakness Ipsilateral Lateral gaze weakness (PPRF or 6th nerve) ‘Crossed hemiplegia’ (extended form of medial lower pontine syndrome)

Marie-Foix Syndrome Site of Lesion Culprit Vessel Description Lateral pons and middle cerebellar peduncle Culprit Vessel Basilar artery: Long circumferential branches or anterior inferior cerebellar artery Description Ipsilateral Hemi ataxia – cerebellar tracts Contralateral Hemisensory pain & temp. loss: Spinothalamic tract (limited form of lateral pontine syndrome)

Locked-in-syndrome Site of Lesion Culprit Vessel Description Bilateral ventral mid pons Culprit Vessel Basilar artery perforators Description Quadriplegia: bilateral cortical spinal tracts Bilateral facial weakness: bilateral corticobulbar tracts Lateral gaze weakness: bilateral fascicles of 6th nerve Aphonia/Dysarthria: bilateral corticobulbar tracts Preserved consciousness (reticular formation is spared) and preserved sensation paralysis of all movements except vertical gaze and eyelid opening. The supranuclear ocular motor pathways lie dorsally, so that vertical eye movements and blinking are intact.

Medulla oblongota Level of inferior olivary nucleus Level of lemniscal decussation Level of pyramidal decussation

Medulla Cross sections At pyramidal decussation At lemniscal decussation

Medullar Cross Section

Medial & Lateral Medullary infarcts

Wallenburg Syndrome Site of Lesion Culprit Vessel Description Lateral medulla Culprit Vessel vertebral artery or its distal branches (superior , middle, inferior lateral medullary), post inf cerebellar artery less common. Description Hiccups Ipsilateral Pain, numbness, impaired sensation over one-half the face: Descending tract and nucleus fifth nerve Ataxia of limbs, falling to side of lesion: Uncertain—restiform body, cerebellar hemisphere, cerebellar fibers, spinocerebellar tract Nystagmus, diplopia, oscillopsia, vertigo, nausea, vomiting: Vestibular nucleus Horner's syndrome (miosis, ptosis, decreased sweating): Descending sympathetic tract Dysphagia, hoarseness, paralysis of palate, paralysis of vocal cord, diminished gag reflex: Issuing fibers ninth and tenth nerves Loss of taste: Nucleus and tractus solitarius Numbness of ipsilateral arm, trunk, or leg: Cuneate and gracile nuclei Weakness of lower face: Genuflected upper motor neuron fibers to ipsilateral facial nucleus Contralateral Impaired pain and thermal sense over half the body, sometimes face: Spinothalamic tract

Dejerine Syndrome Site of Lesion Culprit Vessel Description Medial medulla Culprit Vessel Anteromedial branch of vertebral or Anterior spinal artery. Basilar artery perforators. Description Very rare <1% vertebrobasilar strokes Ipsilateral Paralysis with atrophy of one-half half the tongue: Ipsilateral 12th nerve Contralateral Paralysis of arm and leg, sparing face, contralateral pyramidal tract ; impaired tactile and proprioceptive sense over one-half the body, medial lemniscus

The End Finally!