1. Stroke Syndromes & Eponyms
Wajih

2. Important Perforating arteries

3. 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!

4. 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

5. 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

6. 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.

7. 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.

8. 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.

9. 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.

10. 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.

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

12. 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.

13. Scheme of Arterial supply to brain stem

14. P1 arterial strokes of Mid Brain
Claude
Weber
Medial longitudinal
fasiculus

15. 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).

16. 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

17. 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

18. 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

19. “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.

20. 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.

21. 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

22. 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)

23. 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)

24. 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)

25. 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)

26. 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.

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

28. Medulla Cross sections
At pyramidal decussation
At lemniscal decussation

29. Medullar Cross Section

30. Medial & Lateral Medullary infarcts

31. 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

32. 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

33. The End Finally!