Stroke Syndromes

Main symptom:
Hemiparesis (faciobrachiocrural weakness)
Associated symptoms / Anatomy & vascular territory
• Cortical sensory loss, global aphasia or spatial neglect, hemianopsia, contralateral gaze palsy / • Middle cerebral artery (entire territory) syndrome
• Hemisensory loss, transcortical motor or sensory aphasia / • Middle cerebral artery (deep territory)
• Watershed infarct (between superficial and deep middle cerebral artery territory)
• Sensory loss (face and hand), conduction aphasia, apraxia, Gerstmann syndrome, constructional apraxia / • Perisylvian, superficial middle cerebral artery territory
• Hemisensory loss, gaze palsy, spatial neglect, or expressive aphasia / • Middle cerebral artery, superior division (superficial territory)
• Ipsilateral 3rd nerve palsy (Weber syndrome)
+/- Supranuclear vertical gaze palsy
+/- Sensory deficit / • Posterior cerebral artery--paramedian midbrain perforators
• Ipsilateral 6th nerve palsy
+/- 7th nerve palsy (Millard-Gubler syndrome), internuclear ophthalmoplegia, horizontal gaze palsy, one-and-a-half syndrome / • Basilar artery--paramedian pontine perforators
• Ipsilateral 12th nerve palsy, contralateral loss of position and vibratory sense (medial medullary syndrome--Dejerine syndrome)
• Ipsilateral ataxia
+ Contralateral hemiparesis
• Ipsilateral ataxic hemiparesis / • Vertebral artery, anterior spinal artery--paramedian medullary perforators
Facio-brachial weakness
Associated symptoms / Anatomy & vascular territory
• Cognitive and behavioral abnormalities (abulia, agitation, hyperactivity, neglect) / • Middle cerebral artery complete or lateral lenticulostriate territory
• Anterior cerebral artery proximal perforating branches from Heubner artery territory--caudate infarcts
Crural weakness
Associated symptoms / Anatomy & vascular territory
• Homolateral ataxia / • Anterior cerebral artery distal territory
• Noncortical sensory loss
+/- Transcortical motor aphasia or mutism, mood disturbances / • Superficial borderzone territory between anterior and middle cerebral artery
• Sensory loss, shoulder weakness, gegenhalten, left hand apraxia, alien hand sign, grasp reflex, transient urinary incontinence, abulia, akinetic mutism / • Anterior cerebral artery complete territory
Brachial weakness
Associated symptoms / Anatomy & vascular territory
• Cortical sensory loss, disturbance of volitional saccadic eye movements / • Borderzone territory between anterior and middle cerebral artery
• Middle cerebral artery superficial territory: cortical infarct
Bilateral weakness - hemiparesis
Associated symptoms / Anatomy & vascular territory
+/- Sensory loss / Internal carotid artery territory:
• Bilateral hemispheric
Anterior spinal artery territory:
• Bilateral medullary pyramids
• Spinal cord infarction
• Locked-in syndrome
+/- Supranuclear vertical gaze palsy / Basilar artery territory:
• Bilateral paramedian pontine or mesencephalic
Bilateral weakness - brachial weakness
Associated symptoms / Anatomy & vascular territory
• Bilateral anterior watershed infarctions (man-in-a-barrel syndrome)
• Vertigo, distal amyotrophy / • Anterior spinal artery watershed (“snake-eyes” infarction) (Pullicino 1994)
Bilateral weakness - paraplegia
Associated symptoms / Anatomy & vascular territory
• Akinetic mutism, abulia, grasp, urinary incontinence / • Anterior cerebral artery bilateral
• Sensory level, urinary incontinence / • Anterior spinal artery infarction
Bilateral weakness - pseudobulbar palsy
Associated symptoms / Anatomy & vascular territory
• Facio-pharyngo-glosso-masticatory diplegia with automatic-voluntary dissociation, spasmodic laughing or crying / • Middle cerebral artery bilateral opercular branches
+ Pyramidal signs, intellectual impairment / • Anterior choroidal artery: bilateral perforating branches
+ Pyramidal or cerebellar signs, lack of dementia / • Basilar artery paramedian branches
Sensory strokes
Associated symptoms / Anatomy & vascular territory
• Loss of position sense, impairment of 2-point discrimination, somatotopagnosia, agraphesthesia, astereognosis
+/- Hemiparesis, hemianopsia, aphasia or hemineglect pseudothalamic parietal sensory syndrome
• Faciobrachiocrural elementary sensory loss / • Middle cerebral artery--parietal branches
• Restricted acral sensory syndrome: cheiro(hand)-oral, cheiro-pedal, cheiro-oral-pedal syndrome / • Middle cerebral artery
•Thalamogeniculate pedicle
• Basilar artery: deep perforating or medullary arteries
• Small strokes in lateral thalamus, pontine tegmentum, corona radiata, parietal cortex, midbrain.
• Hemianesthesia, transient hemiparesis, hemiataxia, thalamic astasia, choreoathetoid movements, thalamic hand, paroxysmal pain
+/- Hemianopsia
(Dejerine-Roussy syndrome) / • Thalamogeniculate territory, proximal posterior cerebral artery
Cerebellar ataxia - limb ataxia, gait imbalance
Associated symptoms / Anatomy & vascular territory
+/- Lateropulsion, vertigo, nausea and vomiting, nystagmus, ocular tilt reaction, dysphonia and dysphagia, (nucleus ambiguous: IX, X, XI), ipsilateral facial thermalgesia (5th cranial nerve), Horner syndrome, contralateral thermalgesia of trunk and limbs (Wallenberg syndrome) / • Vertebral artery brainstem branches from vertebral artery occlusion
Contralateral analgesia or thermalgesia
+/- Vertigo, nausea, vomiting, horizontal nystagmus, dysarthria, Horner syndrome, 4th nerve palsy
+ 3rd nerve palsy
+ Hemichoreoathetosis (Benedikt syndrome) / • Superior cerebellar artery: cerebellar + midbrain tegmentum infarction territory
Cerebellar ataxia
Associated symptoms / Anatomy & vascular territory
+/- Supranuclear vertical gaze palsy
+ Defective convergence or convergence-retraction nystagmus / • Basilar or posterior cerebral artery--P1--paramedian perforators
+ Light-near dissociation (Parinaud syndrome) / • Dorsal rostral midbrain syndrome
• Vertigo, tinnitus, ipsilateral hearing loss, dysarthria, Horner syndrome, peripheral 7th nerve palsy, facial hypesthesia, contralateral thermalgesia of the limbs and trunk / • Anterior inferior cerebellar artery--pontocerebellar infarction
Ataxic hemiparesis
Associated symptoms / Anatomy & vascular territory
+/- Sensory symptoms
+/- Dysarthria (dysarthria- clumsy-hand syndrome) / • Thalamogeniculate or basilar artery or middle cerebral artery--lacunar infarctions in pons, thalamus, internal capsule, medulla
+ Aphasia / • Middle cerebral artery-parainsular
Visual symptoms - monocular blindness (amaurosis fugax)
Associated symptoms / Anatomy & vascular territory
+/- Contralateral variable motor and hemisensory deficit / • Internal carotid artery territory ischemia
Visual symptoms - visual-field defects
- sectoranopia
Associated symptoms / Anatomy & vascular territory
• Wedge-shaped defect straddling the horizontal median, pointing towards fixation / • Posterior choroidal artery - lateral geniculate body infarction
• Sector defects adjacent to the vertical meridian, sparing the zone around the horizontal meridian / • Anterior choroidal artery--lateral geniculate body infarction
Visual symptoms - quadrantanopia (inferior noncongruent)
Associated symptoms / Anatomy & vascular territory
+ Optic ataxia, difficulty judging size, distance, movement / • Anterior, middle, or posterior cerebral artery--watershed infarction
+/- Cortical hypesthesia, aphasia (anomia, transcortical sensory, receptive) / • Middle or posterior cerebral artery superficial watershed, middle cerebral artery (parietal optic radiations)
Visual symptoms - quadrantanopia (inferior congruent)
Associated symptoms / Anatomy & vascular territory
• Posterior cerebral artery--upper bank calcarine fissure
Visual symptoms - quadrantanopia (superior noncongruent)
Associated symptoms / Anatomy & vascular territory
• Middle cerebral artery inferior division (temporal optic radiations)
Visual symptoms - quadrantanopia (superior congruent)
Associated symptoms / Anatomy & vascular territory
• Posterior cerebral artery--lower bank calcarine fissure
Visual symptoms - hemianopsia
Associated symptoms / Anatomy & vascular territory
• Isolated, +/- hemiparesis, hemisensory loss, ataxia / • Anterior choroidal artery territory
+ Hemiparesis, sensory loss, aphasia or neglect / • Middle cerebral artery--optic radiation infarction
• Left middle cerebral artery
• Alexia without agraphia / • Posterior cerebral artery territory (occipital, mediotemporal and callosal branches)
+ Cortical blindness (if bilateral- Anton syndrome), release hallucinations, agitated delirium or confusion,
visual and color agnosia,
prosopagnosia
+ Simultanagnosia, ocular ataxia, ocular apraxia (Balint syndrome) / • Posterior cerebral artery bilateral (lower bank of calcarine fissure)
• Middle or posterior cerebral artery watershed (upper bank of calcarine fissure)
• Posterior cerebral artery territory stroke
Visual symptoms - visual hallucinations
Associated symptoms / Anatomy & vascular territory
• In the hemianoptic field, transient or persistent, simple or complex, nonstereotyped / • Posterior cerebral artery territory stroke
• Complex, detailed,
+ inversion of the sleep-wake cycle (peduncular hallucinosis) / • Basilar artery or posterior cerebral artery, paramedian perforators
Encephalopathic symptoms
Associated symptoms / Anatomy & vascular territory
• Agitated delirium, abnormal behavior / • Posterior or middle cerebral artery or basilar artery: paramedian midbrain and thalamus, hippocampus, fusiform and lingual gyri (top-of-the-basilar
• Cognitive impairment-decline in mentation / • Posterior cerebral artery: occipital plus splenial or parahippocampal infarct (Park et al 2009)
• Pontine infarction
• Middle cerebral artery territory—right temporal, inferior frontal, and parietal lobe infarction
• Abulia, manic behavior / • Medial frontal lobe, caudate nucleus (anterior cerebral artery territory)