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Localization of stroke syndromes
Dr.M.Dhanaraj
Localization of stroke syndromes
Three steps
1.Clinical localization of the site of the lesion.
2.Identifying the vascular territory and the vessel involved.
3.Correlating with the imaging findings.
Clinical localization of stroke
syndromes
Prerequisites
1.Functional anatomy of brain.
2.Blood supply to the different parts of brain.
Blood supply of brain-Carotid Arteries
Vertebral artery Circle of willis
Blood supply of brain – vertebral artery
and circle of Willis
Blood supply of brain
ANTERIOR CIRCULATION STROKE SYNDROMES
Anterior circulation
Blood supply-Lateral view
Blood supply-Medial view
Blood supply-Coronal view
Blood supply-Axial view
Middle cerebral artery infarction -
superior branch
Clinical features
1.Contralateral hemiplegia – face and
upper limb more involved than
lower limb.
2. Contralateral hemisensory loss.
3.Conjugate gaze paresis(patient looks
towards the side of lesion.
4.Broca’s dysphasia (if left sided)
Middle cerebral artery infarction -
Inferior branch
Clinical features
1.Contralateral hemianopia.
2.Wernicke’s dysphasia ( if left sided )
3.Left spatial neglect ( if right sided )
Middle cerebral artery infarction - stem
occlusion
Clinical features
1.Contralateral hemiplegia
2. Contralateral hemisensory loss
3. Contralateral gaze palsy
4. Contralateral hemianopia
5.Global dysphasia (Left sided lesion)
6.Anosognosia and amorphosynthesis
(Right sided lesion)
7.Altered sensorium (due to edema)
Middle cerebral artery infarction -
Clinical features
1.Contralateral hemiparesis
2.Contralateral sensory loss
3.Transcortical motor / sensory
aphasia ( left sided lesion)
Lenticular striate artery occlusion
Anterior cerebral artery infarction
Clinical features
1.Contralateral
a.paralysis of leg and foot with paresis of
arm
b.cortical sensory loss over leg and foot
c.presence of primitive reflexes
2.Urinary incontinence
3.Gait apraxia
4.Mutism, delay and lack of spontaneity of
motor acts
5.Apraxia of left sided limbs(with left sided
lesion and corpus callosum involvement)
Internal carotid artery infarction
Clinical features
Variable - based on the
collaterals and mechanism of
stroke (embolism, extension of
thrombus , low flow)
1.Amaurosis fugax
2. Watershed infarctions
3.MCA/ACA- either alone or in
combinations
Posterior circulation stroke syndromes
Posterior circulation
Lateral view
Posterior circulation
Medulla
Lateral medullary syndrome
A. IPSILATERAL
1.Xth cranial nerve palsy
2.Cerebellar signs
3.Horner’s syndrome
4.Impaired pain, temperature
and touch on the upper
half of face
B. CONTRA LATERAL
1.Impaired pain and
temperature over the body
Medial medullary syndrome
A.IPSILATERAL
1.XIIth nerve palsy
B.CONTRALATERAL
1.Hemiplegia – sparing the
face
2.Hemianaesthesia sparing the
face.
Pons-Lower
Medial pontine syndrome – occlusion
of paramedian branch of basilar artery
A.IPSILATERAL
1.Gaze paresis
2.Cerebellar signs
B.CONTRALATERAL
1.Hemiparesis
2.Hemianaesthesia
Lateral pontine syndrome-occlusion of
anterior inferior cerebellar artery
A.IPSILATERAL
1.LMN VIIth nerve palsy
2.Gaze palsy
3.Deafness,tinnitus
4.Cerebellar signs
B.CONTRALATERAL
1.Impairment of pain and
temperature on the
body
MID BRAIN
Weber syndrome-occlusion of
perforating branch of posterior cerebral
artery
Clinical features
1.Ipsilateral
a.3rd nerve palsy
2.Contralateral
a.hemiplegia
Benedikt syndrome-occlusion of
perforating branch of posterior cerebral
Clinical features
1.Ipsilateral
a.3rd nerve palsy
2.Contralateral
a.cerebellar ataxia
Thalamus-occlusion of thalamo
geniculate branches of posterior
cerebral artery
Contralateral
1.Sensory loss
2.Spontaneous pain
3.Choreo athetosis
4.Ataxic tremor
5.Mild hemiparesisTHALAMUS
Occipital lobe-optic pathway and visual
reflexes
Occipital lobe-occlusion of left
calcarine artery
Clinical features
1.Right Hemianopia
Occipital lobe-occlusion of both
calcarine arteries
Clinical features
1.Bilateral hemianopia-
cortical blindness (light
reflex preserved)
Left occipital lobe with corpus
callosum infarction
Left
Clinical features
1.Right hemianopia
2.Alexia without
agraphia
Basilar artery occlusion
Clinical features
1.Paralysis of all four limbs
2.Bulbar paralysis
3.Eye movements
abnormalities
4.Nystagmus
5.Coma
Note: The neurological
deficit is variable depending
upon the ischemia –
modifying factors.
Differentiating features between anterior and posterior
circulation stroke
Clinical features Posterior circulation Anterior circulation
A.History
1.Vertigo Present Absent
2.Unsteadiness Present Absent
B.Physical findings
1.Crossed hemiplegia Present Absent
2.Bilateral deficits Present Absent
3.Cerebellar signs Present Absent
4.Ocular findings(LMN/INO/Gaze deviation to paralysed side) Present Absent
5.Dissociated sensory loss Present Absent
6.Sensory loss over V1 and V2 Present Absent
7.Horners syndrome Present Absent
localization of stroke, CVS, stroke,  for post graduates
localization of stroke, CVS, stroke,  for post graduates
localization of stroke, CVS, stroke,  for post graduates
localization of stroke, CVS, stroke,  for post graduates
localization of stroke, CVS, stroke,  for post graduates
localization of stroke, CVS, stroke,  for post graduates
localization of stroke, CVS, stroke,  for post graduates
localization of stroke, CVS, stroke,  for post graduates
localization of stroke, CVS, stroke,  for post graduates
localization of stroke, CVS, stroke,  for post graduates
localization of stroke, CVS, stroke,  for post graduates
localization of stroke, CVS, stroke,  for post graduates
localization of stroke, CVS, stroke,  for post graduates
Importance of clinical localisation of stroke
1. Careful clinical evaluation in combination with imaging
helps to find out the etiology of stroke and plan the
appropriate treatment.
2. Clinical observations in correlation with imaging helps to
understand neurology / neurophysiology better.
Note:Neurological examination must be tailored
according to the clinical scenario .
Limitations of clinical localisation of
stroke syndromes
1. A single syndrome may occur due to lesion at different sites
Eg. Pure motor hemiplegia
2.A vascular occlusion at a specific site can produce varying
clinical manifestations.
3.Clinical examination may not detect very small or multiple
infarctions(as in SBE).
Note:Imaging is very useful in the above situations.
localization of stroke, CVS, stroke,  for post graduates

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localization of stroke, CVS, stroke, for post graduates

  • 1. Localization of stroke syndromes Dr.M.Dhanaraj
  • 2. Localization of stroke syndromes Three steps 1.Clinical localization of the site of the lesion. 2.Identifying the vascular territory and the vessel involved. 3.Correlating with the imaging findings.
  • 3. Clinical localization of stroke syndromes Prerequisites 1.Functional anatomy of brain. 2.Blood supply to the different parts of brain.
  • 4. Blood supply of brain-Carotid Arteries
  • 5. Vertebral artery Circle of willis Blood supply of brain – vertebral artery and circle of Willis
  • 13. Middle cerebral artery infarction - superior branch Clinical features 1.Contralateral hemiplegia – face and upper limb more involved than lower limb. 2. Contralateral hemisensory loss. 3.Conjugate gaze paresis(patient looks towards the side of lesion. 4.Broca’s dysphasia (if left sided)
  • 14. Middle cerebral artery infarction - Inferior branch Clinical features 1.Contralateral hemianopia. 2.Wernicke’s dysphasia ( if left sided ) 3.Left spatial neglect ( if right sided )
  • 15. Middle cerebral artery infarction - stem occlusion Clinical features 1.Contralateral hemiplegia 2. Contralateral hemisensory loss 3. Contralateral gaze palsy 4. Contralateral hemianopia 5.Global dysphasia (Left sided lesion) 6.Anosognosia and amorphosynthesis (Right sided lesion) 7.Altered sensorium (due to edema)
  • 16. Middle cerebral artery infarction - Clinical features 1.Contralateral hemiparesis 2.Contralateral sensory loss 3.Transcortical motor / sensory aphasia ( left sided lesion) Lenticular striate artery occlusion
  • 17. Anterior cerebral artery infarction Clinical features 1.Contralateral a.paralysis of leg and foot with paresis of arm b.cortical sensory loss over leg and foot c.presence of primitive reflexes 2.Urinary incontinence 3.Gait apraxia 4.Mutism, delay and lack of spontaneity of motor acts 5.Apraxia of left sided limbs(with left sided lesion and corpus callosum involvement)
  • 18. Internal carotid artery infarction Clinical features Variable - based on the collaterals and mechanism of stroke (embolism, extension of thrombus , low flow) 1.Amaurosis fugax 2. Watershed infarctions 3.MCA/ACA- either alone or in combinations
  • 23. Lateral medullary syndrome A. IPSILATERAL 1.Xth cranial nerve palsy 2.Cerebellar signs 3.Horner’s syndrome 4.Impaired pain, temperature and touch on the upper half of face B. CONTRA LATERAL 1.Impaired pain and temperature over the body
  • 24. Medial medullary syndrome A.IPSILATERAL 1.XIIth nerve palsy B.CONTRALATERAL 1.Hemiplegia – sparing the face 2.Hemianaesthesia sparing the face.
  • 26. Medial pontine syndrome – occlusion of paramedian branch of basilar artery A.IPSILATERAL 1.Gaze paresis 2.Cerebellar signs B.CONTRALATERAL 1.Hemiparesis 2.Hemianaesthesia
  • 27. Lateral pontine syndrome-occlusion of anterior inferior cerebellar artery A.IPSILATERAL 1.LMN VIIth nerve palsy 2.Gaze palsy 3.Deafness,tinnitus 4.Cerebellar signs B.CONTRALATERAL 1.Impairment of pain and temperature on the body
  • 29. Weber syndrome-occlusion of perforating branch of posterior cerebral artery Clinical features 1.Ipsilateral a.3rd nerve palsy 2.Contralateral a.hemiplegia
  • 30. Benedikt syndrome-occlusion of perforating branch of posterior cerebral Clinical features 1.Ipsilateral a.3rd nerve palsy 2.Contralateral a.cerebellar ataxia
  • 31. Thalamus-occlusion of thalamo geniculate branches of posterior cerebral artery Contralateral 1.Sensory loss 2.Spontaneous pain 3.Choreo athetosis 4.Ataxic tremor 5.Mild hemiparesisTHALAMUS
  • 32. Occipital lobe-optic pathway and visual reflexes
  • 33. Occipital lobe-occlusion of left calcarine artery Clinical features 1.Right Hemianopia
  • 34. Occipital lobe-occlusion of both calcarine arteries Clinical features 1.Bilateral hemianopia- cortical blindness (light reflex preserved)
  • 35. Left occipital lobe with corpus callosum infarction Left Clinical features 1.Right hemianopia 2.Alexia without agraphia
  • 36. Basilar artery occlusion Clinical features 1.Paralysis of all four limbs 2.Bulbar paralysis 3.Eye movements abnormalities 4.Nystagmus 5.Coma Note: The neurological deficit is variable depending upon the ischemia – modifying factors.
  • 37. Differentiating features between anterior and posterior circulation stroke Clinical features Posterior circulation Anterior circulation A.History 1.Vertigo Present Absent 2.Unsteadiness Present Absent B.Physical findings 1.Crossed hemiplegia Present Absent 2.Bilateral deficits Present Absent 3.Cerebellar signs Present Absent 4.Ocular findings(LMN/INO/Gaze deviation to paralysed side) Present Absent 5.Dissociated sensory loss Present Absent 6.Sensory loss over V1 and V2 Present Absent 7.Horners syndrome Present Absent
  • 51. Importance of clinical localisation of stroke 1. Careful clinical evaluation in combination with imaging helps to find out the etiology of stroke and plan the appropriate treatment. 2. Clinical observations in correlation with imaging helps to understand neurology / neurophysiology better. Note:Neurological examination must be tailored according to the clinical scenario .
  • 52. Limitations of clinical localisation of stroke syndromes 1. A single syndrome may occur due to lesion at different sites Eg. Pure motor hemiplegia 2.A vascular occlusion at a specific site can produce varying clinical manifestations. 3.Clinical examination may not detect very small or multiple infarctions(as in SBE). Note:Imaging is very useful in the above situations.