stroke syndromes

• ANATOMY
• Cerebral hemisphere: Left occipital region plus splenium of corpus collosum

• VASCULAR
• Posterior cerebral artery: Collosal branches

• Neither  -  Alexia - Splenium of corpus collosum
• Contralateral - Visual loss – homonymous hemianopia -    Left occipital region

• ================================
• Pure word blindness. Can write but not read.

• ANATOMY
• Cerebral hemisphere: Posterior limb of external capsule, Pons: Basis pontis

• VASCULAR
• Middle cerebral artery: Small penetrating arteries
• Basilar artery: Small penetrating arteries

Contralateral  Weakness – upper and lower extremity Contralateral  Ataxia – arm and leg

• ANATOMY
• Cerebral hemisphere: Bilateral parietal-occipital lobes

• VASCULAR
• Posterior cerebral artery: Bilateral

• Both - Loss of voluntary but not reflex eye movements
• Both - Optic ataxia – poor visual-motor coordination
• Both - Asimultagnosia – inability to understand visual objects

• ANATOMY
• Midbrain: Tegmentum

• VASCULAR
• Posterior cerebral artery

• Contralateral - Ataxia – arm and leg
• Oculomotor palsy with contralateral tremor and ataxia

• ANATOMY
• Cerebral hemisphere: Bilateral occipital lobes
• VASCULAR
• Posterior cerebral artery: Bilateral
• Basilar artery: Top of the basilar

• Both- Visual loss – bilateral
• Both - Unawareness or denial of blindness

• ANATOMY
• Cerebral hemisphere: Dominant parietal lobe (?angular gyrus? - not listed in www.strokecenter.org)

• VASCULAR
• Middle cerebral artery

• Agraphia (inability to write)
• Acalculia (inability to calculate)
• Right-left confusion
• Finger agnosia (inability to recognize fingers)
• Ideomotor apraxia (may be associated)

aka Inferior medial pontine syndrome.

• ANATOMY
• Pons: Unilateral lesion in the dorsal pontine tegmentum in the caudal third of the pons

• VASCULAR
• Basilar artery: Paramedian branches
• Basilar artery: Short circumferential arteries

Contralateral - Weakness – upper and lower extremity   - Corticospinal tract

Ipsilateral - Weakness – face – entire side - VII nucleus / fascicle

Ipsilateral - Lateral gaze weakness - PPRF or CN VI nucleus

aka lateral medullary syndrome.

Memory aid: Think of body parts.

Mind: vertigo

Eyes: nystagmus, Horner's.

Mouth: N/V, hiccups, dysphagia, dysarthria, dysphonia

Face: ipslateral hemisensory loss (pain and temp)

limbs: ipsilateral ataxia, contralateral pain and temp loss

• VASCULAR
• Vertebral artery: Distal branches
• Vertebral artery: Superior lateral medullary artery
• Posterior inferior cerebellar artery: Less common than vertebral

Ipsilateral - Sensory loss – face – pain and temperature - CN 5 nucleus

Ipsilateral - Facial pain - CN 5 nucleus

Ipsilateral - Ataxia – arm and leg - Restiform body, cerebellum (?Inferior cerebellar peduncle?)

Ipsilateral - Gait ataxia - Restiform body, cerebellum

Ipsilateral - Nystagmus- Vestibular nucleus

Ipsilateral - Nausea / vomiting - Vestibular nucleus

Ipsilateral - Vertigo - Vestibular nucleus

Ipsilateral - Horseness - Nucleus ambiguus

Ipsilateral - Dysphagia - Nucleus ambiguus

Ipsilateral - Horner syndrome - Descending sympathetics

Contralateral - Hemisensory loss – pain and temperature - Spinothalamic tract

Neither - Hiccups

aka lateral pontine syndrome.

• VASCULAR
• Basilar artery: Long circumferential branches
• Anterior inferior cerebellar artery

Ipsilateral - Ataxia – arm and leg - Cerebellar tracts

Contralateral - Weakness – upper and lower extremity - Corticospinal tracts

Contralateral - Hemisensory loss – pain and temperature - Spinothalamic tract

• ==========================
• Lesion in the lateral pons, including the middle cerebellar peduncle.

• 1. Ipsilateral cerebellar ataxia due to involvement of cerebellar tracts
• 2. Contralateral hemiparesis due to corticospinal tract involvement
• 3. Variable contralateral hemihypesthesia for pain and temperature due to spinothalamic tract involvement

aka bilateral ventral pons.

• VASCULAR:
• basilar artery

Both - Weakness – upper and lower extremity - Quadriplegia: bilateral cortical spinal tracts

Both - Weakness – face – entire side - Bilateral corticobulbar tracts

Neither - Lateral gaze weakness - Bilateral fascicles of CN VI

Neither - Dysarthria - Bilateral corticobulbar tracts

• ==============================
• Bilateral ventral pons lesions (iscemic or hemorrhagic) may result in this deefferented state, with preserved consciousness and sensation, but paralysis of all movements except vertical gaze and eyelid opening.

• 1. Quadriplegia due to bilateral corticospinal tract involvement
• 2. Aphonia due to corticobulbar tract involvement to lower cranial nerve nuclei
• 3. Occasionally, impairment of horizontal eye movements due to bilateral involvement of the fascicles of cranial nerve
• 4. Reticular formation is spared, so the patient is typically fully awake. The supranuclear ocular motor pathways lie dorsally, so that vertical eye movements and blinking are intact.

aka Medial Medullary Syndrome.

• ANATOMY
• Medulla: Medial medulla

• VASCULAR
• Vertebral artery: Anteromedial artery
• Anterior spinal artery: Anteromedial artery
• Basilar artery

Contralateral - Weakness – upper and lower extremity - Pyramidal tract

Contralateral - Hemisensory loss – vibration and proprioception - Medial lemniscus

Ipsilateral - Tongue weakness +/- atrophy - CN 12 nucleus

• ==============================
• Rare stroke syndrome (<1% of vertebrobasilar strokes, Bassetti et al., 1994).

• Medial medullary infarct is associated with clinical triad of:
• 1. ipsilateral hypoglossal palsy,
• 2. contralateral hemiparesis, and
• 3. contralateral lemniscal sensory loss.

Variable manifestations may include isolated hemiparesis, tetraparesis, ipsilateral hemiparesis, I or C facial palsy, ataxia, vertigo, nystagmus, dysphagia.

Palatal and pharyngeal weakness rare in pure MMI, common in lateral medullary infarct.

Medial medullary syndrome (Dejerine syndrome).

• Memory aids:
• 1. remember that CN 12 is in the medulla.
• 2. remember that motor nuclei are midline.

• ANATOMY: 
• Temporal and parietal lobe, lateral and inferior aspects.

Contralateral - Visual loss – homonymous hemianopia

Contralateral - Visual loss – upper quadrant anopsia

Contralateral - Constructional apraxia - Non-dominant hemisphere

Contralateral - Aphasia – receptive - Dominant hemisphere (Wernicke’s area)

• ANATOMY:
• Lateral aspects of frontal and parietal lobes.

Contralateral - Weakness – upper and lower extremity - Face, arm > leg

Contralateral - Weakness – face – lower half

Contralateral - Hemisensory loss – upper and lower extremity

Contralateral - Sensory loss – face – all modalities

Contralateral - Hemineglect - Non-dominant hemisphere

Contralateral - Aphasia – expressive - Dominant hemisphere (Broca’s area)

Obviously, the name says it all - no eponym on www.strokecenter.org

• ANATOMY
• Cerebral hemisphere: Occipital and infero-medial temporal lobes

• VASCULAR
• Posterior cerebral artery

Contralateral - Visual loss – homonymous hemianopia - Optic pathway, calcarine cortex

• ======================
• Visual field defects are frequently the only neurological abnormalities. Other associated syndromes: alexia without agraphia, visual or color anomia.

aka thalamic pain syndrome.

• ANATOMY
• Thalamus

• VASCULAR
• Posterior cerebral artery: Penetrating branches to thalamus

• Contralateral - Hemisensory loss – all modalities
• Contralateral- Hemi-body pain

aka ventral pontine syndrome.

• ANATOMY
• Pons: Basis pontis and fascicles of CN VI amd VII

• VASCULAR
• Basilar artery: Short circumferential branches
• Basilar artery: Paramedian branches

Contralateral - Weakness – upper and lower extremity - Pyramidal tract

• Ipsilateral - Lateral gaze weakness - CN VI
• Ipsilateral - Weakness – face – entire side - CN VII

=============================

A unilateral lesion of the ventrocaudal pons may involve the basis pontis and the fascicles of cranial nerves VI and VII.

• Symptoms include:
• 1. Contralateral hemiplegia (sparing the face) due to pyramidal tract involvement
• 2. Ipsilateral lateral rectus palsy with diplopia that is accentuated when the patient looks toward the lesion, due to cranial nerve VI involvement.
• 3. Ipsilateral peripheral facial paresis, due to cranial nerve VII involvement.

Anatomically, they both affect the ventral-aspect of the pons (eg. both are ventral pontine syndromes).

However, Millard-Gubler takes out CN 7 (ipsilateral facial palsy) and CN 6, whereas Raymond's syndrome only takes out CN 6.  

Hence, Millard-Gubler = Raymond's syndrome + ipsilatl CN7.

Note: both have contralateral U/E and L/E weakness (pyramidal tract involvement).

• aka Ventral pontine Syndrome.
• aka Alternating abducens hemiplegia.

• ANATOMY
• Pons: Ventral medial pons

• VASCULAR
• Basilar artery: Paramedian branches

Ipsilateral - Lateral gaze weakness - CN VI

Contralateral - Weakness – upper and lower extremity - Pyramidal tract

• ============================
• Raymond Syndrome (Alternating abducens hemiplegia) A unilateral lesion of the ventral medial pons, which affects the ipsilateral abducens nerve fascicles and the corticospinal tract but spares cranial nerve VII.

• 1. Ipsiplateral lateral rectus paresis, due to cranial nerve VI involvement
• 2. Contralateral hemiplegia, sparing the face, due to pyramidal tract involvement

• ANATOMY
• Midbrain: Base

• VASCULAR
• Posterior cerebral artery: Penetrating branches to midbrain

Contralateral - Weakness – upper and lower extremity - Corticospinal tract

Ipsilateral - Lateral gaze weakness????? - CN 3 QUESTIONABLE - all 'google' sources state 'lateral gaze palsy'... but they look like they are coming from the same source.  Red book says 'CN 3 palsy'... which technically should be difficulty adducting eye (eg. medial gaze palsy!!).  Evan, what do you think?

• 1. corticobulbar tracts - dysathria
• 2. corticospinal tracts - tetraparesis
• 3. bilateral CN 6 fasciculi - horizontal eye paresis

note: cognition and vertical eye movements intact.