STROKE SYNDROMES MAIN SYMPTOM HEMIPARESIS (FACIOBRACHIOCRURAL WEAKNESS) ASSOCIATED SYMPTOMS

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)