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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)

• 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

• 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
+/- 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

• Ipsilateral 12th nerve palsy,
contralateral loss of position and
vibratory sense (medial medullary
syndrome--Dejerine syndrome)

• Vertebral artery, anterior spinal artery-paramedian medullary perforators

• Ipsilateral ataxia
+ Contralateral hemiparesis
• Ipsilateral ataxic hemiparesis
Facio-brachial weakness
Associated symptoms

Anatomy & vascular territory

transient urinary incontinence.Sensory loss Anatomy & vascular territory Internal carotid artery territory: • Bilateral hemispheric Anterior spinal artery territory: • Bilateral medullary pyramids • Spinal cord infarction • Locked-in syndrome +/. agitation. abulia.Supranuclear vertical gaze palsy Bilateral weakness .• Cognitive and behavioral abnormalities (abulia. shoulder weakness. akinetic mutism • Anterior cerebral artery complete territory Brachial weakness Associated symptoms • Cortical sensory loss.hemiparesis Associated symptoms +/. left hand apraxia.brachial weakness Basilar artery territory: • Bilateral paramedian pontine or mesencephalic .Transcortical motor aphasia or mutism. gegenhalten. hyperactivity. disturbance of volitional saccadic eye movements Anatomy & vascular territory • Borderzone territory between anterior and middle cerebral artery • Middle cerebral artery superficial territory: cortical infarct Bilateral weakness . mood disturbances • Superficial borderzone territory between anterior and middle cerebral artery • Sensory loss. grasp reflex. alien hand sign. 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 +/.

cheiro-oral-pedal syndrome • Middle cerebral artery •Thalamogeniculate pedicle • Basilar artery: deep perforating or medullary arteries . spasmodic laughing or crying • Middle cerebral artery bilateral opercular branches + Pyramidal signs. abulia. hemianopsia. impairment of 2-point discrimination. intellectual impairment • Anterior choroidal artery: bilateral perforating branches + Pyramidal or cerebellar signs.Associated symptoms Anatomy & vascular territory • Bilateral anterior watershed infarctions (man-in-a-barrel syndrome) • Vertigo.pseudobulbar palsy Associated symptoms Anatomy & vascular territory • Facio-pharyngo-glosso-masticatory diplegia with automatic-voluntary dissociation. aphasia or hemineglect pseudothalamic parietal sensory syndrome Anatomy & vascular territory • Middle cerebral artery--parietal branches • Faciobrachiocrural elementary sensory loss • Restricted acral sensory syndrome: cheiro(hand)-oral. grasp. agraphesthesia. distal amyotrophy Bilateral weakness . urinary incontinence • Anterior cerebral artery bilateral • Sensory level.Hemiparesis. cheiro-pedal.paraplegia Associated symptoms • Anterior spinal artery watershed (“snake-eyes” infarction) (Pullicino 1994) Anatomy & vascular territory • Akinetic mutism. astereognosis +/. somatotopagnosia. urinary incontinence • Anterior spinal artery infarction Bilateral weakness . lack of dementia • Basilar artery paramedian branches Sensory strokes Associated symptoms • Loss of position sense.

vertigo. tinnitus. Horner syndrome. gait imbalance Associated symptoms Anatomy & vascular territory +/. proximal posterior cerebral artery Cerebellar ataxia . Horner syndrome. paroxysmal pain +/.Supranuclear vertical gaze palsy Anatomy & vascular territory • Basilar or posterior cerebral artery-P1--paramedian perforators + Defective convergence or convergence-retraction nystagmus + Light-near dissociation (Parinaud syndrome) • Dorsal rostral midbrain syndrome • Vertigo. peripheral 7th nerve palsy. Horner syndrome. ipsilateral facial thermalgesia (5th cranial nerve). 4th nerve palsy • Superior cerebellar artery: cerebellar + midbrain tegmentum infarction territory + 3rd nerve palsy + Hemichoreoathetosis (Benedikt syndrome) Cerebellar ataxia Associated symptoms +/. choreoathetoid movements.limb ataxia. transient hemiparesis. ocular tilt reaction. pontine tegmentum.Lateropulsion. facial hypesthesia. nystagmus. nausea and vomiting. hemiataxia. contralateral thermalgesia of the limbs and trunk • Anterior inferior cerebellar artery-pontocerebellar infarction Ataxic hemiparesis . nausea. vomiting. horizontal nystagmus.• Small strokes in lateral thalamus. parietal cortex. thalamic astasia.Hemianopsia (Dejerine-Roussy syndrome) • Thalamogeniculate territory. corona radiata. thalamic hand. dysarthria. XI). X. • Hemianesthesia. (nucleus ambiguous: IX.Vertigo. dysarthria. dysphonia and dysphagia. ipsilateral hearing loss. contralateral thermalgesia of trunk and limbs (Wallenberg syndrome) • Vertebral artery brainstem branches from vertebral artery occlusion Contralateral analgesia or thermalgesia +/. midbrain.

sectoranopia Associated symptoms • Internal carotid artery territory ischemia Anatomy & vascular territory • Wedge-shaped defect straddling the horizontal median. or posterior cerebral artery--watershed infarction +/.quadrantanopia (inferior noncongruent) Associated symptoms Anatomy & vascular territory + Optic ataxia. difficulty judging size.Cortical hypesthesia.clumsyhand syndrome) • Thalamogeniculate or basilar artery or middle cerebral artery--lacunar infarctions in pons.quadrantanopia (superior noncongruent) Associated symptoms Anatomy & vascular territory • Middle cerebral artery inferior division (temporal optic radiations) Visual symptoms . thalamus. receptive) • Middle or posterior cerebral artery superficial watershed. middle. pointing towards fixation • Posterior choroidal artery .monocular blindness (amaurosis fugax) Associated symptoms Anatomy & vascular territory +/. transcortical sensory. distance.Dysarthria (dysarthria.Associated symptoms Anatomy & vascular territory +/. movement • Anterior. medulla + Aphasia • Middle cerebral artery-parainsular Visual symptoms .lateral geniculate body infarction • Sector defects adjacent to the vertical meridian. internal capsule.Contralateral variable motor and hemisensory deficit Visual symptoms .quadrantanopia (inferior congruent) Associated symptoms Anatomy & vascular territory • Posterior cerebral artery--upper bank calcarine fissure Visual symptoms . aphasia (anomia.Sensory symptoms +/.visual-field defects . sparing the zone around the horizontal meridian • Anterior choroidal artery--lateral geniculate body infarction Visual symptoms . middle cerebral artery (parietal optic radiations) Visual symptoms .quadrantanopia (superior congruent) Associated symptoms Anatomy & vascular territory .

agitated delirium or confusion. abnormal behavior • Posterior or middle cerebral artery or basilar artery: paramedian midbrain and thalamus. + inversion of the sleep-wake cycle (peduncular hallucinosis) • Basilar artery or posterior cerebral artery. ataxia • Anterior choroidal artery territory + Hemiparesis. sensory loss. nonstereotyped • Posterior cerebral artery territory stroke • Complex. transient or persistent.hemianopsia Associated symptoms Anatomy & vascular territory • Isolated. simple or complex. release hallucinations.• Posterior cerebral artery--lower bank calcarine fissure Visual symptoms . mediotemporal and callosal branches) + Cortical blindness (if bilateralAnton syndrome).visual hallucinations Associated symptoms • Middle or posterior cerebral artery watershed (upper bank of calcarine fissure) • Posterior cerebral artery territory stroke Anatomy & vascular territory • In the hemianoptic field. prosopagnosia + Simultanagnosia. paramedian perforators Encephalopathic symptoms Associated symptoms Anatomy & vascular territory • Agitated delirium. 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 .hemiparesis. +/. aphasia or neglect • Middle cerebral artery--optic radiation infarction • Left middle cerebral artery • Alexia without agraphia • Posterior cerebral artery territory (occipital. visual and color agnosia. ocular apraxia (Balint syndrome) • Posterior cerebral artery bilateral (lower bank of calcarine fissure) Visual symptoms . detailed. hemisensory loss. ocular ataxia. hippocampus.

caudate nucleus (anterior cerebral artery territory) . manic behavior • Medial frontal lobe. and parietal lobe infarction • Abulia. inferior frontal.• Middle cerebral artery territory—right temporal.