Εγκεφαλικά Ημισφαίρια &

Αγγειακά Σύνδρομα
ΠΑΝΑΓΙΩΤΗΣ ΜΗΤΣΙΑΣ
ΚΑΘΗΓΗΤΗΣ ΝΕΥΡΟΛΟΓΙΑΣ, ΙΑΤΡΙΚΗ ΣΧΟΛΗ, ΠΚ
ΔΙΕΥΘΥΝΤΗΣ ΝΕΥΡΟΛΟΓΙΚΗΣ ΚΛΙΝΙΚΗΣ ΠΑΓΝΗ
Cortical Regions (Φλοιϊκές Περιοχές)
o Primary motor cortex (πρωτεύων κινητικός φλοιός)
… precentral gyrus of the frontal lobe

o Primary somatosensory cortex (πρωτεύων αισθητικός φλοιός)

… postcentral gyrus of the parietal lobe

o Primary visual cortex (πρωτεύων οπτικός φλοιός)

… calcarine cortex of the posterior occipital lobe

o Primary auditory cortex (πρωτεύων ακουστικός φλοιός)

… superior temporal gyrus of the temporal lobe.

Knowing the locations of the motor cortex and these three primary sensory cortices allows for a
logical deduction o the functions of the rest of the cortical surface
Dominant vs. Non-dominant Hemisphere
Επικρατητικό - Μη-επικρατητικό Ημισφαίριο)
o The hemisphere contralateral to the side of handedness is considered the dominant
hemisphere
₋ e.g., the left hemisphere in a right-handed patient

o The hemisphere ipsilateral to the side of handedness is considered the non-dominant

hemisphere
₋ e.g., the right hemisphere in a right-handed patient

o Most patients are right-handed, so their left hemisphere is the dominant hemisphere
o Language dysfunction (διαταραχή λόγου) is most commonly due to lesions in the dominant
(usually left) hemisphere
o Neglect (αμέλεια) is most commonly due to lesions in the non-dominant (usually right)
hemisphere (causing left-sided neglect)
 Parietal Lobes – Sensation
Βρεγματικοί Λοβοί - Αισθητικότητα
Primary Sensory Modalities
− Pain and Temperature
− Pallesthesia (παλλαισθησία)
− Joint position sense (θέση μελών στο
χώρο-ιδιοδεκτικότητα)

Cortical Sensory Modalities

− 2-point discrimination
− Graphesthesia
− Stereognosis
− Sensory attention(inattention)
Parietal Lobes:
Spatial Attention (χωρική αντίληψη)
❖ The parietal lobe regions bounded by the somatosensory cortex anteriorly and the visual
cortex posteriorly are ideally situated to combine visual and spatial information, playing roles
in awareness of the body in space, spatial reasoning, and mathematical processing.
❖ The projection from the occipital lobe superiorly to the parietal lobe (the dorsal stream) is
referred to as the “where” pathway:
… Visual information is processed here to determine where things are in space with respect to the body
… Lesions here can cause neglect:
❖ The patient is unaware of one half of the world.
❖ Neglect is more common with lesions in the nondominant parietal lobe, which is most commonly the right parietal lobe causing
left-sided neglect.
… Examination findings in patients with neglect may include extinction to double simultaneous stimulation, lack of awareness of
deficits (anosognosia; e.g., not acknowledging that a paretic limb is weak despite inability to move it), and in severe cases,
inability to recognize the neglected body parts as one’s own)
❖ Lesions in the angular gyrus of the dominant (usually left) parietal lobe can cause Gerstmann’s syndrome:
… left-right confusion, inability to count (acalculia), inability to name the fingers (finger agnosia), and inability to write (agraphia)
Parietal Lobes:
Praxis (ευπραξία)
• Parietal lesions can also cause difficulty performing a complex learned action – apraxia
₋ This can be demonstrated by asking a patient to mime an action (e.g., “pretend you are taking out a pack of
matches and lighting one,” or “pretend you are brushing your teeth”).
• There are several types of apraxia:
÷ Limb-kinetic apraxia (κινητική απραξία):
÷ a loss of dexterity in performing actions
÷ Ideational apraxia (ιδεατή απραξία):
÷ inability to conceive of the idea of how to accurately perform an action, leading to errors in how the action is performed
÷ Ideomotor apraxia (ιδεοκινητική απραξία):
÷ inability to convert an idea about how to do something into a motor plan. Affected patients may be able to explain the intended action
but are unable to perform it normally, making errors in sequencing and/or timing o the component movements o complex learned
actions.

• Although these terms are commonly confused, their names provide clues to what they signify:
₋ kinetic is difficulty with movements themselves
₋ ideational is loss of the idea of how to perform an action
₋ ideomotor is difficulty translating an idea into a motor plan.
₋ The latter two types of apraxia are generally caused by lesions of the parietal lobe in the dominant (usually
left) hemisphere
Temporal Lobes (κροταφικοί λοβοί):
Recognition Memory (μνήμη αναγνώρισης)
▪ The temporal lobes are ideally located to combine sensory input from olfactory, auditory,
visual, and somatosensory cortices.
▪ The temporal lobes are thus ideally suited to play a role in recognition memory, since
memories are internal representations o sensory experiences. Lesions o the medial temporal
lobes (including the hippocampus) can cause amnesia
▪ The flow of visual information inferiorly to the temporal lobe (the ventral stream) is referred
to as the “what pathway:”
▪ Visual information is processed here to determine what things are (recognition memory).

▪ The dominant (usually left ) inferior temporal lobe houses the visual word form area
necessary for reading, and the nondominant (usually right) inferior temporal lobe houses the
face recognition area.
▪ Inability to read is called alexia and inability to recognize aces is referred to as prosopagnosia.
 Fontal Lobes – Motor
Μετωπιαίοι Λοβοί - Κίνηση
Frontal Lobe
Horizontal Gaze (οριζόντιο βλέμμα)

The signal to voluntarily move the eyes comes

from the frontal eye fields (Brodmann Area 8).
Just as each hemisphere controls the contralateral
side of the body and sees the contralateral visual
field, the frontal eye elds send the eyes to the
contralateral side:
 Stroke vs. Seizure
Αγγειακό Εγκεφαλικό Επεισόδιο – Επιληπτική Κρίση
Frontal and Temporal Lobes:
Language (Λόγος)
➢ The inferior frontal gyrus lies in proximity to the auditory and motor cortices and is adjacent to
the premotor cortex or the ace. It is therefore ideally positioned to combine auditory and
motor functions or speech production.
➢ The inferior frontal gyrus houses Broca’s area for speech production.
➢ Wernicke’s area for speech recognition lies at the junction of the auditory cortex (superior
temporal gyrus) and the parietal cortex, where auditory regions are adjacent to parietal
regions involved in awareness of one’s surroundings.
➢ In most righthanded patients, language is localized to the left hemisphere, and this is true in
many left -handed patients as well.
➢ However, in some patients (more commonly left-handed patients), language may localize to the right hemisphere.

➢ Lesions in and around Broca’s and Wernicke’s areas lead to speech disturbances (aphasia).
Αφασία (Διαταραχή Λόγου)
Aphasias (Language Deficit)
Aphasias are language deficits

Aphasias are categorized based on the patient’s ability to:

→ produce speech
→ comprehend speech
→ repeat words and phrases
Broca’s aphasia (μη ευφραδής ή εκφραστική αφασία):
• The primary deficit is in production of speech (non-fluent or expressive aphasia), but the patient can
generally still comprehend.
• Patients with Broca’s aphasia may have difficulty with comprehension of grammatically complex phrases
• In the most severe Broca’s aphasias, the patient is mute.
• When less severe, the patient may have effortful speech with frequent errors.
• Since comprehension is generally largely preserved in Broca’s aphasia, the patient is aware of and
frustrated by the inability to speak.
• In a pure Broca’s aphasia, the patient cannot repeat phrases stated by the examiner but can comprehend
(i.e., can follow commands).

Transcortical motor aphasia:

• A patient has an expressive aphasia with preserved repetition
Wernicke’s aphasia (αφασία πρόσληψης – ευφραδής αφασία)
• Comprehension is impaired (receptive aphasia), and although the prosody (melody and rhythm) of
speech is preserved (fluent aphasia), the content is nonsensical.
• The patient cannot understand his or her own nonsensical speech, and so may not appear
concerned by the deficit.
• In pure Wernicke’s aphasia, a patient cannot repeat phrases.

Transcortical sensory aphasia.

• If repetition is preserved in a receptive aphasia
Global aphasia:
• If both production and comprehension are impaired, this is called a

Mixed transcortical aphasia:

• Rarely, patients with both productive and receptive aphasia are still able to repeat what they hear

Note
• All of the transcortical aphasias are characterized by preserved repetition, and named for the
primary language deficit:
• transcortical motor aphasia is characterized by a deficit in speech production (motor output)
• transcortical sensory aphasia is characterized by a deficit in speech comprehension (“sensation” of speech)
• mixed transcortical aphasia is characterized by a mix of both expressive and receptive aphasia
Conduction aphasia (αφασία αγωγής)
• If a patient’s only language deficit is repetition with preserved comprehension and production
• Conduction between Wernicke’s area and Broca’s area (via the arcuate fasciculus) is disrupted.

MR Diffusion Tensor Tractography – In-vivo Anatomy

o Sudden-onset aphasia:
o most commonly due to stroke in the left middle cerebral artery territory
o can also be due to a seizure or postictal state if the seizure activity originates in or spreads to
language regions.

o Subacute development of aphasia:

o left-sided chronic subdural hematoma
o tumor affecting language regions.

o Insidious development of aphasia:

o neurodegenerative diseases, such as primary progressive aphasia
 Μετωπιαίοι Λοβοί - Επιτελικές Λειτουργίες
Frontal Lobes - Executive Functions
The frontal lobes support executive
functions including working memory,
decision making, abstract reasoning, and
emotional processing.
Frontal lobe lesions can cause:
₋ abulia:
₋ decreased initiative
₋ decreased motivation
₋ decreased speech
₋ decreased emotional response
₋ behavioral disinhibition
₋ impairments in any o the above
executive functions
Υποφλοιώδεις Δομές: Θάλαμος και Βασικά Γάγγλια
Subcortical Structures: Thalamus and Basal Ganglia

The thalamus and basal ganglia are

“islands” of gray matter in the subcortical
white matter
Both are nodes in a variety of circuits that
begin and/or end in the cortex, brainstem,
and/or cerebellum
Thalamus
o The left and right thalamus are positioned on either side of the third ventricle, just superior to
the midbrain.
o The thalamus is a collection of nuclei, most o which project to one or more cortical regions
o only the reticular nuclei do not project to the cortex, but rather to other thalamic nuclei

o Four basic types of circuitry pass through thalamic nuclei en route to the cortex:
 Thalamic Circuitry (θαλαμικά κυκλώματα)
1. Sensory pathways.
÷ All sensory pathways synapse in the thalamus, which transmits sensory in formation to the respective
sensory cortices.
÷ Smell is the only sensory modality that reaches the cortex before the thalamus (transmitted directly to the
olfactory cortex, which then transmits smell in formation to the thalamus (dorsomedial nucleus)
2. Motor control pathways.
÷ The ventral anterior (VA) and ventral lateral (VL) nuclei of the thalamus participate in cortical–basal
ganglia–cortical loops and cerebellar–cortical pathways
3. Consciousness/arousal pathways.
÷ These pathways begin in the brainstem reticular activating system and project to both thalami, which in
turn project diffusely throughout the cortex
4. Cognition/emotion pathways.
÷ Corticocortical loops pass through the thalamus, playing roles in diverse cognitive functions.
÷ The circuit of Papez which participates in memory and emotion: hippocampus→ fornix→mamillary
bodies→anterior nucleus of the thalamus→anterior cingulate→entorhinal cortex→hippocampus.
➢ Individual thalamic nuclei can be affected by small strokes
• e.g., lacunar stroke in ventral posterior medial/ventral posterior lateral [VPM/VPL] thalamic nuclei causing contralateral sensory
loss

➢ Larger lesions of the thalamus can cause decreased level o consciousness

➢ The thalamus is commonly affected by hypertensive hemorrhage, which also often affects the
adjacent posterior limb of the internal capsule
• contralateral hemiparesis/hemiplegia + contralateral hemisensory loss + depressed level of consciousness

➢ Given its diffuse connections with diverse cortical regions, lesions of the thalamus are said to
be able to “do anything” (i.e., cause any type of deficit), including causing “cortical” signs (e.g.,
aphasia, neglect, cognitive deficits) and eye movement abnormalities (in part due to effects on
nearby midbrain pathways or eye movements).
The Basal Ganglia (Βασικά Γάγγλια)
• The basal ganglia include the caudate (κερκοφόρος πυρήνας), putamen (κέλυφος), globus
pallidus (ωχρά σφαίρα), and subthalamic nucleus (υποθαλάμιος πυρήνας)
• The caudate and putamen together are referred to as the striatum (ραβδωτό σώμα)
• The putamen and globus pallidus together are referred to as the lenticular nuclei (φακοειδής
πυρήνας).
• The basal ganglia are part of circuits that initiate and coordinate movements
• Dysfunction in the basal ganglia leads to movement disorders (e.g., Parkinson’s disease)
• When the basal ganglia are affected by cerebrovascular disease, the surrounding internal
capsule (έσω κάψα) is also often affected, causing the predominant manifestation to be
contralateral weakness, with movement disorders being relatively uncommon in this scenario.
• One exception is stroke o the subthalamic nucleus, which can produce contralateral hemiballismus
(unilateral ballistic movements).
• Slower growing lesions involving the basal ganglia (e.g., tumors, toxoplasmosis) can cause
contralateral movement disorders
 Arterial Supply of the Cerebral
Hemispheres
➢ The brain, brainstem, and cerebellum are supplied by arteries
arising from:
… the paired internal carotid arteries (the anterior circulation)
… the paired vertebral arteries (the posterior circulation)
➢ The internal carotid arteries arise from the common carotid
arteries, which themselves arise from the aortic arch (from the
brachiocephalic trunk on the right and directly from the aortic arch
on the left)
➢ Each carotid artery ultimately gives rise to:
… middle cerebral artery (MCA)
… anterior cerebral artery (ACA)
… these arteries together supply the majority o the cerebral hemispheres
including the frontal lobes, parietal lobes, and superior and lateral
temporal lobes
➢ Each internal carotid artery also gives rise to:
… ophthalmic artery (which supplies the retina)
… anterior choroidal artery (which supplies the posterior thalamus and
internal capsule)
➢ The vertebral arteries arise from the subclavian arteries, join to form the basilar artery at
around the level of the pontomedullary junction, and end by giving o the posterior cerebral
arteries (PCAs) at the level of the upper midbrain
➢ The PCAs supply the regions o the cerebral hemispheres not supplied by the MCAs and ACAs:
• occipital lobes
• inferior and medial temporal lobes.

➢ Before giving rise to the PCAs, the vertebrobasilar system gives to three paired circumferential
arteries that supply the lateral brainstem and cerebellum
• superior cerebellar arteries [SCAs]
• anterior inferior cerebellar arteries [AICAs]
• posterior inferior cerebellar arteries [PICAs]
o The anterior circulation and posterior circulation are linked by the posterior communicating
arteries
o The ACAs are linked by the anterior communicating artery.
o These connections form the circle of Willis on the inferior surface of the brain, which provides
routes or collateral flow.
o Not all patients have a complete circle of Willis, and some patients have anatomic variants
Magnetic Resonance Angiography
CT Angiography
Anatomic variants of intracranial vessels
❑ Hypoplastic vertebral artery.
▪ Many patients have one dominant vertebral artery and a smaller hypoplastic nondominant vertebral artery.
▪ When this occurs, the basilar artery appears to swing to the side o the nondominant vertebral artery, and
the vertebral canal is smaller on the side o the congenitally smaller vertebral artery. These features help to
distinguish a congenitally smaller vertebral artery from a pathologically smaller one (e.g., due to dissection
or atherosclerosis).
❑ Azygous ACA:
▪ both ACAs emerge from a common trunk
❑ Fetal PCA:
▪ the PCA arises from the internal carotid artery rather than the top o the basilar. This variant may occur
unilaterally or bilaterally
❑ Artery of Percheron:
▪ a single artery from one o the PCAs supplies both thalami (rather than an individual supply on each side).
The Vascular Territories of the ACA, MCA, and PCA
o Most generally, the ACAs and MCAs supply the anterior, medial, and lateral aspects o the
hemispheres, and the PCAs supply the posterior and inferior aspects.
o On the cortical surface:
o the MCAs supply the lateral surface of the frontal, temporal, and parietal lobes
o the ACAs supply the medial surface o the frontal and parietal lobes
o the PCAs supply the occipital lobes and the inferior temporal lobes.

o Extending subcortically:
o the MCAs supply the majority of the hemispheres, creating a trapezoidal shape in the axial plane—
anteriorly
o medially to this trapezoid are supplied by the ACAs
o posteriorly and inferiorly are supplied by the PCAs (including the thalamus, which is supplied by
penetrating vessels arising rom the PCAs and posterior communicating arteries).
Watershed (Borderzone) Territories
❖ The watershed (borderzone) territories are the regions at the border of two arterial territories.
❖ The MCA-ACA and MCA-PCA borderzones are the most commonly discussed borderzones
❖ There is also a borderzone between AICA and PICA, as well as a deep borderzone territory
between the lenticulostriate branches o the MCA (penetrating rom below) and the
leptomeningeal branches of the MCA (penetrating from above).
▪ Although the common teaching is that borderzone infarction is due to hypoperfusion, borderzone
strokes can also be caused by emboli: the smallest possible emboli travel as distally as possible before
causing an occlusion, they will arrive at the end-arterial territories, which are the borderzones.

❖ So although borderzone infarction can certainly be due to hypoperfusion, this is not always the
cause, and an embolic etiology should also be considered as the etiology of borderzone
infarction
Clinical Syndromes Associated With Cerebral
Vascular Territories
Any artery or arterial branch may be affected by ischemic stroke, with corresponding symptoms
related to the location and size o the infarct.

Neurology is learnt stroke by stroke

MCA Territory Infarction
• The MCA territory includes the majority o the cerebral hemisphere, including portions of the frontal,
temporal, and parietal lobes with the exception o the anterior, medial, and superior frontal lobes
and the medial and superior parietal lobes (supplied by the ACA), and the occipital and inferior
temporal lobes (PCA territory).
• The functional regions supplied by the MCA therefore include:
₋ the motor and premotor regions
₋ somatosensory cortex
₋ the frontal eye fields
₋ the language areas (found on the left in the majority of patients)
₋ parietal regions responsible for spatial attention (right parietal lesions may cause left-sided neglect)
₋ the superior and inferior radiations of the visual pathways as they pass through the parietal and temporal
lobes, respectively.
• A full left MCA syndrome causes right hemiplegia and hemisensory loss, aphasia, gaze deviation
toward the left , and right homonymous hemianopia.
• A full right MCA syndrome causes left hemiplegia and hemisensory loss, left-sided neglect, gaze
deviation to the right, and left-sided homonymous hemianopia.
The MCA stem (στέλεχος) is called the M1
segment of the MCA
The MCA stem gives off the lenticulostriate
(φακοραβδωτές αρτηρίες) penetrating
branches that supply the basal ganglia and
internal capsule before dividing into superior
and inferior branches known as the M2
divisions
ACA Τerritory Infarction
o ACA strokes cause contralteral hemiparesis
affecting the leg>arm>face
o ACA stroke can also cause cognitive changes
such as abulia.
o The ACAs are connected by the anterior
communicating artery.
o Proximal to the anterior communicating
artery, the ACAs are labeled A1 segments
o Distal to the anterior communicating artery,
they are labeled A2 segments
DWI-MRI
ACA Territory
Infarction
Azygous ACA
In some patients, both ACAs arise rom a common trunk
(azygous ACA)
Occlusion of both ACAs simultaneously can cause acute
paraplegia, mimicking acute spinal pathology.
◦ The presence o cognitive symptoms usually distinguishes
bilateral ACA infarction rom acute spinal cord pathology.
Typically, the MCA supplies the face and arm areas on the lateral surface of the homunculus and
the ACA supplies the leg area
MCA strokes cause contralateral face and arm weakness >> leg weakness
ACA strokes cause contralateral leg weakness >> face and arm weakness
This is true for strokes affecting the cortical surface.
◦ However, the motor fibers join subcortically and travel together, so a stroke that affects the subcortical
white matter pathways can cause a complete contralateral hemiparesis or hemiplegia affecting the ace,
arm, and leg (e.g., a lacunar stroke in the posterior limb o the internal capsule or a full MCA territory
infarct affecting the cortex and subcortical white matter).
CT scan - MCA Territory Infarction
Recurrent Artery of Huebner Territory Infarction
The recurrent artery o Huebner is a branch o the ACA that supplies the head of the caudate and
the adjacent internal capsule.
Infarction can cause contralateral hemiparesis and/or movement disorder, which may be
accompanied by cognitive deficits.
Anterior Choroidal Artery Territory Infarction
The anterior choroidal artery branches directly from the
internal carotid artery
The AChA supplies the posterior thalamus (including the
lateral geniculate nucleus) and the internal capsule
(including descending motor and ascending
thalamocortical pathways).
Infarction in the territory of the anterior choroidal artery
can cause contralateral visual field defects, contralateral
hemiparesis, and/or contralateral hemisensory loss, and
can also cause cortical signs (e.g., neglect if the right
hemisphere is affected) due to interruption of
thalamocortical pathways.
PCA Territory Infarction
The PCAs supply the occipital lobes, inferior medial
temporal lobes, and the thalami.
Depending on the extent of infarction in the PCA
territory, deficits can include:
x contralateral homonymous hemianopia or superior
quadrantanopia,
x impaired short-term memory
x inability to read with spared ability to write (alexia
without agraphia)
x decreased ability to recognize faces (prosopagnosia)
x changes in cognition or level of arousal (if there is
thalamic involvement).
DWI-MRI - PCA Territory Infarction
o The PCAs are connected to the anterior circulation by
the posterior communicating arteries
o Proximal to each posterior communicating artery, the
PCA is called the P1 segment, and distal to the
posterior communicating artery, it is called the P2
segment
o In some patients, one or both PCAs arise from the
internal carotids rather than the top of the basilar
artery, a variant referred to as a fetal PCA
Artery of Percheron
In some patients, the left and right thalami are both
supplied by a single artery that arises rom the PCA,
referred to as the artery of Percheron.
Occlusion of this artery can lead to bi-thalamic infarction
causing acutely altered mental status. This is a rare
global, rather than focal, stroke syndrome
Lacunar Strokes (κενοτοπιώδη/κενοχωριώδη ΑΕΕ)
Lacunar strokes are caused by occlusion of small penetrating arteries affecting the subcortical white matter
(internal capsule), subcortical gray matter (basal ganglia, thalamus), or anterior pons.
Lacunar stroke syndromes include:
• Pure motor stroke:
unilateral hemiparesis/hemiplegia due to involvement o the posterior limb o the internal capsule or the anterior pons.

• Pure sensory stroke

unilateral hemisensory loss due to involvement o the VPL/VPM nuclei o the thalamus

• Ataxic-hemiparesis:
unilateral hemiparesis/hemiplegia (due to involvement o the corticospinal tract) with ataxia in the weak limb(s) due to
interruption o the corticopontocerebellar fibers destined or the middle cerebellar peduncles
this can occur due to lacunar stroke in either the internal capsule or the anterior pons, both of which are places where
the corticospinal tract and corticopontocerebellar fibers run together

• Dysarthria–clumsy hand:
dysarthria and unilateral upper limb ataxia
localization is the same as or ataxia-hemiparesis (internal capsule or anterior pons).
 Pure Motor Stroke Pure Sensory Stroke Ataxic Hemiparesis
Posterior Limb of Internal Capsule Thalamus Basis Pontis
Infarction in the Watershed
(Borderzone) Territories
o The MCA-ACA watershed regions span the “stripes” at
the border o the two territories.
o Τhe part of the motor homunculus supplied by the MCA-
ACA watershed region includes the proximal arm and leg,
which are joined at the shoulder and hip in the
homunculus.
o Infarction in the MCA-ACA borderzone can cause
proximal arm and leg weakness with preserved strength
distally in the hands and feet.
• When this occurs bilaterally, it causes what is called the “person in a
barrel” syndrome since the distal arms and legs function well but the
proximal limbs are weak (simulating a person in a barrel with the hands and
feet sticking out).
The MCA-PCA watershed region is at the
parietooccipital junction.
When the MCA-PCA watershed region is affected
bilaterally, the patient will often have deficits in
visual attention that can include some or all of the
elements of Balint’s syndrome:
◦ optic ataxia,
◦ ocular apraxia,
◦ simultanagnosia