SINDROMES POR ISQUEMIA CEREBRAL

Racimo de signos y sntomas ocasionados por la oclusin de una

arteria (debido a una lesin aterotrombtica o emblica) del sistema
nervioso central.
classification
Large vessel stroke within the anterior
circulation
Large vessel stroke within the posterior
circulation
Small vessel disease of either vascular bed
Cerebral circulation
Anterior circulation- MCA, ACA, and Anterior
choroidal artery
Posterior circulation-Vertebral artery, Basilar
artery and Posterior cerebral artery
Circle of Willis
Anterior and posterior circulation
Stroke within the anterior circulation
Due to occlusion of Internal carotid artery and
its branches
Middle cerebral artery, Anterior cerebral artery
and Anterior choroidal artery

Middle cerebral Artery
M1 segment(proximal)- deep penetrating or
lenticulostriate branches Internal capsule,
caudate nuclues, putamen and outer pallidus
M1 segment
Cerebral Hemisphere in coronal Section
M2 Segment
M2(distal)- superior and inferior divisions- the
entire superolateral surface of frontal and
parietal lobe except frontal pole, strip along the
superomedial frontal and parietal cortex,
occipital lobe convolutions and medial
temporal cortex
M2 segment
Complete MCA syndrome
Contralateral hemiplegia
Contralateral hemianaesthesia
Contralateral homonymous hemianopia
Gaze preference to the ipsilateral side
If dominant hemisphere involved-Global aphasia
If non dominant hemisphere involved- Hemispatial
neglect, anasognosia and constructional apraxia
Partial syndromes
M1 syndrome-occlusion of lenticulostriate
branches-
If ischemia of internal capsule produces pure
motor or sensorymotor stroke contralateral to
the side of lesion
If ischemia of putamen, pallidus- predominantly
parkinsonian features
Cerebral Hemisphere in coronal Section
M2 syndromes
If superior division involved
Brachial syndrome- weakness of hand and arm
Frontal opercular syndrome-Brocas aphasia with facial
weakness with or without arm weakness
proximal part of the superior division involved- clinical
features of motor weakness, sensory disturbances and brocas
aphasia
M2 syndrome
If inferior division of M2 involved-
If dominant hemisphere- Wernickes aphasia without
weakness with contralateral homonymous superior
quadrantanopia
If non dominant hemisphere- Hemispatial neglect , spatial
agonosia without weakness
M2 segment
Anterior Cerebral artery
A1 segment- from internal carotid to anterior
communicating artery- branches to anterior
limb of internal capsule, anteroinferior caudate,
anterior hypothalamus
A2 segment-distal to anterior communicating
artery- supplies frontal pole, entire medial part
of cerebral hemispheres


Precommunal A1 segment
Post communal A2 segment
A1 segment
A1 segment occlusion rarely produces clinical
syndrome because collateral flow through
anterior communicating artery and collaterals
from MCA and PCA
A2 syndrome
Motor area for leg and foot-c/l paralysis of foot and leg
Sensory area for foot and leg-c/l cortical sensory loss of
foot and leg
Sensorimotor area in paracentral lobule-urinary
incontinence
Medial surface of posterior frontal lobe-c/l grasp and
suckling reflex
Cingulate gyrus and the medial inferior portions of
frontal, parietal and temporal lobes-abulia

Anterior choroidal artery
Supplies posterior limb of internal capsule,
retrolentiform and sublentiform parts
Complete syndrome rare due to collaterals from
MCA, PCA, and ICA
Syndrome comprises
c/l hemiplegia
c/l hemianaesthesia
c/l homonymous hemianopia
Others
Internal carotid artery
Common carotid artery
Stroke within the posterior circulation
Paired Vertebral arteries
Basilar artery
Paired Posterior cerebral arteries
Gives small penetrating branches and short and
long circumferential branches

Posterior circulation
Posterior circulation
Supplies
Cerebellum
Medulla
Pons
Midbrain
Thalamus
Subthalamus
Hippocampus
Medial part of temporal lobe
Occipital lobe
Posterior cerebral artery
P1 segment-Precommunal- Midbrain, thalamus
and subthalamus
P2 segment-Temporal and occipital cortex
P1 syndromes
Due to the involvement of ipsilateral
subthalamus, cerebral peduncles and midbrain
P1 syndrome
Midbrain
Claudes- 3
rd
nerve palsy with c/l ataxia- Red nuclues
Webers- 3
rd
nerve palsy with c/l hemiplegia-Cerebral
peduncle
Subthalamus-c/l hemiballismus
Thalamus- Thalamic dejerine Roussy syndrome- c/l
hemisensory loss followed later by severe agonising
pain


Midbrain Syndromes
P2 syndromes
Infarction of medial temporal and occipital lobes
Occipital lobe-c/l homonymous hemianopia with
macular sparing, if visual association area
spared, patient aware of visual defect
Medial temporal lobe- Memory impairement
Visual hallucinations


P2 syndromes
Antons syndrome-bilateral occlusion in distal
PCAs bilateral occipital lobe infarction-
cortical blindness and patient often unaware
and even deny it
Balints syndrome-bilateral visual association
areas- palinopsia and asimultagnosia
P2 syndromes
Vertebral(V4) and PICA arteries
V4 and PICA
V1 and V4- prone for atherothrombosis
If V1 occlusion
If occlusion is in subclavian artery proximal to
origin of vertebral artery-subclavian steal
syndrome
Lateral medullary syndrome(Wallenburgs)
Caused due to occlusion of V4 segment or PICA
Descending tract and nucleus of trigeminal nerve- Pain,
numbness and abnormal sensation over one half of face
Vestibular nucleus-Vertigo, nausea, vomiting and diplopia
Issuing fibres of 9
th
and 10
th
nerve nucleus- Dysphagia,
hoarseness, palatal paralysis
Restiform body, and cerebellar hemispheres-Ataxia of limbs
Descending sympathetic tract-Horners syndrome
Spinothalamic tract- c/l loss of pain and temperature

Medullary syndromes
Medial medullary syndrome
Infarction of pyramid- c/l hemiplegia of arm and
leg, sparing face
If medial lemniscus-c/l loss of tactile and
proprioception
If hypoglossal nerve nucleus involved- ipsilateral
LMN hypoglossal nerve palsy atrophy of half of
tongue.
Basilar Artery
Paramedian- wedge of pons in midline
Short circumerential- lateral two thirds of pons
and middle and superior cerebellar peduncles
Long circumferential- Superior and anterior
inferior cerebellar

Basilar artery syndromes
Occlusion of basilar artery-b/l brainstem signs
Occlusion of basilar branch artery- unilateral
motor, sensory and cranial nerves

Basilar artery syndromes
Complete basilar artery occlusion(Locked in
state)-b/l long tract(sensory/motor) with cranial
nerve and cerebellar dysfunction- preserved
consciousness,quadriplegia and cranial nerve
signs
Basilar artery branch-syndrome of anterior inferior cerebellar artery(lateral
inferior pontine syndrome)
Anterior inferior cerebellar artery- lateral part of
inferior pons and anterior part of inferior
cerebellar hemispheres
Cerebellum-Ataxia of limb and gait
7
th
nerve nuclues- Facial weakness
8
th
nerve nucleus-Deafness, tinnitus, vertigo, nausea, vomiting
Spinothalamic tract-c/l loss of pain and temperature
Inferior pontine syndrome

Basilar artery branch-Syndrome of superior cerebellar artery(Lateral superior pontine
syndrome)
Superior cerebellar artery- lateral part of
superior pons and superior surface of cerebellar
hemispheres
Superior and middle cerebellar peduncles and superior cerebellar
hemisphere-Ataxia of limb and gait
Vestibular nucleus-dizziness, nausea and vomiting
Spinothalamic tract-c/l loss of pain and temperature
Superior pontine syndrome
Medial pontine syndromes
Caused due to occlusion of paramedian and
short circumferential branches of basilar artery
Corticobulbar and corticospinal-c/l face, arm
and leg paralysis
Cerebellar peduncles-ataxia of limb and gait
Reference: Harrisons 18e