localization of stroke, CVS, stroke, for post graduates

New localization of stroke syndromes
1.Clinical localization of the site of the lesion.
2.Identifying the vascular territory and the vessel involved.
3.Correlating with the imaging findings.

1. Localization of stroke syndromes
Dr.M.Dhanaraj

2. Localization of stroke syndromes
Three steps
1.Clinical localization of the site of the lesion.
2.Identifying the vascular territory and the vessel involved.
3.Correlating with the imaging findings.

3. Clinical localization of stroke
syndromes
Prerequisites
1.Functional anatomy of brain.
2.Blood supply to the different parts of brain.

4. Blood supply of brain-Carotid Arteries

5. Vertebral artery Circle of willis
Blood supply of brain –vertebral artery
and circle of Willis

6. Blood supply of brain

7. ANTERIOR CIRCULATION STROKE SYNDROMES

8. Anterior circulation

9. Blood supply-Lateral view

10. Blood supply-Medial view

11. Blood supply-Coronal view

12. Blood supply-Axial view

13. Middle cerebral artery infarction -
superior branch
Clinical features
1.Contralateral hemiplegia –face and
upper limb more involved than
lower limb.
2. Contralateral hemisensory loss.
3.Conjugate gaze paresis(patient looks
towards the side of lesion.
4.Broca’s dysphasia (if left sided)

14. Middle cerebral artery infarction -
Inferior branch
Clinical features
1.Contralateral hemianopia.
2.Wernicke’s dysphasia ( if left sided )
3.Left spatial neglect ( if right sided )

15. Middle cerebral artery infarction -stem
occlusion
Clinical features
1.Contralateral hemiplegia
2. Contralateral hemisensory loss
3. Contralateral gaze palsy
4. Contralateral hemianopia
5.Global dysphasia (Left sided lesion)
6.Anosognosia and amorphosynthesis
(Right sided lesion)
7.Altered sensorium (due to edema)

16. Middle cerebral artery infarction -
Clinical features
1.Contralateral hemiparesis
2.Contralateral sensory loss
3.Transcortical motor / sensory
aphasia ( left sided lesion)
Lenticular striate artery occlusion

17. Anterior cerebral artery infarction
Clinical features
1.Contralateral
a.paralysis of leg and foot with paresis of
arm
b.cortical sensory loss over leg and foot
c.presence of primitive reflexes
2.Urinary incontinence
3.Gait apraxia
4.Mutism, delay and lack of spontaneity of
motor acts
5.Apraxia of left sided limbs(with left sided
lesion and corpus callosum involvement)

18. Internal carotid artery infarction
Clinical features
Variable -based on the
collaterals and mechanism of
stroke (embolism, extension of
thrombus , low flow)
1.Amaurosis fugax
2. Watershed infarctions
3.MCA/ACA-either alone or in
combinations

19. Posterior circulation stroke syndromes

20. Posterior circulation
Lateral view

21. Posterior circulation

22. Medulla

23. Lateral medullary syndrome
A.IPSILATERAL
1.X
th
cranial nerve palsy
2.Cerebellar signs
3.Horner’s syndrome
4.Impaired pain, temperature
and touch on the upper
half of face
B. CONTRA LATERAL
1.Impaired pain and
temperature over the body

24. Medial medullary syndrome
A.IPSILATERAL
1.XII
th
nerve palsy
B.CONTRALATERAL
1.Hemiplegia –sparing the
face
2.Hemianaesthesia sparing the
face.

25. Pons-Lower

26. Medial pontine syndrome –occlusion
of paramedian branch of basilar artery
A.IPSILATERAL
1.Gaze paresis
2.Cerebellar signs
B.CONTRALATERAL
1.Hemiparesis
2.Hemianaesthesia

27. Lateral pontine syndrome-occlusion of
anterior inferior cerebellar artery
A.IPSILATERAL
1.LMN VII
th
nerve palsy
2.Gaze palsy
3.Deafness,tinnitus
4.Cerebellar signs
B.CONTRALATERAL
1.Impairment of pain and
temperature on the
body

28. MID BRAIN

29. Weber syndrome-occlusion of
perforating branch of posterior cerebral
artery
Clinical features
1.Ipsilateral
a.3
rd
nerve palsy
2.Contralateral
a.hemiplegia

30. Benedikt syndrome-occlusion of
perforating branch of posterior cerebral
Clinical features
1.Ipsilateral
a.3
rd
nerve palsy
2.Contralateral
a.cerebellar ataxia

31. Thalamus-occlusion of thalamo
geniculate branches of posterior
cerebral artery
Contralateral
1.Sensory loss
2.Spontaneous pain
3.Choreo athetosis
4.Ataxic tremor
5.Mild hemiparesis
THALAMUS

32. Occipital lobe-optic pathway and visual
reflexes

33. Occipital lobe-occlusion of left
calcarine artery
Clinical features
1.Right Hemianopia

34. Occipital lobe-occlusion of both
calcarine arteries
Clinical features
1.Bilateral hemianopia-
cortical blindness (light
reflex preserved)

35. Left occipital lobe with corpus
callosum infarction
Left
Clinical features
1.Right hemianopia
2.Alexia without
agraphia

36. Basilar artery occlusion
Clinical features
1.Paralysis of all four limbs
2.Bulbar paralysis
3.Eye movements
abnormalities
4.Nystagmus
5.Coma
Note: The neurological
deficit is variable depending
upon the ischemia –
modifying factors.

37. Differentiating features between anterior and posterior
circulation stroke
Clinical features Posterior circulationAnterior circulation
A.History
1.Vertigo Present Absent
2.Unsteadiness Present Absent
B.Physical findings
1.Crossed hemiplegia Present Absent
2.Bilateral deficits Present Absent
3.Cerebellar signs Present Absent
4.Ocular findings(LMN/INO/Gaze deviation to paralysed side) Present Absent
5.Dissociated sensory loss Present Absent
6.Sensory loss over V1 and V2 Present Absent
7.Horners syndrome Present Absent

51. Importance of clinical localisation of stroke
1. Careful clinical evaluation in combination with imaging
helps to find out the etiology of stroke and plan the
appropriate treatment.
2. Clinical observations in correlation with imaging helps to
understand neurology / neurophysiology better.
Note:Neurological examination must be tailored
according to the clinical scenario .

52. Limitations of clinical localisation of
stroke syndromes
1. A single syndrome may occur due to lesion at different sites
Eg. Pure motor hemiplegia
2.A vascular occlusion at a specific site can produce varying
clinical manifestations.
3.Clinical examination may not detect very small or multiple
infarctions(as in SBE).
Note:Imaging is very useful in the above situations.