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Localization in neurology 1
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Stroke syndromes

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Stroke syndromes

  1. 1. M2 Unit Presented by M.SATHISH KUMAR
  2. 2. Stroke syndromes Cluster of signs and symptoms produced due to the occlusion of an artery(due to an atherothrombotic lesion or an emboli or dissection ) supplying a particular region of the brain
  3. 3. classification Large vessel stroke within the anterior circulation Large vessel stroke within the posterior circulation Small vessel disease of either vascular bed
  4. 4. Cerebral circulation Anterior circulation- MCA, ACA, and Anterior choroidal artery Posterior circulation-Vertebral artery, Basilar artery and Posterior cerebral artery
  5. 5. Circle of Willis
  6. 6. Anterior and posterior circulation
  7. 7. 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
  8. 8. Middle cerebral Artery M1 segment(proximal)- deep penetrating or lenticulostriate branches– Internal capsule, caudate nuclues, putamen and outer pallidus
  9. 9. M1 segment
  10. 10. Cerebral Hemisphere in coronal Section
  11. 11. 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
  12. 12. M2 segment
  13. 13. 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
  14. 14. 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
  15. 15. Cerebral Hemisphere in coronal Section
  16. 16. 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
  17. 17. 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
  18. 18. M2 segment
  19. 19. 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
  20. 20. Precommunal A1 segment
  21. 21. Post communal A2 segment
  22. 22. A1 segment A1 segment occlusion rarely produces clinical syndrome because collateral flow through anterior communicating artery and collaterals from MCA and PCA
  23. 23. 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
  24. 24. 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
  25. 25. Others Internal carotid artery Common carotid artery
  26. 26. Stroke within the posterior circulation Paired Vertebral arteries Basilar artery  Paired Posterior cerebral arteries Gives small penetrating branches and short and long circumferential branches
  27. 27. Posterior circulation
  28. 28. Posterior circulation Supplies  Cerebellum  Medulla  Pons  Midbrain  Thalamus  Subthalamus  Hippocampus  Medial part of temporal lobe  Occipital lobe
  29. 29. Posterior cerebral artery P1 segment-Precommunal- Midbrain, thalamus and subthalamus P2 segment-Temporal and occipital cortex
  30. 30. P1 syndromes Due to the involvement of ipsilateral subthalamus, cerebral peduncles and midbrain
  31. 31. P1 syndrome Midbrain Claudes- 3rd nerve palsy with c/l ataxia- Red nuclues Webers- 3rd 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
  32. 32. Midbrain Syndromes
  33. 33. 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
  34. 34. 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
  35. 35. P2 syndromes
  36. 36. Vertebral(V4) and PICA arteries
  37. 37. 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
  38. 38. 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 9th and 10th 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
  39. 39. Medullary syndromes
  40. 40. 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.
  41. 41. 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
  42. 42. Basilar artery syndromes Occlusion of basilar artery-b/l brainstem signs Occlusion of basilar branch artery- unilateral motor, sensory and cranial nerves
  43. 43. 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
  44. 44. 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  7th nerve nuclues- Facial weakness  8th nerve nucleus-Deafness, tinnitus, vertigo, nausea, vomiting  Spinothalamic tract-c/l loss of pain and temperature
  45. 45. Inferior pontine syndrome
  46. 46. 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
  47. 47. Superior pontine syndrome
  48. 48. 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
  49. 49. Reference: Harrisons 18e
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