Stroke Syndromes

Main symptom:

Hemiparesis (faciobrachiocrural weakness)

Associated symptoms Anatomy & vascular territory

• Cortical sensory loss, global aphasia • Middle cerebral artery (entire territory)
or spatial neglect, hemianopsia, syndrome
contralateral gaze palsy

• Hemisensory loss, transcortical • Middle cerebral artery (deep territory)

motor or sensory aphasia
• Watershed infarct (between superficial
and deep middle cerebral artery territory)

• Sensory loss (face and hand), • Perisylvian, superficial middle cerebral

conduction aphasia, apraxia, artery territory
Gerstmann syndrome, constructional
apraxia

• Hemisensory loss, gaze palsy, • Middle cerebral artery, superior division

spatial neglect, or expressive aphasia (superficial territory)

• Ipsilateral 3rd nerve palsy (Weber • Posterior cerebral artery--paramedian

syndrome) midbrain perforators
+/- Supranuclear vertical gaze palsy
+/- Sensory deficit

• Ipsilateral 6th nerve palsy • Basilar artery--paramedian pontine

+/- 7th nerve palsy (Millard-Gubler perforators
syndrome), internuclear
ophthalmoplegia, horizontal gaze
palsy, one-and-a-half syndrome

• Ipsilateral 12th nerve palsy, • Vertebral artery, anterior spinal artery--

contralateral loss of position and paramedian medullary perforators
vibratory sense (medial medullary
syndrome--Dejerine syndrome)

• Ipsilateral ataxia
+ Contralateral hemiparesis

• Ipsilateral ataxic hemiparesis

Facio-brachial weakness

Associated symptoms Anatomy & vascular territory

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

• Bilateral anterior watershed infarctions

(man-in-a-barrel syndrome)

• Vertigo, distal amyotrophy • Anterior spinal artery watershed

(“snake-eyes” infarction) (Pullicino 1994)

Bilateral weakness - paraplegia

Associated symptoms Anatomy & vascular territory

• Akinetic mutism, abulia, grasp, • Anterior cerebral artery bilateral

urinary incontinence

• Sensory level, urinary incontinence • Anterior spinal artery infarction

Bilateral weakness - pseudobulbar palsy

Associated symptoms Anatomy & vascular territory

• Facio-pharyngo-glosso-masticatory • Middle cerebral artery bilateral

diplegia with automatic-voluntary opercular branches
dissociation, spasmodic laughing or
crying

+ Pyramidal signs, intellectual • Anterior choroidal artery: bilateral

impairment perforating branches

+ Pyramidal or cerebellar signs, lack • Basilar artery paramedian branches

of dementia

Sensory strokes
Associated symptoms Anatomy & vascular territory

• Loss of position sense, impairment • Middle cerebral artery--parietal

of 2-point discrimination, branches
somatotopagnosia, agraphesthesia,
astereognosis
+/- Hemiparesis, hemianopsia,
aphasia or hemineglect
pseudothalamic parietal sensory
syndrome

• Faciobrachiocrural elementary
sensory loss
 • Restricted acral sensory syndrome: • Middle cerebral artery
cheiro(hand)-oral, cheiro-pedal,
cheiro-oral-pedal syndrome •Thalamogeniculate pedicle

• Basilar artery: deep perforating or

medullary arteries

• Small strokes in lateral thalamus,

pontine tegmentum, corona radiata,
parietal cortex, midbrain.

• Hemianesthesia, transient • Thalamogeniculate territory, proximal

hemiparesis, hemiataxia, thalamic posterior cerebral artery
astasia, choreoathetoid movements,
thalamic hand, paroxysmal pain
+/- Hemianopsia
(Dejerine-Roussy syndrome)

Cerebellar ataxia - limb ataxia, gait imbalance

Associated symptoms Anatomy & vascular territory

+/- Lateropulsion, vertigo, nausea • Vertebral artery brainstem branches

and vomiting, nystagmus, ocular tilt from vertebral artery occlusion
reaction, dysphonia and dysphagia,
(nucleus ambiguous: IX, X, XI),
ipsilateral facial thermalgesia (5th
cranial nerve), Horner syndrome,
contralateral thermalgesia of trunk
and limbs (Wallenberg syndrome)

Contralateral analgesia or • Superior cerebellar artery: cerebellar +

thermalgesia midbrain tegmentum infarction territory
+/- Vertigo, nausea, vomiting,
horizontal nystagmus, dysarthria,
Horner syndrome, 4th nerve palsy

+ 3rd nerve palsy

+ Hemichoreoathetosis (Benedikt
syndrome)

Cerebellar ataxia
Associated symptoms Anatomy & vascular territory

+/- Supranuclear vertical gaze palsy • Basilar or posterior cerebral artery--

P1--paramedian perforators
+ Defective convergence or
convergence-retraction nystagmus

+ Light-near dissociation (Parinaud • Dorsal rostral midbrain syndrome

syndrome)
 • Vertigo, tinnitus, ipsilateral hearing • Anterior inferior cerebellar artery--
loss, dysarthria, Horner syndrome, pontocerebellar infarction
peripheral 7th nerve palsy, facial
hypesthesia, contralateral
thermalgesia of the limbs and trunk

Ataxic hemiparesis
Associated symptoms Anatomy & vascular territory

+/- Sensory symptoms • Thalamogeniculate or basilar artery or

+/- Dysarthria (dysarthria- clumsy- middle cerebral artery--lacunar
hand syndrome) infarctions in pons, thalamus, internal
capsule, medulla

+ Aphasia • Middle cerebral artery-parainsular

Visual symptoms - monocular blindness (amaurosis fugax)

Associated symptoms Anatomy & vascular territory

+/- Contralateral variable motor and • Internal carotid artery territory

hemisensory deficit ischemia

Visual symptoms - visual-field defects

- sectoranopia
Associated symptoms Anatomy & vascular territory

• Wedge-shaped defect straddling the • Posterior choroidal artery - lateral

horizontal median, pointing towards geniculate body infarction
fixation

• Sector defects adjacent to the • Anterior choroidal artery--lateral

vertical meridian, sparing the zone geniculate body infarction
around the horizontal meridian

Visual symptoms - quadrantanopia (inferior noncongruent)

Associated symptoms Anatomy & vascular territory

+ Optic ataxia, difficulty judging size, • Anterior, middle, or posterior cerebral

distance, movement artery--watershed infarction

+/- Cortical hypesthesia, aphasia • Middle or posterior cerebral artery

(anomia, transcortical sensory, superficial watershed, middle cerebral
receptive) artery (parietal optic radiations)

Visual symptoms - quadrantanopia (inferior congruent)

Associated symptoms Anatomy & vascular territory

• Posterior cerebral artery--upper bank

calcarine fissure

Visual symptoms - quadrantanopia (superior noncongruent)

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

• Cognitive impairment-decline in • Posterior cerebral artery: occipital plus

mentation splenial or parahippocampal infarct (Park
et al 2009)

• Pontine infarction

• Middle cerebral artery territory—right

temporal, inferior frontal, and parietal
lobe infarction

• Abulia, manic behavior • Medial frontal lobe, caudate nucleus

(anterior cerebral artery territory)