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NeurovascularMedicine.com
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Vascular Patterns


Learning objectives

  • To understand the vascular syndromes
  • Associate clinical signs
  • Appropriate diagnostic tests

Introduction

  • Strokes are discrete and are caused by bleeding or infarct in a precise anatomical area often with a matching clinical syndrome.
  • It is important to spot these syndromes. Experience helps and knowing what signs to look for and correlating with imaging.
  • Below is a summary table of vessels and findings and a link to the individual topic.
Vessel occludedDetails
Internal carotid artery
  • Ipsilateral frontal and parietal/occipital and temporal lobes
  • Ipsilateral cortical infarction depending on degree of collaterals and COW flow
  • Mimics an MCA infarction or less as ACA may get some collateral supply across anterior communicating artery
Ophthalmic artery Transient/fixed Eye Monocular blindness. Exclude Giant cell Arteritis with history and CRP/ESR. Non arteritis then get Doppler.
Anterior cerebral artery
  • Contralateral face/arm/leg weak Leg > arm
  • C/L face/arm/leg weakness leg > arm
  • C/L sensory loss
  • No hemianopia
  • C/L contralateral gaze palsy
  • Expressive Dysphasia (D)
  • Visuospatial (ND)
  • Dyspraxia (D)
  • Neglect (ND) apathy
  • Abulia, disinhibition and euphoria.
  • Paracentral lobule infarction causes urinary incontinence
Anterior choroidal artery
  • Homonymous field defect 
  • Motor/sensory loss
Middle cerebral artery Proximal MCA artery M1
  • Infarction of the basal ganglia Internal capsule out towards the cortex.
  • Damage worse the more proximal the occlusion as lenticulostriates to basal ganglia affected
  • C/L face/arm/leg weakness arm > leg
  • C/L sensory loss
  • C/L hemianopia
  • C/L contralateral gaze palsy
  • Dysphasia(D)
  • Visuospatial(ND)
  • Neglect (ND)
  • Dyspraxia (D)
Distal MCA
  • Lenticulostriate arteries may be spared 
Superior branch of MCA
  • Frontal lobe infarction
  • Face/arm weakness
  • Gaze paresis
  • Expressive dysphasia (D) and dyspraxia (D)
Posterior inferior branch  of MCA
  • Parietal lobe with sensory loss
  • Homonymous hemianopia
Posterior cerebral artery
  • Contralateral Hemianopia
  • Non-Dominant Side
    • Spatial disorientation
    • Neglect
    • Prosopagnosia
Bilateral PCA occlusion
  • Altitudinal hemianopia, cortical blindness (blindness with preservation of pupillary light response ? Anton?s syndrome)
  • Bilateral thalamic stroke causes amnestic symptoms
Basilar Artery
  • Headache, dizziness, vertigo, seizures, coma, quadriplegia
  • Locked in syndrome, IIIrd nerve lesion, limb weakness
  • Only vertical gaze remains intact and opening and closing eyelids
Top of the basilar artery occlusion
  • Usually embolic infarction of midbrain, thalamus, hypothalamus and mediobasal portions of the temporal and occipital lobes
  • IIIrd nerve palsy, Vertical gaze palsy, ataxia, sleepiness and even coma, impaired attention and memory.
Posterior inferior cerebellar artery(or vertebral artery infarction) Dorsolateral infarction or Wallenburg syndrome
  • Horner's syndrome
  • IX nerve and X weakness
  • Dysphagia and hoarseness
  • Nystagmus and Cerebellar ataxia (spinocerebellar tracts) same side
  • Contralateral spinothalamic signs and Symptoms
  • Altered facial sensation.
Medial medulla
  • Hypoglossal weakness same side
  • Contralateral hemisensory Symptoms
  • Autonomic disturbance
  • Apnoea ?ondine?s curse
Posterior communicating artery
Lateral striate  (lenticulostriate) lacunar type infarcts of basal ganglia and internal capsule as mentioned below
Basilar artery occlusion
  • Headache, dizziness, vertigo, seizures, coma, quadriplegia
  • Locked in syndrome, IIIrd nerve lesion, limb weakness
  • Only vertical gaze remains intact and opening and closing eyelids
  • Consider thrombolysis
Top of the basilar artery occlusion
  • Usually embolic infarction of midbrain, thalamus, hypothalamus and mediobasal portions of the temporal and occipital lobes
  • IIIrd nerve palsy, Vertical gaze palsy, ataxia, sleepiness and even coma, impaired attention and memory.
Midbrain Weber syndrome
  • Anterior brainstem infarction
  • Contralateral hemiparesis
  • Ipsilateral IIIrd nerve palsy
Benedikt syndrome
  • Paramedian midbrain (red nucleus)
  • Contralateral cerebellar dysfunction
  • Partial ipsilateral IIIrd nerve nucleus
Nothnagel syndrome
  • Dorsolateral midbrain lesion
  • Complete contralateral loss of sensation
  • Ipsilateral Horner's syndrome
  • Ipsilateral IIIrd nerve palsy
  • Ispilateral cerebellar signs
Basilar artery branches to Medial Midbrain
  • ? IIIrd nerve palsy
  • C|L hemiparesis and hemiataxia or tremor
P1 segment of PCA supply
  • Lateral Midbrain ? C|L hemisensory loss
  • Vertical gaze palsies
Pons - Millard-Gubler syndrome 
  • Pontine lesion involving VIth and VII
  • Contralateral hemiparesis
  • Ipsilateral 6th and 7th

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