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Capsular (and Pontine) Warning Syndromes

Learning objectives

  • Learning
  • Understand
  • Integrate
  • Reflect

  • Capsular warning syndrome first described by Donnan in 1993
  • Repeated sensory and/or motor symptoms affecting at least two of the face, arm and leg, without cortical signs
  • Recurrent stereotyped lacunar TIAs with increased risk of developing stroke
  • Can also happen with pontine strokes
  • Exact aetiology of the syndrome not clear
  • Presumed angiopathy of a lenticulostriate artery.
  • Ischaemia within the internal capsule
  • Might be large vessel syndrome restricting flow to perforator vessels
  • Possibly seen with pontine perforators too (pontine warning syndrome)
  • crescendo episodes of ischaemia restricted to the region of the internal capsule
  • Usually causing symptoms affecting face, arm, and leg.
  • Small vessel disease associated with hypertension, diabetes mellitus, and dyslipidemia
  • Repeated sensory and/or motor symptoms affecting at least two of the face, arm and leg, without cortical signs
  • Pontine warning syndrome : gaze palsies, dysarthria and ataxic hemiparesis
  • FBC, U&E, LFTs, Glucose, lipids
  • CT/CTA as needed
  • Carotid doppler if anterior circulation
  • MRI may show a lacunar infarct in the internal capsule or the corona radiata. With a pontine warning syndrome evidence of infarction involving pontine corticospinal and sensory tracts may be seen
  • Consider MRA to look for vascular stenosis
  • EEG if seizure suspected
Differentials of repeated stereotypical negative neurology
  • Severe Carotid stenosis
  • Artery to artery embolisation
  • Migraine
  • Seizures
  • Reperfusion therapies where indicated - reperfusion of an MCA may increase flow to the lenticulostriate artery.
  • Admission to stroke unit
  • Aspirin 300 mg +/- Clopidogrel
  • Optimise BP control if hypertension and glucose control if diabetic
  • Statin to lower Cholesterol