Vascular Territory Strokes

Learning objectives

Learning
Understand
Integrate
Reflect

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 occluded	Details
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 Wallenberg 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 Ipsilateral 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