Identifying Vascular Syndromes

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Learning objectives

  • Vascular Supply to the brain
  • Can Correlate vessel and clinical findings
  • Can correlate vessel and cause and management

Introduction

Ischaemic strokes due to thrombus or embolism are discrete and cause a syndrome based on the vessel affected. 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 and clinical findings




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)
Middle cerebral artery 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
Lateral striate(lenticulostriate) Occlusion of small penetrating vessels causes lacunar type infarcts of basal ganglia and internal capsule
Posterior cerebral artery

Both Sides

  • 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)

Lateral Medulla - 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 with Ondine's curse