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Vascular Patterns

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

    NonDominant 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 ?ondine?s curse

Occlusion of Artery and Clinical findings

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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