Stroke Syndromes
Main symptom:
Hemiparesis (faciobrachiocrural weakness)
Associated symptoms
Anatomy & vascular territory
• Cortical sensory loss, global aphasia
or spatial neglect, hemianopsia,
contralateral gaze palsy
• Middle cerebral artery (entire
territory) syndrome
• Hemisensory loss, transcortical
motor or sensory aphasia
• Middle cerebral artery (deep
territory)
• Watershed infarct (between
superficial and deep middle cerebral
artery territory)
• Sensory loss (face and hand),
conduction aphasia, apraxia,
Gerstmann syndrome, constructional
apraxia
• Perisylvian, superficial middle
cerebral artery territory
• Hemisensory loss, gaze palsy,
spatial neglect, or expressive aphasia
• Middle cerebral artery, superior
division (superficial territory)
• Ipsilateral 3rd nerve palsy (Weber
syndrome)
+/- Supranuclear vertical gaze palsy
+/- Sensory deficit
• Posterior cerebral artery--paramedian
midbrain perforators
• Ipsilateral 6th nerve palsy
+/- 7th nerve palsy (Millard-Gubler
syndrome), internuclear
ophthalmoplegia, horizontal gaze
palsy, one-and-a-half syndrome
• Basilar artery--paramedian pontine
perforators
• Ipsilateral 12th nerve palsy,
contralateral loss of position and
vibratory sense (medial medullary
syndrome--Dejerine syndrome)
• Vertebral artery, anterior spinal
artery--paramedian medullary
perforators
• Ipsilateral ataxia
+ Contralateral hemiparesis
• Ipsilateral ataxic hemiparesis
Facio-brachial weakness
Associated symptoms
Anatomy & vascular territory
• Cognitive and behavioral
abnormalities (abulia, agitation,
hyperactivity, neglect)
• Middle cerebral artery complete or
lateral lenticulostriate territory
• Anterior cerebral artery proximal
perforating branches from Heubner
artery territory--caudate infarcts
Crural weakness
Associated symptoms
Anatomy & vascular territory
• Homolateral ataxia
• Anterior cerebral artery distal
territory
• Superficial borderzone territory
between anterior and middle cerebral
artery
• Noncortical sensory loss
+/- Transcortical motor aphasia or
mutism, mood disturbances
• Sensory loss, shoulder weakness,
gegenhalten, left hand apraxia, alien
hand sign, grasp reflex, transient
urinary incontinence, abulia, akinetic
mutism
Brachial weakness
Associated symptoms
• Cortical sensory loss, disturbance of
volitional saccadic eye movements
• Anterior cerebral artery complete
territory
Anatomy & vascular territory
• Borderzone territory between anterior
and middle cerebral artery
• Middle cerebral artery superficial
territory: cortical infarct
Bilateral weakness - hemiparesis
Associated symptoms
+/- Sensory loss
Anatomy & vascular territory
Internal carotid artery territory:
• Bilateral hemispheric
Anterior spinal artery territory:
• Bilateral medullary pyramids
• Spinal cord infarction
• Locked-in syndrome
+/- Supranuclear vertical gaze palsy
Basilar artery territory:
• Bilateral paramedian pontine or
mesencephalic
Bilateral weakness - brachial weakness
Associated symptoms
Anatomy & vascular territory
• Bilateral anterior watershed
infarctions (man-in-a-barrel syndrome)
• Vertigo, distal amyotrophy
Bilateral weakness - paraplegia
Associated symptoms
• Anterior spinal artery watershed
(“snake-eyes” infarction) (Pullicino
1994)
Anatomy & vascular territory
• Akinetic mutism, abulia, grasp,
urinary incontinence
• Anterior cerebral artery bilateral
• Sensory level, urinary incontinence
• Anterior spinal artery infarction
Bilateral weakness - pseudobulbar palsy
Associated symptoms
Anatomy & vascular territory
• Facio-pharyngo-glosso-masticatory
diplegia with automatic-voluntary
dissociation, spasmodic laughing or
crying
• Middle cerebral artery bilateral
opercular branches
+ Pyramidal signs, intellectual
impairment
• Anterior choroidal artery: bilateral
perforating branches
+ Pyramidal or cerebellar signs, lack
of dementia
• Basilar artery paramedian branches
Sensory strokes
Associated symptoms
• Loss of position sense, impairment
of 2-point discrimination,
somatotopagnosia, agraphesthesia,
astereognosis
+/- Hemiparesis, hemianopsia,
aphasia or hemineglect
pseudothalamic parietal sensory
syndrome
Anatomy & vascular territory
• Middle cerebral artery--parietal
branches
• Faciobrachiocrural elementary
sensory loss
• Restricted acral sensory syndrome:
cheiro(hand)-oral, cheiro-pedal,
cheiro-oral-pedal syndrome
• Middle cerebral artery
•Thalamogeniculate pedicle
• Basilar artery: deep perforating or
medullary arteries
• Small strokes in lateral thalamus,
pontine tegmentum, corona radiata,
parietal cortex, midbrain.
• Hemianesthesia, transient
hemiparesis, hemiataxia, thalamic
astasia, choreoathetoid movements,
thalamic hand, paroxysmal pain
+/- Hemianopsia
(Dejerine-Roussy syndrome)
• Thalamogeniculate territory, proximal
posterior cerebral artery
Cerebellar ataxia - limb ataxia, gait imbalance
Associated symptoms
Anatomy & vascular territory
+/- Lateropulsion, vertigo, nausea
and vomiting, nystagmus, ocular tilt
reaction, dysphonia and dysphagia,
(nucleus ambiguous: IX, X, XI),
ipsilateral facial thermalgesia (5th
cranial nerve), Horner syndrome,
contralateral thermalgesia of trunk
and limbs (Wallenberg syndrome)
• Vertebral artery brainstem branches
from vertebral artery occlusion
Contralateral analgesia or
thermalgesia
+/- Vertigo, nausea, vomiting,
horizontal nystagmus, dysarthria,
Horner syndrome, 4th nerve palsy
• Superior cerebellar artery: cerebellar
+ midbrain tegmentum infarction
territory
+ 3rd nerve palsy
+ Hemichoreoathetosis (Benedikt
syndrome)
Cerebellar ataxia
Associated symptoms
+/- Supranuclear vertical gaze palsy
Anatomy & vascular territory
• Basilar or posterior cerebral artery-P1--paramedian perforators
+ Defective convergence or
convergence-retraction nystagmus
+ Light-near dissociation (Parinaud
syndrome)
• Dorsal rostral midbrain syndrome
• Vertigo, tinnitus, ipsilateral hearing
loss, dysarthria, Horner syndrome,
peripheral 7th nerve palsy, facial
hypesthesia, contralateral
• Anterior inferior cerebellar artery-pontocerebellar infarction
thermalgesia of the limbs and trunk
Ataxic hemiparesis
Associated symptoms
Anatomy & vascular territory
+/- Sensory symptoms
+/- Dysarthria (dysarthria- clumsyhand syndrome)
• Thalamogeniculate or basilar artery
or middle cerebral artery--lacunar
infarctions in pons, thalamus, internal
capsule, medulla
+ Aphasia
• Middle cerebral artery-parainsular
Visual symptoms - monocular blindness (amaurosis fugax)
Associated symptoms
Anatomy & vascular territory
+/- Contralateral variable motor and
hemisensory deficit
Visual symptoms - visual-field defects
- sectoranopia
Associated symptoms
• Internal carotid artery territory
ischemia
Anatomy & vascular territory
• Wedge-shaped defect straddling the
horizontal median, pointing towards
fixation
• Posterior choroidal artery - lateral
geniculate body infarction
• Sector defects adjacent to the
vertical meridian, sparing the zone
around the horizontal meridian
• Anterior choroidal artery--lateral
geniculate body infarction
Visual symptoms - quadrantanopia (inferior noncongruent)
Associated symptoms
Anatomy & vascular territory
+ Optic ataxia, difficulty judging size,
distance, movement
• Anterior, middle, or posterior cerebral
artery--watershed infarction
+/- Cortical hypesthesia, aphasia
(anomia, transcortical sensory,
receptive)
• Middle or posterior cerebral artery
superficial watershed, middle cerebral
artery (parietal optic radiations)
Visual symptoms - quadrantanopia (inferior congruent)
Associated symptoms
Anatomy & vascular territory
• Posterior cerebral artery--upper bank
calcarine fissure
Visual symptoms - quadrantanopia (superior noncongruent)
Associated symptoms
Anatomy & vascular territory
• Middle cerebral artery inferior division
(temporal optic radiations)
Visual symptoms - quadrantanopia (superior congruent)
Associated symptoms
Anatomy & vascular territory
• Posterior cerebral artery--lower bank
calcarine fissure
Visual symptoms - hemianopsia
Associated symptoms
Anatomy & vascular territory
• Isolated, +/- hemiparesis,
hemisensory loss, ataxia
• Anterior choroidal artery territory
+ Hemiparesis, sensory loss, aphasia
or neglect
• Middle cerebral artery--optic radiation
infarction
• Left middle cerebral artery
• Alexia without agraphia
• Posterior cerebral artery territory
(occipital, mediotemporal and callosal
branches)
+ Cortical blindness (if bilateralAnton syndrome), release
hallucinations, agitated delirium or
confusion,
visual and color agnosia,
prosopagnosia
+ Simultanagnosia, ocular ataxia,
ocular apraxia (Balint syndrome)
• Posterior cerebral artery bilateral
(lower bank of calcarine fissure)
Visual symptoms - visual hallucinations
Associated symptoms
• Middle or posterior cerebral artery
watershed (upper bank of calcarine
fissure)
• Posterior cerebral artery territory
stroke
Anatomy & vascular territory
• In the hemianoptic field, transient
or persistent, simple or complex,
nonstereotyped
• Posterior cerebral artery territory
stroke
• Complex, detailed,
+ inversion of the sleep-wake cycle
(peduncular hallucinosis)
• Basilar artery or posterior cerebral
artery, paramedian perforators
Encephalopathic symptoms
Associated symptoms
Anatomy & vascular territory
• Agitated delirium, abnormal
behavior
• Posterior or middle cerebral artery or
basilar artery: paramedian midbrain
and thalamus, hippocampus, fusiform
and lingual gyri (top-of-the-basilar
• Cognitive impairment-decline in
• Posterior cerebral artery: occipital
mentation
plus splenial or parahippocampal
infarct (Park et al 2009)
• Pontine infarction
• Middle cerebral artery territory—right
temporal, inferior frontal, and parietal
lobe infarction
• Abulia, manic behavior
• Medial frontal lobe, caudate nucleus
(anterior cerebral artery territory)