Cerebrovascular

Question 1

Stroke syndrome:

1. Quadrantanopsia or hemianopsia
2. Transcortical aphasia, or hemi-inattention

Answer 1

MCA/PCA borderzone infarct. Affects temporo-occipital portion of distal MCA territory

Question 2

Stroke syndrome:

1. producing proximal >> distal sensory & motor deficit in upper extremity, variable lower extremity involvement. Hand and face spared.

Answer 2

MCA/ACA borderzone infarct: affects superficial frontal and parietal parasagittal cortical areas

“Man in a barrel”

Question 3

List the divisions of the MCA

Answer 3

M1: Main trunk with deep penetrators and lenticulostriate arteries.

M2: In sylvian fissure where two divisions arise

M3: All cortical branches

M4: Over the cortical Surface

Question 4

Stroke syndrome:

A right handed patient with…

1. Hemiplegia of right face, arm, and leg
2. Hemianesthesia of right side
3. Right homonymous hemianopsia
4. Deviation of head and eyes to Left
5. Global aphasia

Answer 4

Left MCA stem occlusion.

Question 5

Stroke Syndrome:

In a right handed patient…

1. Left face, arm, leg hemiplegia
2. Left sided hemianesthesia
3. Left homonymous hemianopsia
4. Deviation of head and eyes to right
5. Anosognosia and amorphosynthesis

Answer 5

Right MCA Stem occlusion

Image on left is SWI

Image on right is DWI

Question 6

Stroke Syndrome:

In a right-handed patient:

1. Numbness and weakness of left arm >> leg
2. Dysarthria but no aphasia
3. Left facial droop
4. Right deviation of head and eyes
5. Consciousness preserved

Answer 6

Right superior division MCA

1. The rolandic branches cause the sensorimotor deficits of the contralateral face and arm >> leg
2. Cortical-subcortial branch causes brachial monoplegia

Question 7

Stroke Syndrome:

In a right-handed patient:

Numbness and weakness of right arm >> leg
Initial global aphasia, then dysarthria
Right facial droop
Left deviation of head and eyes
Consciousness preserved

Answer 7

Left MCA superior division

1. Ascending frontal branch: initial mutism and mild comprehension defect, then dysfluent, agrammatic speech with normal comprehension
2. Rolandic branches: sensorimotor paresis with severe dysarthria but little aphasia
3. Cortical-subcortical branch: brachial monoplegia
4. Ascending parietal: No sensorimotor, just a conduction aphasia

Question 8

Stroke Syndrome:

In a right handed patient

1. Wernicke’s aphasia
2. Superior right quadrantanopsia or hemianopsia
3. agitated confusional state
4. No weakness or sensory loss

Answer 8

Left MCA Inferior division

This is nearly always from a cardiogenic embolus

Question 9

Stroke Syndrome:

In a right handed patient

1. Left hemi-neglect
2. Superior left quadrantanopsia or hemianopsia
3. Agitated confusional state
4. No weakness or numbness

Answer 9

Right sided inferior division MCA

Nearly always from a cardiogenic embolus

Question 10

Stroke Syndrome

1. Finger agnosia
2. Acalcula
3. Right-left confusion
4. Alexia +/- agraphia
5. Ideational apraxia

Answer 10

Gerstmann’s syndrome

Dominant parietal lobe

Question 11

Stroke Syndrome:

1. Anosognosia
2. Autoprosopagnosia
3. Hemi-neglect
4. Constructional apraxia
5. Dressing apraxia

What is the anatomic location (not the cerebrovascular territory)

Answer 11

Non-dominant parietal lobe lesion

Question 12

Cortical Syndrome:

1. docile
2. hyperoral
3. hypersexual
4. hypomobile
5. hypermetamorphosis
6. visual agnosia

What is the eponym and anatomic location, not the cerebrovascular territory

Answer 12

Kluver-Bucy Syndrome: Bilateral anterior poles of temporal lobes

Question 13

Stroke Syndrome:

1. Paraplegia (both legs weak)
2. Abulia
3. Motor aphasia
4. Frontal lobe personality changes

Answer 13

ACA stem occlusion proximal to the ACOM (the A1 segment), but only if both arteries arise from one ACA.

Otherwise, the ACOM will allow perfusion of both sides from one ACA and the stroke will be well tolerated.

Question 14

Stroke Syndrome:

1. Sensorimotor defect of left foot >> shoulder and arm
2. Motor defect of foot and leg >> thigh
3. Head and eyes deviated to the right
4. Urinary incontinence
5. Left grasp reflex
6. Paratonia (gegenhalten)

Answer 14

ACA stem occlusion in the A2 segment (distal to the ACOM). In this case, the right A2 is involved.

If the left A2 segment is involved, you might see an alien hand too

Question 15

Stroke Syndrome:

Transcorticomotor aphasia (halting, one or two word speech, repetition is preserved, writing is impaired)

Answer 15

Heubner’s artery occlusion, a branch of the ACA. This serves the anterior frontal lobe.

Heubner’s artery comes off of the A2 segment just distal to the ACOM

Question 16

Stroke Syndrome:

In a right handed individual…

1. Transient hemiparesis
2. Dysarthria
3. Abulia or agitation
4. Stuttering and language difficulty

Answer 16

Left ACA penetrating branches infarct.

The right causes visuospatial neglect instead of language difficulty

Question 17

Stroke Syndrome:

In a right handed individual…

Transient hemiparesis
 Dysarthria
 Abulia or agitation
 Visuospatial neglect

Answer 17

Right ACA penetrating branches infarct

Question 18

Stroke Syndrome:

In a right handed individual…

Transient hemiparesis
 Dysarthria
 Abulia or agitation
 inattentive, abulia, forgetful, agitation, psychosis

Answer 18

Bilateral caudate infarcts - from ACA distribution

Question 19

Stroke Syndrome:

In a right handed individual…

1. Left hemiplegia
2. Left hypesthesia
3. Left homonymous hemianopsia
4. Cognitive function completely spared

This syndrome is not uniform. Name the structures involved

Answer 19

Right anterior choroidal artery occlusion; this is a long narrow artery from the ICA just above the PCOM. Supplies the internal globus pallidus, the PLIC, the optic tract, choroid plexus

Question 20

Variations in PCA anatomy

Answer 20

in 70%, both PCA’s originate from the bifurcation of the basilar artery. In 20-25%, one of the pCA’s comes from the ICA. In everyone else, both PCA’s come from the ICA’s. See diagram

Question 21

Stroke Syndrome:

1. Left sensory loss
2. Transient left hemiparesis
3. after an interval, pain, paresthesia, hyperpathia
4. Distortion of taste
5. Athetotic posturing of hand
6. Depression

Answer 21

“Dejerine and Roussy” Syndrome - Thalamic (on this case on the right). Infarction of sensory relay nucli due to occlusion of thalamogeniculates. These come from the PCA

Question 22

Stroke Syndrome:

1. CN III palsy
2. Left hemiplegia
3. Stupor
4. Coma
5. Left ataxic tremor

Answer 22

Weber Syndrome, aka subthalamic or central midbrain syndrome - in this case on the right

Due to occlusion of interpeduncular branches of the PCA

Question 23

Stroke Syndrome:

1. Hemiballismus
2. Hemichoreoathetosis
3. Deep sensory loss
4. Hemiataxia
5. Tremor

Answer 23

Anteromedial-inferior thalamic syndrome: Occlusion of thalamoperforate branches of PCA.

Occlusion of the dominant dorsomedial nucleus gives rise to korsakoff syndrome

Question 24

Stroke Syndrome:

1. Homonymous hemianopsia
2. Visual hallucinations in blind areas
3. Metamorphopsia (visual distortion)
4. Palinopsia (afterimages)
5. Alexia
6. Anomia, especially for colors and visually presented objects
7. Occasionally memory impairment

Answer 24

Occlusion of branches to posterior temporal and occipital lobes from branches of the PCA

Question 25

A patient with "bilateral homonymous hemianopsia" with unformed visual hallucinations, but pupillary reactions normal, optic disks normal. Usually insist that they are not blind and will walk into closed doors, etc

Answer 25

Anton Syndrome, aka Cortical Blindness. Result of successive infarctions from embolus (PCA Distribution) or thrombus of upper basilar artery.

Question 26

Stroke syndrome: 1. Psychic paralysis of fixation of gaze 2. Optic ataxia (failure to grasp objects under visual guidance) 3. Visual inattention (affecting mainly periphery of visual field) 4. Amnesia 5. Prosopagnosia

Answer 26

**Balint Syndrome: bilateral occipital-parietal border zone infarcts.** The amnesia is a Korsakoff amnestic state from bilatearl inferomedial temporal lobes, and the medial temporal occipital lesions cause the prosopagnosia.

Question 27

What is the anatomy of the vertebral arteries: i.e. where do they come from and what do they serve?

Answer 27

They have a long extracranial course and pass through C6-C1 and so are vulnerable to trauma, spondylosis, and compression. They are the chief arteries of the medulla, the lower 3/4 of the pyramids, the medial lemniscus, all of the lateral medullary region, the restiform body, and the posterior-inferior part of the cerbellum. Stroke can cause a wallenberg (lateral medullary) syndrome of nystagmus, oscillopsia, vertigo, nausea, vomiting, contralateral pain and temperature deficit, ipsilateral horner's, CN IX and X weakness, ipsilateral ataxia

Question 28

Stroke Syndrome: 1. Nystagmus 2. Oscillopsia 3. Vertigo, nausea, vomiting 4. right body pain/temperature loss 5. left horner's 6. Hoarseness, dysphagia 7. Vertical diplopia and illusion of tilting of vision 8. left ataxia, falling to left 9. loss of taste 10. pain, burning, impaired sensation of left face Name the syndrome, describe the anatomy of each of the above, and the vascular distribution(s)

Answer 28

Wallenberg syndrome, Lateral Medullary syndrome. On this case it is the left 1. Vestibular nucleus: nystagmus, vertigo, etc 2. spinothalamic tract: contralateral pain/temp on body 3. Descending sympathetics: Horner's 4. CN IX/X: hoarse, swallowing, etc 5. Otolithic nucleus: vertical diplopia 6. spinocerebellar fibers: ipsilateral ataxia 7. Nucleus solitarius: loss of taste. **NOTE - may also cause wild fluctuations in BP like a pheochromocytoma** 8. Rarely nucleus cuneatus and gracilis causing ipsilateral numbness of limbs Vascular distribution: 80% due to occlusion of vertebral artery, 20% from PICA (Posterior inferior cerebellar artery)

Question 29

Stroke Syndrome: 1. Paralysis of left arm and leg 2. Impaired LT and position sense on left body 3. tongue deviates to right or is atrophied on right 4. Sensation to face is spared

Answer 29

Medial medullary syndrome, in this case on the right

Question 30

Stroke Syndrome 1. Ipsilateral ataxia 2. Sometimes hiccups

Answer 30

Posterior medullary region. The image is of a tumor, but it's in the correct anatomic location.

Question 31

Stroke Syndrome: 1. Palate paralysis on left 2. Hoarseness 3. Loss of sensation to the right body 4. +/- ipsilateral tongue paralysis (different eponym if this is part of the syndrome)

Answer 31

Avellis syndrome without the tongue paralysis, Jackson syndrome with it. These are syndromes that occur when the tegmentum of the medulla is infarcted Spinothalamic tract CN X, XII, and corticospinal tracts

Question 32

What are the branches of the basilar artery and what do they perfuse?

Answer 32

1. Paramedian - subthalamic and high midbrain 2. Short circumferential - supplies lateral 2/3 of pons and middle and superior cerebellar peduncles 3. Long circumferential - anterior-inferior cerebellar artery and superior cerebelar artery

Question 33

Stroke Syndrome 1. Weakness of all ext 2. Weakness of ocular nerves 3. Diplopia 4. Dysconjugate gaze 5. INO 6. Horz or Vert nystagmus 7. visual field defects 8. bilateral cerebellar ataxia 9. coma 10. sensory defecits

Answer 33

Basilar artery syndrome 1. corticobulbar and corticospinal tracts 2. MLF 3. Vestibular apparatus 4. Visual cortex 5. Cerebellar peduncles and hemispheres 6. Medial lemniscus and spinothalamic tracts

Question 34

Stroke Syndrome: 1. Paralysis of left gaze 2. Preservation of convergence 3. Nystagmus 4. Left ataxia of limbs 5. Diplopia 6. Right facial droop 7. Right arm/leg weakness 8. Right light touch and position sense deficits

Answer 34

Medial inferior pontine syndrome - from occlusion of paramedian branch of basilar artery. In this case, it is the left side that is occluded 1. PPRF 2. Vestibular nuclei 3. Middle cerebral peduncle 4. CN VI 5. Corticobulbar and corticospinal tracts 6. medial lemniscus

Question 35

Stroke Syndrome: 1. Horz and vert nystagmus 2. Vertigo 3. Nausea 4. Oscillopsia 5. Deafness/tinnitus 6. Right facial paralysis 7. Right facial numbness 8. paralysis of conjugate gaze to right 9. Pain and temperature sensation loss over left side of body

Answer 35

Lateral inferior pontine syndrome: from occlusion of the AICA - anterior inferior cerebellar artery 1. CN VIII 2. CN VII 3. PPRF 4. Middle cerebellar peduncles and hemisphere 5. Sensory nucleus of V (Descending fibers) 6. Spinothalamic tract

Question 36

Name the Lacunar Stroke Syndromes and their anatomic correlates

Answer 36

1. Pure motor hemiparesis: lenticulostriates (internal capsule). Weakness of face = arm = leg 2. Pure sensory hemiparesis: Lateral thalamus or parietal white matter 3. Mixed sensorimotor 4. Clumsy hand - dysarthria: basis pontis lesion 5. Ataxia hemiparesis: pons, midbrain, capsule, parietal white matter