MIDDLE CEREBRAL ARTERY

Middle cerebral artery - complete

Eponym:
Anatomy:
Vascular: Middle cerebral artery: Proximal occlusion at MCA stem

Signs & Symptoms:

*Side: Manifestation: Comments:
C Weakness - upper and lower extremity Somatic motor area for face, arm > leg
C Weakness - face - lower half
C Hemisensory loss - upper and lower extremity
C Sensory loss - face - all modalities
N Aphasia - receptive Dominant hemisphere (Wenicke's area)
N Aphasia - expressive Dominant hemisphere (Broca's area)
C Hemineglect Non-dominant hemisphere
C Lateral gaze weakness
I Gaze preference
C Visual loss - homonymous hemianopia

Middle cerebral artery - superior division

Eponym:
Anatomy:
Vascular: Middle cerebral artery: Superior Division

Signs & Symptoms:

*Side: Manifestation: Comments:
C Weakness - upper and lower extremity (face, arm > leg)
C Weakness - face - lower half
C Hemisensory loss - upper and lower extremity
C Sensory loss - face - all modalities
C Hemineglect (Non-dominant hemisphere)
C Aphasia - expressive Dominant hemisphere (Broca's area)

Middle cerebral artery - inferior division

Eponym:
Anatomy:
Vascular: Middle cerebral artery: Inferior Division

Signs & Symptoms:

*Side: Manifestation: Comments:
C Visual loss - homonymous hemianopia
C Visual loss - upper quadrant anopsia
C Constructional apraxia Non-dominant hemisphere
C Aphasia - receptive Dominant hemisphere (Wernicke's area)

Gerstmann Syndrome
Eponym: Gerstmann Syndrome
Anatomy: Cerebral hemisphere: Dominant parietal lobe
Vascular: Middle cerebral artery
Signs & Symptoms:
*Side: Manifestation: Comments:
N Agraphia (inability to write)
N Acalculia (inability to calculate)
N Right-left confusion
N Finger agnosia (inability to recognize fingers)
N Ideomotor apraxia May be associated

POSTERIOR CEREBRAL ARTERY

Posterior cerebral artery - unilateral occipital
Eponym:
Anatomy Cerebral hemisphere: Posterior limb of external capsule
: Pons: Basis pontis
Vascular: Middle cerebral artery: Small penetrating arteries
Basilar artery: Small penetrating arteries

Signs & Symptoms:

*Side: Manifestation: Comments:
C Weakness - upper and lower extremity
C Ataxia - arm and leg

*Side: Ipsilateral, Contralateral, Both, Neither

Notes:
Weakness usually more prominent in leg than arm; extensor plantar response; no facial involvement
or dysarthria. Other locations include thalamocapsular lesions, red nucleus, anterior cerebral artery
distribution. Also called "homolateral ataxia and crural paresis."

Posterior cerebral artery - unilateral occipital

Eponym:
Anatomy Cerebral hemisphere: Occipital and infero-medial temporal lobes.
:
Vascular: Posterior cerebral artery

Signs & Symptoms:

*Side: Manifestation: Comments:
C Visual loss - homonymous hemianopia Optic pathway, calcarine cortex

*Side: Ipsilateral, Contralateral, Both, Neither

Notes:
Visual field defects are frequently the only neurological abnormalities. Other associated syndromes:
alexia without agraphia, visual or color anomia.
Balint Syndrome
Eponym: Balint Syndrome
Anatomy Cerebral hemisphere: Bilateral parietal-occipital lobes
:
Vascular: Posterior cerebral artery: Bilateral

Signs & Symptoms:

*Side: Manifestation: Comments:
B Loss of voluntary but not reflex eye movements
B Optic ataxia - poor visual-motor coordination
B Asimultagnosia - inability to understand visual
objects

Cortical blindness
Eponym: Anton Syndome
Anatomy: Cerebral hemisphere: Bilateral occipital lobes
Vascular: Posterior cerebral artery: Bilateral
Basilar artery: Top of the basilar

Signs & Symptoms:

*Side: Manifestation: Comments:
B Visual loss - bilateral
N Unawareness or denial of blindness

*Side: Ipsilateral, Contralateral, Both, Neither

Notes:
May have visual hallucinations.

Weber Syndrome
Eponym: Weber Syndrome
Anatomy: Midbrain: Base
Vascular: Posterior cerebral artery: Penetrating branches to midbrain

Signs & Symptoms:

*Side: Manifestation: Comments:
C Corticospinal tract
Weakness - upper and lower extremity
I Lateral gaze weakness CN 3

Alexia without agraphia

Eponym:
Anatomy: Cerebral hemisphere: Left occipital region plus splenium of corpus
collosum
Vascular: Posterior cerebral artery: Collosal branches

Signs & Symptoms:

*Side: Manifestation: Comments:
N Alexia Splenium of corpus collosum
C Visual loss - homonymous hemianopia Left occipital region

*Side: Ipsilateral, Contralateral, Both, Neither

Notes:
Pure word blindness. Can write but not read.

Thalamic pain syndrome

Eponym: Dejerine-Roussy syndrome
Anatomy: Thalamus
Vascular: Posterior cerebral artery: Pentrating branches to thalamus

Signs & Symptoms:

*Side: Manifestation: Comments:
C Hemisensory loss - all modalities
C Hemi-body pain

Anterior inferior ce

ANT. INF. CEREBELLAR ARTERY

Lateral pontine syndrome
Eponym: Marie-Foix Syndrome
Anatomy
:
Vascular: Basilar artery: Long circumferential branches
Anterior inferior cerebellar artery

Signs & Symptoms:

*Side: Manifestation: Comments:
I Ataxia - arm and leg Cerebellar tracts
C Weakness - upper and lower extremity Corticospinal tracts
C Hemisensory loss - pain and temperature Spinothalamic tract

*Side: Ipsilateral, Contralateral, Both, Neither

Notes:
Marie-Foix Syndrome
Lesion in the lateral pons, including the middle cerebellar peduncle.
1. Ipsilateral cerebellar ataxia due to involvement of cerebellar tracts
2. Contralateral hemiparesis due to corticospinal tract involvement
3. Variable contralateral hemihypesthesia for pain and temperature due to spinothalamic tract
involvement.

PICA

POST. INF. CEREBELLAR ARTERY

Lateral medullary syndrome
Eponym: Wallenberg Syndrome
Anatomy:
Vascular: Vertebral artery: Distal branches
Vertebral artery: Superior lateral medullary artery
Posterior inferior cerebellar artery: Less common than vertebral

Signs & Symptoms:

*Side: Manifestation: Comments:
I Sensory loss - face - pain and temperature CN 5 nucleus
I Facial pain CN 5 nucleus
I Ataxia - arm and leg Restiform body, cerebellum
I Gait ataxia Restiform body, cerebellum
I Nystagmus Vestibular nucleus
I Nausea / vomiting Vestibular nucleus
I Vertigo Vestibular nucleus
I Horseness Nucleus ambiguus
I Dysphagia Nucleus ambiguus
I Horner syndrome Descending sympathetics
C Hemisensory loss - pain and temperature Spinothalamic tract
N Hiccups

BASILAR ARTERY
Locked-in Syndrome

Eponym:
Anatomy Pons: Bilateral ventral pons
:
Vascular: Basilar artery

Signs & Symptoms:

*Side: Manifestation: Comments:
B Weakness - upper and lower extremity Quadriplegia: bilateral cortical spinal tracts
B Weakness - face - entire side Bilateral corticobulbar tracts
N Lateral gaze weakness Bilateral fascicles of CN VI
N Dysarthria Bilateral corticobulbar tracts

*Side: Ipsilateral, Contralateral, Both, Neither

Notes:
Bilateral ventral pons lesions (iscemic or hemorrhagic) may result in this deefferented state, with
preserved consciousness and sensation, but paralysis of all movements except vertical gaze and eyelid
opening.
1. Quadriplegia due to bilateral corticospinal tract involvement
2. Aphonia due to corticobulbar tract involvement to lower cranial nerve nuclei
3. Occasionally, impairment of horizontal eye movements due to bilateral involvement of the
fasciclesof cranial nerve
4. Reticular formation is spared, so the patient is typically fully awake. The supranuclear ocular motor
pathways lie dorsally, so that vertical eye movements and blinking are intact.

Lateral pontine syndrome

Eponym: Marie-Foix Syndrome
Anatomy
:
Vascular: Basilar artery: Long circumferential branches
Anterior inferior cerebellar artery

Signs & Symptoms:

*Side: Manifestation: Comments:
I Ataxia - arm and leg Cerebellar tracts
C Weakness - upper and lower extremity Corticospinal tracts
C Hemisensory loss - pain and temperature Spinothalamic tract

*Side: Ipsilateral, Contralateral, Both, Neither

Notes:
Marie-Foix Syndrome
Lesion in the lateral pons, including the middle cerebellar peduncle.
1. Ipsilateral cerebellar ataxia due to involvement of cerebellar tracts
2. Contralateral hemiparesis due to corticospinal tract involvement
3. Variable contralateral hemihypesthesia for pain and temperature due to spinothalamic tract
involvement.

Ventral pontine syndrome

Eponym: Raymond Syndrome
Anatomy Pons: Ventral medial pons
:
Vascular: Basilar artery: Paramedian branches

Signs & Symptoms:

*Side: Manifestation: Comments:
I Lateral gaze weakness CN VI
C Weakness - upper and lower extremity Pyramidal tract

*Side: Ipsilateral, Contralateral, Both, Neither

Notes:
Raymond Syndrome (Alternating abducens hemiplegia) A unilateral lesion of the ventral medial pons,
which affects the ipsilateral abducens nerve fascicles and the corticospinal tract but spares cranial
nerve VII.
1. Ipsiplateral lateral rectus paresis, due to cranial nerve VI involvement
2. Contralateral hemipegia, sparing the face, due to pyramidal tract involvement.

Ventral pontine syndrome

Eponym: Millard-Gubler Syndrome
Anatomy Pons: Basis pontis and fascicles of CN VI amd VII
:
Vascular: Basilar artery: Short circumferential branches
Basilar artery: Paramedian branches

Signs & Symptoms:

*Side: Manifestation: Comments:
C Weakness - upper and lower extremity Pyramidal tract
I Lateral gaze weakness CN VI
I Weakness - face - entire side CN VII

*Side: Ipsilateral, Contralateral, Both, Neither

Notes:
Millard-Gubler Syndrome
A unilateral lesion of the ventrocaudal pons may invovle the basis pontis and the fascicles of cranial
nerves VI and VII. Symptoms include:
1. Contralateral hemiplegia (sparing the face) due to pyramidal tract involvement
2. Ipsilateral lateral rectus palsy with diplopia that is accentuated when the patient looks toward the
lesion, due to cranial nerve VI involvement.
3. Ipsilateral peripheral facial paresis, due to cranial nerve VII involvement.

Inferior medial pontine syndrome

Eponym: Foville Syndrome
Anatomy Pons: Unilateral lesion in the dorsal pontine tegmentum in the caudal third of the pons
:
Vascular: Basilar artery: Paramedian branches
Basilar artery: Short circumferential arteries

Signs & Symptoms:

*Side: Manifestation: Comments:
C Weakness - upper and lower extremity Corticospinal tract
I Weakness - face - entire side VII nucleus / fascicle
I Lateral gaze weakness PPRF or CN VI nucleus

*Side: Ipsilateral, Contralateral, Both, Neither

Notes:
Foville Syndrome, Inferior medial pontine syndrome
Unilateral lesion in the dorsal pontine tegmentum in the caudal third of the pons.
1. Contralateral hemiplegia (with facial sparing) due to corticospinal tract involvement
2. Ispilateral peripheral-type facial palsy, due to cranial nerve VII nucleus/fascicle involvement.
3. Inability to move the eyes conjugately to the ipsilateral side due to paramedian pontine reticular
formaiton and/or abducens nerve nucleus invovlement. That is, patient is unable to look toward the
lesion.
Note: this is also called Millard-Gubler syndrome.

Posterior cerebral artery - unilateral occipital

Eponym:
Anatomy Cerebral hemisphere: Posterior limb of external capsule
: Pons: Basis pontis
Vascular: Middle cerebral artery: Small penetrating arteries
Basilar artery: Small penetrating arteries

Signs & Symptoms:

*Side: Manifestation: Comments:
C Weakness - upper and lower extremity
C Ataxia - arm and leg

*Side: Ipsilateral, Contralateral, Both, Neither

Notes:
Weakness usually more prominent in leg than arm; extensor plantar response; no facial involvement
or dysarthria. Other locations include thalamocapsular lesions, red nucleus, anterior cerebral artery
distribution. Also called "homolateral ataxia and crural paresis."

Cortical blindness
Eponym: Anton Syndome
Anatomy: Cerebral hemisphere: Bilateral occipital lobes
Vascular: Posterior cerebral artery: Bilateral
Basilar artery: Top of the basilar

Signs & Symptoms:

*Side: Manifestation: Comments:
B Visual loss - bilateral
N Unawareness or denial of blindness

*Side: Ipsilateral, Contralateral, Both, Neither

Notes:
May have visual hallucinations.

Medial medullary syndrome

Eponym: Dejerine Syndrome
Anatomy Medulla: Medial medulla
:
Vascular: Vertebral artery: Anteromedial artery
Anterior spinal artery: Anteromedial artery
Basilar artery

Signs & Symptoms:

*Side: Manifestation: Comments:
C Weakness - upper and lower extremity Pyramidal tract
 C Hemisensory loss - vibration and proprioception Medial lemniscus
I Tongue weakness +/- atrophy Cn 12 nucleus

*Side: Ipsilateral, Contralateral, Both, Neither

Notes:
Rare stroke syndrome (<1% of vertebrobasilar strokes, Bassetti et al., 1994). Medial medullary infarct
is associated with clinical triad of ipsilateral hypoglossal palsy, contralateral hemiparesis, and
contralateral lemniscal sensory loss. Variable manifestations may include isolated hemiparesis,
tetraparesis, ipsilateral hemiparesis, I or C facial palsy, ataxia, vertigo, nystagmus, dysphagia. Palatal
and pharyngeal weakness rare in pure MMI, common in lateral medullary infarct.

VERTEBRAL ARTERY
Medial medullary syndrome

Eponym: Dejerine Syndrome

Anatomy Medulla: Medial medulla
:
Vascular: Vertebral artery: Anteromedial artery
Anterior spinal artery: Anteromedial artery
Basilar artery

Signs & Symptoms:

*Side: Manifestation: Comments:
C Weakness - upper and lower extremity Pyramidal tract
C Hemisensory loss - vibration and proprioception Medial lemniscus
I Tongue weakness +/- atrophy Cn 12 nucleus

*Side: Ipsilateral, Contralateral, Both, Neither

Notes:
Rare stroke syndrome (<1% of vertebrobasilar strokes, Bassetti et al., 1994). Medial medullary infarct
is associated with clinical triad of ipsilateral hypoglossal palsy, contralateral hemiparesis, and
contralateral lemniscal sensory loss. Variable manifestations may include isolated hemiparesis,
tetraparesis, ipsilateral hemiparesis, I or C facial palsy, ataxia, vertigo, nystagmus, dysphagia. Palatal
and pharyngeal weakness rare in pure MMI, common in lateral medullary infarct.

Lateral medullary syndrome

Eponym: Wallenberg Syndrome
Anatomy:
Vascular: Vertebral artery: Distal branches
Vertebral artery: Superior lateral medullary artery
Posterior inferior cerebellar artery: Less common than vertebral

Signs & Symptoms:

*Side: Manifestation: Comments:
I Sensory loss - face - pain and temperature CN 5 nucleus
I Facial pain CN 5 nucleus
I Ataxia - arm and leg Restiform body, cerebellum
 I Gait ataxia Restiform body, cerebellum
I Nystagmus Vestibular nucleus
I Nausea / vomiting Vestibular nucleus
I Vertigo Vestibular nucleus
I Horseness Nucleus ambiguus
I Dysphagia Nucleus ambiguus
I Horner syndrome Descending sympathetics
C Hemisensory loss - pain and temperature Spinothalamic tract
N Hiccups

ANT. SPINAL ARTERY

Medial medullary syndrome

Eponym: Dejerine Syndrome

Anatomy Medulla: Medial medulla
:
Vascular: Vertebral artery: Anteromedial artery
Anterior spinal artery: Anteromedial artery
Basilar artery

Signs & Symptoms:

*Side: Manifestation: Comments:
C Weakness - upper and lower extremity Pyramidal tract
C Hemisensory loss - vibration and proprioception Medial lemniscus
I Tongue weakness +/- atrophy Cn 12 nucleus

*Side: Ipsilateral, Contralateral, Both, Neither

Notes:
Rare stroke syndrome (<1% of vertebrobasilar strokes, Bassetti et al., 1994). Medial medullary infarct
is associated with clinical triad of ipsilateral hypoglossal palsy, contralateral hemiparesis, and
contralateral lemniscal sensory loss. Variable manifestations may include isolated hemiparesis,
tetraparesis, ipsilateral hemiparesis, I or C facial palsy, ataxia, vertigo, nystagmus, dysphagia. Palatal
and pharyngeal weakness rare in pure MMI, common in lateral medullary infarct.

Links & References:

Medial medullary stroke: report of seven patients and review of the literature. Neurology 1997
Apr;48(4):882-90. Article
Dejerine, J. Semiologie des affections du systeme nerveux. Paris: Masson, 1914. Article