Last edited: 8/24/2021
1. STROKE SYNDROMES
Stroke Syndromes: MCA, ACA, ICA, PCA, Vertebrobasilar Artery
Strokes
OUTLINE
I) ANTERIOR CIRCULATION STROKES
II) POSTERIOR CIRCULATION STROKES
III) WATERSHED INFARCTS
IV) SUMMARY TABLES
V) REVIEW QUESTIONS
VI) REFERENCES
Introduction
A stroke occurs when the blood supply to a part of the
brain is cut off or when it isn’t receiving enough oxygen
A stroke syndrome is a series of symptoms that occur
when a particular area of the brain is damaged
I) ANTERIOR CIRCULATION STROKES
These account for roughly 70% of strokes
MIDDLE CEREBRAL ARTERY (MCA) STROKE
This is the most common type of stroke
The MCA supplies:
o Lateral portions of frontal and parietal lobes
o Superior part of the temporal lobe
o Basal Ganglia
Superior division infarct
May damage the following structures:
o Primary Motor Cortex (lateral portion)
 Contralateral weakness or paralysis of upper
limbs, face and upper trunk
o Primary somatosensory cortex (lateral portion)
 Contralateral sensory loss of upper limbs, face
and upper trunk
o Frontal eye field
 Ipsilateral gaze deviation
o Broca’s area
 Broca’s (Expressive) aphasia (can understand but
not speak)
Inferior division infarct
May damage the following structures:
o Wernicke’s area
 Wernicke’s (Receptive) aphasia (can speak but
not understand)
o Optic radiations
 Contralateral homonymous hemianopia or
quadrantanopia without macular sparing
Infarct of the MCA on the non-dominant side
(Usually right side) can result in damage to the following
structures:
o Right parietal and temporal lobe
 Apraxia → Difficulty performing voluntary actions
despite intact motor function and desire to
perform movement
 Hemieglect → Unaware of visual or somatic
sensations on contralateral side of the body
Stroke syndromes
Medical Editor: Adara Garcia Maestu
ANTERIOR CEREBRAL ARTERY (ACA) STROKE
The ACA supplies:
o Medial portions of frontal and parietal lobes
o Basal Ganglia
An infarct may damage the following structures:
Primary motor cortex (medial portion)
o Contralateral weakness or paralysis of lower limbs
and lower trunk
Primary somatosensory cortex (medial portion)
o Contralateral sensory loss of lower limbs and trunk
Paracentral lobule of parietal lobe
o Urinary incontinence
o Fecal incontinence
Prefrontal cortex and anterior cingulate cortex
o Abulia→ Decreased motivation to perform tasks
o Akinetic mutism
 Occurs in bilateral frontal lobe infarcts
 Severe decreased motivation to perform tasks
 No response to pain
 Catatonic
Anterior/superior frontal lobe
o Transcortical motor aphasia→ Similar to Broca’s
aphasia but maintain the ability to repeat phrases
INTERNAL CAROTID ARTERY (ICA) STROKE
The ICA supplies both the MCA and ACA, therefore a
mixture of both these stroke syndromes’ symptoms can
be seen with a severe ICA infarct
In 5% of patients it ICA infarct can cause PCA stroke
syndrome due to fetal variant
ICA also supplies the retina and infarct may cause:
o Amaurosis Fugax→ Transient ipsilateral mono-ocular
vision loss that may become permanent if not treated
LENTICULOSTRIATE ARTERIES
Small arterial branches off the MCA that supply
subcortical and brainstem structures
An infarct damages the posterior limb of the internal
capsule and other basal ganglia resulting in various
lacunar stroke syndromes:
Pure Motor Stroke
o Contralateral weakness of whole side
Sensorimotor Stroke
o Contralateral weakness of whole side
o Contralateral sensory loss/paresthesia of whole side
Ataxic Hemiparesis
o Ipsilateral weakness and ataxia
Dysarthria (clumsy hand syndrome)
o Contralateral weakness of face and hand
o Dysarthria
Pure Sensory Stroke
o Contralateral sensory loss/paresthesia of whole side
NEURO PATHOLOGY: Note #1. 1 of 3
 II) POSTERIOR CIRCULATION STROKES  Ipsilateral sensory loss of face
• Pain
These account for roughly 30% of strokes • Temperature
POSTERIOR CEREBRAL ARTERY (PCA) o Spinothalamic Tract
 Contralateral sensory loss of the whole side
The PCA supplies: • Pain
o Midbrain • Temperature
o Occipital lobes
o Posteromedial region of temporal lobe
o Thalamus BASILAR ARTERY + AICA
An infarct may damage the following structures: Basilar artery gives off:
o Paramedian branches
Occipital lobe  Supply medial pons
o Homonymous Hemianopia with macular sparing o Superior Cerebellar Artery
o Anterior Inferior Cerebellar Artery (AICA)
Thalamus  Supply lateral pons
o Variable/contralateral sensory loss or paresthesia of
whole side Infarct of paramedian arteries
o Visual field cut (damage to lateral geniculate nucleus)
o Decreased arousal or coma May cause damage to the following structures:
o CN VI (Abducens) nucleus
Midbrain  Ipsilateral loss of eye abduction
o Weber Syndrome  Medial gaze deviation
 Ipsilateral CN III palsy o Medial Longitudinal Fasciculus (MLF)
 Contralateral hemiplegia  Internuclear ophthalmoplegia→ Inability to co-
o Claude Syndrome ordinate eye movements
 Ipsilateral CN III palsy o Paramedian Pontine Reticular Formation (PPRF)
 Contralateral ataxia  Loss of ipsilateral gaze
o Benedikt Syndrome o Medial Lemniscus
 Combination of Weber and Claude syndromes  Contralateral loss of fine touch, proprioception and
vibration
o Corticospinal tract
VERTEBRAL ARTERY + PICA  Contralateral weakness
Vertebral Artery gives off:
o Anterior Spinal Artery (ASA) Infarct of AICA
 Supplies medial medulla
o Posterior Inferior Cerebellar Artery (PICA) May cause damage to the following structures:
 Supplies lateral medulla and posterior inferior o Middle Cerebellar Peduncles
cerebellum  Ipsilateral Ataxia→ Impaired co-ordination and
balance
o Vestibular Nucleus
Infarct of vertebral artery/ASA  Vertigo
May damage the following structures:  Nausea and Vomiting
o CN XII nucleus  Nystagmus
 Ipsilateral tongue deviation o Cochlear Nuclei
o Medial Lemniscus  Decreased hearing
 Contralateral sensory loss of whole side  Tinnitus
• Proprioception o Descending Sympathetic tracts
• Fine touch  Horner’s Syndrome (Ptosis, Anhidrosis, Miosis)
• Vibrations o CN V (trigeminal) nucleus + tract
o Corticospinal tracts in pyramids before decussation  Ipsilateral loss of sensation to face
 Contralateral weakness or paralysis of whole side  Loss of ipsilateral corneal reflex
 Ipsilateral mastication muscle weakness
o Spinothalamic Tracts
Infarct of PICA (Wallenburg Syndrome)  Contralateral loss of pain and temperature on
May damage the following structures: whole side
o Inferior cerebellar peduncles o CN VII (facial) nucleus
 Ipsilateral facial weakness (usually lower part)
 Ipsilateral ataxia→ Impaired co-ordination and
balance
o Nucleus Ambiguus (CN IX, X, XI) III) WATERSHED INFARCTS
 Dysphagia
 Hoarseness Infarcts of watershed areas→ Regions of the brain
 Vocal cord paralysis (dysphonia) situated furthest away from supplying blood vessels
 Diminished cough and gag reflexes o Found where two vascular territories anastamose
 Contralateral uvular deviation
Most susceptible to infarction during low perfusion states
o Vestibular nuclei
(↓ BP)
 Nausea and Vomiting
 Vertigo MCA / ACA watershed zone infarct
 Nystagmus
Contralateral weakness/paralysis and sensory loss of
o Descending Sympathetic Tracts
upper and lower extremities
 Ipsilateral Horner’s syndrome (Ptosis, Miosis,
Also known as “Man in a Barrel” Syndrome
Anhidrosis)
o Spinal Trigeminal Nucleus (CN V)

2 of 3 NEURO PATHOLOGY: Note #1. Stroke syndromes

 MCA / PCA watershed zone infarct  Oculomotor apraxia→ Inability to shift gaze
Visual dysfunctions voluntarily despite desire to do so and intact
function of extraocular muscles
o Prosopagnosia→ Patient sees objects/people but
can’t make out what/who they are
o Homonymous Hemianopia
o Balint’s Syndrome (rare)
 Simultanagnosia→ Inability to perceive more than
one object at a time Eg. Patient will see individual
trees but is unable to recognize the forest
 Optic ataxia→ Lack of co-ordination between
visual input and hand movements Eg. Patient
touches their own nose but struggles to touch the
physician’s finger

IV) SUMMARY TABLES

Table 1-1 Stroke Syndromes Summary Table

Vessel Symptoms Vessel Symptoms

Contralateral weakness/paralysis and sensory Ataxia

loss of upper limbs, face and upper trunk Dysphagia, Dysphonia, ↓ gag and cough
Ipsilateral gaze deviation PICA reflexes
MCA Aphasia (expressive, receptive or both) (Lateral Contralateral uvular deviation
Contralateral Homonymous hemianopia Medulla) Vertigo, N/V, Nystagmus
without macular sparing Ipsilateral Horner’s Syndrome
Apraxia + Hemineglect if infarct on non- Loss of pain and temperature on ipsilateral
dominant hemisphere face and contralateral whole side

Contralateral weakness/paralysis and sensory

loss of lower limbs and lower trunk Vertebral Contralateral weakness/paralysis and sensory
Urinary and fecal incontinence Artery/ASA loss (fine touch, vibration + proprioception) of
ACA
Abulia or Akinetic mutism (Medial whole side
Transcortical motor aphasia (able to repeat Medulla) Ipsilateral tongue deviation
phrases)

Ataxia
Vertigo, N/V, Nystagmus
Hearing loss + tinnitus
Mixture of MCA and ACA symptoms AICA Ipsilateral Horner’s Syndrome
ICA May have PCA symptoms if fetal variant (Lateral Ipsilateral loss of sensation to face, loss of
present Pons) corneal reflex and weakness of mastication
Amaurosis Fugax
and facial muscles
Contralateral loss of pain and temperature on
whole side
Homonymous Hemianopia with macular
Basilar Contralateral weakness and loss of fine touch,
sparing
Artery proprioception and vibration
PCA Variable or contralateral sensory
(Medial Ipsilateral loss of eye abduction→ Medial gaze
loss/paresthesia of whole side (thalamus)
Pons) deviation
Weber, Claude or Benedikt Syndromes
Intranuclear ophthalmoplegia
(midbrain)

V) REVIEW QUESTIONS

VI) REFERENCES
● Parvathaneni A, M Das J. Balint Syndrome. [Updated 2021 Jun
30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls
Publishing; 2021 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK544347/

Stroke syndromes NEURO PATHOLOGY: Note #1. 3 of 3