Stroke Syndromes and Localization

Ozcan Ozdemir, MD
Clinical Stroke Fellow, LHSC
 Stroke localization and
syndromes
„ Objective
Stroke definition, symptoms
Stroke mimics
Stroke syndromes
 Stroke: An Operational
Definition
„ A clinical syndrome.

„ Focal neurological deficits due to

presumed vascular disturbance within the
central nervous system that evolve over a
short period of time (seconds to hours)
and last more than 24 hours (1 hr).
 Case Study
„ 82 year old man brought to hospital after he was found
to be in a confused state and wandering the hallway of
his apartment complex.
„ He gave the wrong date and thought he was in a park
Neurological examination did not reveal any visual field
cut, weakness, or inccordination.
 Case Study

„ Fever 38.5°, abnormal lung examination

„ Determination: Not a stroke.

„ Actual diagnosis: Pneumonia with septic

encephalopathy
70 years old gentelman with unremarkable vascular history
presented with sudden onset of speech disturbance and
right arm weakness (Symptom onset 1 hour)/
Neurological examination revealed right arm weakness and
expressive aphasia
His son noticed that his right arm has been shaking for almost
1 week
 Major stroke syndromes I
„ Middle cerebral artery (MCA) „ Anterior cerebral
„ contralateral hemiparesis
„ contralateral sensory loss artery (ACA)
„ arm and face > leg „ contralateral leg
„ contralateral homonymous weakness and sensory
hemianopsia
„ gaze preference toward the side
loss
of the lesion „ Bilateral: altered
„ receptive or expressive aphasia mental status, abulia,
(dominant)
„ agnosia (non-dominant)
akinetic mutism
 Major stroke syndromes II
„ Posterior cerebral „ Vertebrobasilar artery
artery (PCA) „ visual field deficits
„ contralateral „ diplopia
homonymous „ nystagmus
hemianopsia „ dysphagia
„ dysarthria
„ cortical blindness „ vertigo
„ visual agnosia „ ataxia
„ weakness and sensory loss
„ altered mental status
„ bilateral symptoms/signs
„ impaired memory „ decreased LOC
 Is the patient having a stroke?
„ Goldstein et al reviewed 1994 report regarding
the accuracy and reliability of symptoms and
findings for the evaluation of patients with
suspected stroke and TIA.
„ The presence of acute facial paresis, arm drift or
abnormal speech increases the likehood of
stroke
„ Symptoms associated with high agreement for
the diagnosis of stroke and TIA vs non-vascular
event:
Sudden change in speech, visual loss, diplopia,
paralysis or weaknes, numbness or tingling
JAMA 2005;19:2931-2401
 Misdiagnosis of stroke
Norris Lancet 1982;1:1523

„ 821 patients consecutively admitted to a

stroke unit from ER
„ Evaluators – Interns then neurology
„ Initial studies - History and physical
„ Further studies – CT head, LP, EEG
 Misdiagnosis of stroke
Norris Lancet 1982;1:1523

„ Stroke mimic rate 13%

„ Post-ictal state, non-convulsive status (5%)
„ Confusional state: metabolic, psychogenic, drugs,
alcohol
„ Subdural hematoma
„ CNS tumor
„ Radial-nerve palsy
„ Vertigo
„ Encephalitis
„ Cardiac failure
„ Multiple sclerosis
Conditions that mimic stroke in the ER
Libman et al. Arch Neurol 1995; 52:1119-22

„ 411 consecutive patients presenting to ER

with initial diagnosis of stroke
„ 75% made by ER physician
„ Diagnosed as “Mimic” or “True stroke” by
history and physical alone
„ Stroke or hemorrhage = “true” stroke
„ Mimics: 78 patients (19%)
Conditions that mimic stroke in the ER
Libman et al. Arch Neurol 1995; 52:1119-22
„ Seizure with post-ictal „ Transient global amnesia
deficit (17%) „ Dementia
„ Systemic infection (17%) „ Multiple Sclerosis
„ Brain tumor (15%) „ Demyelinating disease
„ Toxic-Metabolic „ Cervical spine fracture
disturbance (13%)
„ Myasthenia Gravis
„ Positional vertigo
„ Parkinsonism
„ Cardiac Syncope „ Hypertensive
„ Trauma encephalopathy
„ Subdural hematoma „ Conversion disorder
„ Herpes encephalitis
Mimics of acute ischemic stroke
„ Seizures
„ Post-ictal “Todd’s paresis”
„ Non-convulsive status
epilepticus
„ Vascular lesions
„ Intracerebral hemorrhage
„ Extra-axial hemorrhage (EDH,
SDH)
„ Subarachnoid hemorrhage
„ Venous sinus thrombosis
„ Mass lesions
„ Tumors or abcess
„ Toxic / Metabolic
Hypo-/hyper-glycemia,
„
hyponatremia, hypercalcemia
„ Drug intoxication
„ Infections
„ Encephalitis, meningitis
„ Systemic
„ Migraine with aura
(complicated)
„ Hypertensive
encephalopathy
„ Multiple sclerosis
„ Transient global amnesia
„ Positional vertigo
„ Psychiatric (‘conversion
disorder’)
 Clues to non-ischemic etiology
„ Subacute
„ History of trauma, epilepsy, malignancy,
diabetes
„ Prominent headache
„ Migraine, ICH, mass lesion
„ Positive visual and/or sensory symptoms (“aura”)
„ Loss of consciousness at onset (ictal)
„ Fluctuating LOC, incontinence, tongue biting
„ Rapidly improving LOC & deficits
„ Early focal seizures unusual with ischemic stroke
„ Inconsistent findings
„ Lack of objective signs such as reflex changes or
does not fit an anatomical pattern / vascular territory
Misdiagnosis of Stroke in tPA-Treated Patients

„ 6/151 patients had a final diagnosis other

than acute ischemic stroke
4 conversion disorder
1 complex migraine
Todd`s paralysis
„ No ICH was seen after thrombolysis

A.Scott et al. Annals of Emergency Medicine

 Useful Questions??
„ Vomiting is more common in ICH (48-67%), SAH (48-68%)
and posterior circulation strokes (29% vs 2% ant circulation)
Lacunar stroke 1-2%
„ Headache
ICH 33-41%
SAH 78-87%
Lacunar stroke 3-7%
Embolic 9-18% and thrombotic stroke 11-17%
Post circulation stroke 40%
Decreased consciousness
ICH 39-57%
SAH 48-68%
Ischemic stroke 2-29%
Lacunar 2-3%
Post-circulation 18%
„ Time of onset
„ Preceeding palpitation
„ Activity at the onset of symptoms (majority on daily
activity)
„ Temporal course and progression of findings

Fluctuations??? Stepwise??? Gradual??

Max at onset
SAH 64-84%, Lacune 38-54%, Embolic 79-82%
Thrombotic 40-66%, ICH 34-44%
Stepwise /slutter
Thrombosis 32-34%, Lacune 28-30%, Others <15%
Gradual
ICH 51-63%
65 years old lady, PMH of diabetes and hypertension presented with acute
onset left sided facial drop, left upper and lower extremity paralysis at 8.00
am (Woke up normally).
No headache and neck pain, vomiting, nausea, duble vision, balance problem,
visual disturbance, speech disturbance sensory symptoms. No fluctuations were
Observed. She was aware of her deficit.

Neurological exam: BP 176/89 Alert, oriented. Left facial drop. Left upper extr power
1/5 (prox, distal) , left lower extr 1/5 (prox, distal). Upgoing toes on the left.
 Lacunar syndromes

„ The term of lacuna was primarly used in

pathological studies (1838)
„ CM Fisher described several syndromes
Pure motor hemiplegia
Pure sensory stroke
Homolateral ataxia and crural paresis
Dysartria-clumsy hand syndrome
Sensory-motor stroke (Proposed later)
„ Lacune refers to a small deep infarct
attributable to a primary arterial disease that
involves a penetrating branch of a large
cerebral artery.
„ Vessels are 100-400 µm in size and
infarction could be as large as 15 mm.
„ Putamen, thalamus, internal capsule, pons,
corona radiata
 Pure motor hemiplegia
„ A paralysis complete or incomplete of the
face, arm and the leg on one side
unaccompanied by sensory signs, visual
field defect, dyphasia, agnosia and
apraxia.
„ PMH ranged from 7-9% in stroke registries.
„ 2/3 cases, lacunes are in internal capsule
„ Pons (28%), corona radiata, cerebral peduncle
and the medullary pyramid
„ Pontine versus internal capsule?????
Cannot be distinguished
Transient dysartria, gait ataxia, vertigo is more
common in pontine origin PMH
 Pure sensory stroke
„ 6% of LCAS are sensory strokes.
„ Original paper of Fisher suggested objective
sensory loss
„ However subjective sensory symptoms in the
absence of objective signs were reported by CM
Fisher
„ Complete or incomplete sensory syndromes
„ Localization: Thalamus (thalamus or
thalamocortical pathways, anterior limb internal
capsule
„ Non-lacunar lesions were found in 0-3% in
several studies
 Sensory- motor stroke
„ Originally is not included in LACS
„ Several autopsy cases were reported and
SMS was described
„ SMS is the second most common lacunar
syndromes
„ Location: Thalamus, internal capsule,
corona radiata
 Dysartria-clumsy hand syndrome
Ataxic hemiparesis
„ Dysartria is associated with a LACS in 53% of cases
„ The dysartria and the ataxia of the upper limb is the
prominent component
„ Upper neuron type facial paresis and lingual paresis can
also accompany
„ Internal capsule, pons , corona radiata

„ 94% of patients supported lacunar hypothesis

Ataxic hemiparesis
„ Original description of AH was homolateral ataxia and
crural paresis
„ The syndrome of AH has both cerebellar and pyramidal
elements.
„ Ataxic hemiparesis can be due to internal capsule,
corona radiata, pons involvement.
„ 66 years old gentelman, R handed, presented with acute
onset of slurred speech and clumsiness on left hand.
Denied headache, double vision, visual disturbance,
vertigo, speech disturbance, vomiting and nausea.
Neurological exam: Dysartria, left hand impaired
alternating movements (slowness of movements).

MRA is completely normal

 Some points about lacunar syndromes
„ 5% of pure motor presentation could be non-
ischemic stroke origin with acute onset of
deficits.
„ LACS is not synonymous with the presence of
hypertensive arteriopathy.
„ Complete investigations must be performed on
all patients presenting with lacunar syndromes
76 years old gentelman with a history of hypertension (10 years) presented
with 4 fluctuating episodes of right sided face, upper and lower extremity weakness
followed by tinhling sensation on right side of his face, arm and leg.
Between episodes he was completely normal. Finally he had right facial drop, right
pronator drift sign and right lower extremity was slightly weaker. Otherwise normal.

MRA was completely normal

 Capsular warning sign: crescendo
subcortical transient ischemic attacks
„ Donnan 1980 described the
Possible mechanisms
capsular warning syndrome. In situ atheromatous plaque
„ Stereotypic nature of the TIAs Large vessel atheroma lipping over
preceding lacunar infarction. the penetrator origins
„ Brief bursts of hemiplegia, Vasospasm
hemisensory loss or other Intermittent metabolic dysfunction
expressions of LACS and (Increase in lactate, spreading depression
complete resolution between
like event, peri-infarct depolarizations)
events
„ Basal ganglia, pons, corona
radiata and other adjacent
motor pathways
 Striocapsular infarcts
„ Defined as large 20 mm>
subcortical infarcts in the territory
of lentriculostriate arteries.
„ There are usually 2 medial and 4-
5 lateral LSAs.
„ LSAs supply lateral globus
pallidus, medial putamen,
putamen, external capsule, head
of caudate, the anterior limb of the
internal capsule, anterior party of
the periventricular corona radiata
„ LSAs are end-arteries and arise
with acute angle from main trunk
M1
„ Their presentation, prognosis and
pathogenesis are different
24 years old gentelman , R handed , woke up normally and went to bathroom,
Developed sudden onset of right sided paralysis and speech arrest. He could
express himself. (8.30 am). 9.30 his neurological examination revelaed expressive
aphasia. His comprehension was 80% intact. Repetition was impaired.
Motor power on right upper extremity was 3/5 and 4/5 in lower extremity. Sensory
Examination showed decreased pinprick sensation on right-sided face, arm and leg.
No gaze palsy, visual cut was detected. IV tpa was given at 10.00 am.
Major improvement was seen. Left with right sided hemiparesis (arm>leg)+decreased
Pinprick sensation on right side of his body (face, arm and leg, trunk was not involved)
 Clinical presentation
„ Preceeding TIAs in the ipsilateral carotid
artery is reported in 10-12%
„ Facio-bracial weakness 99%

„ 60% neglect and aphasia

„ Recovery

Full 38%
Absent 29%
Anterior choroidal artery infarcts
„ Originates from internal carotid artery
„ First branch of the ICA distal to the posterior
communicating artery
„ Supplies optic tract, lateral geniculate body,
cerebral pedincule, tip of temporal lobe,
choroidal phelexus of lateral ventricule,posterior
part of the amygdaloid nucleus, posterior two-
thirds of the posterior limb of the internal
capsule, globus pallidus
„ Involvement of posterior corona radiata is still a
debate
„ Etiology is small vessel disease,
cardioembolism, carotid artery atherosclerotic
disease
„AChA territory infarcts represent between 1%-
10%
„The classical triad consisting of hemiplegia,
hemianesthesia, homonymus hemianopia is rare
„The most frequent type of presentation is lacunar
syndrome
90% cases have motor hemiparesis with or without sensory deficit.
Motor symptoms are due to internal capsule, posterior corona radiata
involvement, cerebral peduncule ????
Sensory symptoms are quite variable
Ataxic hemiparesis (hypesthetic) is also described
„Visual field loss
Homonymus hemianopsia
Upper quadrantonopia
Upper and lower sector anopia (sparing of horizontal meridian occur)
„Neuropsychological cortical signs
 Middle cerebral artery syndromes
„ According to vascular territories
Main trunk occlusion
Upper division syndromes
Lower division syndromes
Branch occlusion
„ According to hemisphere side (Right
versus left)
„Hemiplegiaand hemiparesis
Combined deep and superficial infarction
Contralateral hemiplegia, hemianesthesia, homonymus
hemianopia, conjugate gaze deviation in the contralateral
side
Neuropsychological disturbances
Aphasia, apraxia, visuospatial neglect, motor
impersistence, dressing and constructional apraxia
Deep infarction alone
Convexity infarctions
Faciobracial predominance
Opercular and insular infarcts leads to face, oropharynx
weakness
Distal predominance paresis affects the lower face, fingers,
forearm, toes and lower leg
„MCA superior or anterior division territory infarcts
Supplies the frontal, superior parietal lobes
Prominent faciobracial deficit
Hemisensory loss
Conjugate eye deviation
Non-dominant hemipshere
Visuspatial abnormalities for non-dominant hemisphere
Denial of hemiplegia, dysprosodia, motor impersistence,
dressing apraxia, constructional apraxia
Dominant hemisphere
Aphasia, alexia with agraphia
Gerstmann`s syndrome (right-left disorientation, finger agnosia,
acalculia and dysgraphia)
„InferiorDivision MCA Infarctions
Supplies the lateral surface of the temporal lobe
and inferior parietal lobule
14% patients have inf division of MCA
Usually have no elementary motor or sensory
abnormalities
They often have a visual field defect
Wernicke`s aphasia and conduction aphasia
Acute confusional state (right middle temporal
gyrus and inf parietal lobe)
59 years old gentelman, R handed, PMH of atrial fibrillation and NIDDM
presented with left sided weakness (Arm>leg). He was trying to talk however
he could not able to vocalize any sound. He also had swallowing diffuculty.
Denied headache, double vision, vertigo.
NE: Fully alert, oriented. Mute, could not smile or prodrude his tongue. Obey simple
and complex commands. Left arm 3/5 power, left lower extremity power was 4/5.
Sensory examination was normal. Cortical signs: sensory extinction on left side.
No evidenece of anasognosia ,motor impersitence
 Major stroke syndromes
„ Posterior cerebral „ Vertebrobasilar artery
artery (PCA) „ visual field deficits
„ contralateral „ diplopia
homonymous „ nystagmus
„ dysphagia
hemianopsia
„ dysarthria
„ cortical blindness „ Vertigo and dizziness
„ visual agnosia (<1% isolated)
„ ataxia
„ altered mental status
„ weakness and sensory loss
„ impaired memory „ bilateral symptoms/signs

„ Less likely aphasia „ decreased LOC

„ Hearing loss
(anomic, transcortical
sensory)
 Basilary artery occlusive disease
„ Decreased LOC 16%
„ Motor signs
Hemiplegia 44%
Tetraparesis/tetraplegia 5%
„ Cerebellar 43%
„ Vertigo/dizziness 47%
„ Nausea 30%
„ Sensory abnormalities 34%
„ Headache 36%
„ Ocular abnormalities 39%
„ Bulbar/pseudobulbar 64%
„ A 57 year-old lady, R handed, had transient attack of dizziness and
left face tingling sensation that lasted 15 minutes. Awakening next
day she felt dizzy as if the room were rocking or wavering like a
ship. She leaned to the left when she tried to stand. Her voice was
hoarse. She also vomited couple of times and gagged as she tried
to swallow water.

NE showed diminished pain and temperature sensation on the left face and
right body including limbs. Nystagmus, worse on looking leftward, left ptosis
with a smaller pupil. Decreased palatal motion on the left.
Lateral Medullary Syndrome
 Isolated lateral medullary
syndrome

75 % occurs suddenly
25% non-sudden
Headache, vertigo, gait
ataxia occurs earlier
Dysphagia, hiccups, sensory
Symptoms occur lately
„ Very common signs and symptoms (90%)
Sensory symptoms and signs (96%)
Sensory gradient may occur
Several sensory patterns can occur
Ipsilat trigeminal
Bilateral trigeminal
Contralateral trigeminal
Isolated limb/body
Isolated trigeminal
26 % only have classical pattern
25% (contralat trigeminal-limb/body pattern)
Large group (51% bilateral trigeminal)
Ventral group (100% contralateral trigeminal)
Isolated limb/body sensory symptoms (57%) occur
In lateral group
„ Gait ataxia 92%
„ Horner sign 88%
„ Dizziness 92%
Moderately common sign 50-70%
Dysphagia
Hoarseness
Vertigo
Nystagmus (horizontal or rotational to the side opposite to the lesion,
more prominent on looking down)
Limb ataxia
Nausea, vomiting and headache
Less common symptoms 40%
Diplopia
Skew deviation
Gaze deviation
Facial weakness
Dysartria
„ Etiology
Pure lateral medullary infarction
67% had VA disease
Large artery vessel infarction was the most
frequent cause
15% had dissection
5% cardioembolic
Isolated PICA
Most likely cardiogenic embolism
Less often dissection and VA disease
„ 57 years old, R Handed gentelman, 7.30 pm, developed sudden
onset of profound left sided hemiplegia (arm=leg) associated with
left facial drop. He also mentioned dizziness, headache (occipital,
non-throbbing, constant) and vomited several times. Denies double
vision, visual disturbance. He improved 2 hour later and had left
sided weakness and facial drop. However still vomiting and felt dizzy
with headache.

PMH of dyslipidemia

NE: Alert, oriented. EOMs were full. Tongue deviated to the right
Rotatuar nystagmus on the right gaze.
Power on the left upper limb 4/5,
Lower limb 4/5 (distal=proximal). Left facial drop, dysartria.
 Medial Medullary Syndrome
„ Contralateral arm and leg weakness
„ Ipsilateral weakness of tongue
„ Contralateral loss of position sense
„ Kim et al reported abnormal ocular findings in
medial medullary infarction (4/8 ipsilateral to the
lesion, 5/8 gaze-evoked)
„ Ocular finding scan be explained by MLF,
nucleus prepositus hypglossi or efferent
vestibular connection involvement

Neurology 2005;65:1294-1298
 MainReferences
„ J.P Mohr et al. Stroke Pathophysiology, Diagnosis, and
Management. Fourth edition. 2005
„ J Bogousslavsky. Stroke Syndromes. Second Edition.
„ LR Caplan. Caplan`s Stroke. A Clinical Approach. Third
Edition
„ G Donnan, B Norrving, J Bamford, J Bogousslavsky.
Subcortical stroke. Second edition.
A 74-year old man with a history of
hypertension, diabetes and coronary
artery disease developed a sudden onset
staggering gait with a tendency to fall to
the right. For several hours later he
vomited and was confused.

Neurological examination showed rotatory nystagmus on left gaze , ataxia

on right arm and marked lateropulsion on right when sitting or attemting to
stand