Stroke Syndromes

Figure 4-1

DWI sequence demonstrating left ACA territory infarct in a patient that presented with right leg weakness

Contralateral leg > arm weakness and numbness
Loss of voluntary control of micturition
Recurrent artery of Heubner infarct: caudate head, anterior limb of internal capsule, anterior putamen leads to contralateral arm/face weakness and dysarthria

Right (nondominant) MCA Infarct

Left hemiparesis, sensory loss
Left hemineglect (Fig. 4-2)

Figure 4-2

Hemispatial neglect. The right hemisphere attends to both fields, and the left hemisphere primarily attends to the right field. Therefore, a right hemispheric stroke can lead to left hemispatial neglect, whereas neglect from a left hemispheric stroke is much less common. Patient A: normal. Patient B: right hemispheric stroke (grayed), with left hemifield neglect. Patient C: left hemispheric stroke, with no neglect due to preserved right hemisphere allowing for attention to both fields
- Posterior parietal cortex lesion
Visual neglect
- Right inferior frontal gyrus
Spatial neglect: difficulty attending to one side, often accompanied with visual or sensory neglect as well
Contralateral hemianopia
Constructional and dressing apraxia
Topographical disorientation
Visual agnosia: impaired recognition of visual material with normal visual, auditory, tactile acuity
Prosopagnosia: inability to recognize previously known faces with preserved voice recognition
Capgras delusion: belief that familiar persons have been replaced by imposters
Anosognosia: lack of interest/concern in deficits (or denial), typically in left hemispace

Left (dominant) MCA (Fig. 4-3)

Figure 4-3

Left MCA stroke. Noncontrast head CT (top left) shows hyperdense left MCA artery. Follow-up head CT (top right) shows hypodensity corresponding to the left MCA territory. DWI and ADC sequences (bottom left and right, respectively) show hyperintense and hypointense signal suggesting acute infarct

Right hemiparesis, sensory loss

Aphasia (Table 4-1)

Table 4-1

Aphasias

Type	Fluency	Comprehension	Repetition	Naming	Writing	Location	Vascular territory
Broca’s (expressive/motor)	Nonfluent	Preserved	Impaired	Impaired	Impaired	Inferior frontal lobe	MCA, M2 superior trunk
Wernicke’s (receptive/sensory)	Fluent	Impaired	Impaired	Impaired	Impaired	Superior temporal lobe	MCA, M2 inferior trunk
Transcortical motor	Nonfluent	Preserved	Preserved	Relatively preserved	Impaired	Inferior frontal lobe, adjacent to Broca’s area	MCA, M2 superior trunk
Transcortical sensory	Fluent	Impaired	Preserved (echolalia)	Impaired	Impaired	Middle and inferior temporal gyrus	MCA, M2 inferior trunk
Global	Nonfluent	Impaired	Impaired	Impaired	Impaired	Entire L MCA	MCA
Conduction	Fluent with paraphasic errors	Preserved	Impaired	Impaired	Spelling errors, transposition of words and syllables	Arcuate fasiculus, superior temporal gyrus	MCA
Aphemia	Severe dysarthria	Preserved	Preserved	Preserved	Preserved	Left frontal lobe, pars opercula is, inferior peri-rolandic gyrus	L MCA, M2 superior trunk
Anomic aphasia	Fluent	Preserved	Preserved	Impaired	Preserved	Temporal-parietal lobe	MCA
Thalamic aphasia	Fluent	Impaired	Intact	Impaired	Impaired	Thalamus	PCA

Broca – MCA superior division
Wernicke – MCA inferior division
Transcortical motor: like Broca’s aphasia repetition preserved
Transcortical sensory: like Wernicke but repetition preserved
Global

Apraxia
Gerstmann Syndrome
- Dominant parietal lobe, angular gyrus
- Agraphia, acalculia, right/left confusion, finger agnosia

Lacunar Syndromes (Fig. 4-4)

Infarcts <1.5 cm in diameter, due to lipohyalinosis and occlusion of end arteries (lenticulostriates, thalamic and brain stem perforating arteries)
Pure motor hemiparesis (most common): posterior limb of internal capsule, corona radiata, basis pontis
Pure sensory stroke: contralateral thalamus, internal capsule
Ataxic hemiparesis: posterior limb of internal capsule, corona radiata, pons
Clumsy hand dysarthria: contralateral pons, anterior limb/genu of internal capsule
Mixed sensorimotor: contralateral internal capsule, thalamus, pons

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