Large-vessel stroke syndromes (assumes left hemispheric dominance)
| Vascular territory | Signs and symptoms |
|---|---|
| Internal carotid artery | Combined anterior cerebral artery/middle cerebral artery syndromes; ipsilateral monocular visual loss secondary to transient central retinal artery occlusion (amaurosis fugax); branch retinal artery occlusions may present as ipsilesional altitudinal field cuts. |
| Anterior cerebral artery | Contralateral leg numbness and weakness, possibly ipsilateral (‘sympathetic’) or contralateral ideomotor apraxia, (L) transcortical motor aphasia, (R) motor neglect. Occasionally urinary incontinence (medial micturition centre), ipsilateral eye deviation and paratonic rigidity. |
| Middle cerebral artery | Superior division (lateral frontal and superior parietal lobes): contralateral face/arm (more than leg) numbness and weakness, contralateral homonymous hemianopia (lower fields), cortical hand syndrome*, ipsilateral gaze preference, [dom] expressive aphasia, [non-dom] contralateral hemispatial neglect, agraphaesthesia, astereognosis. Inferior division (lateral temporal and inferior parietal lobes): contralateral homonymous hemianopia (upper fields), [dom] receptive aphasia, [non-dom] constructional apraxia. |
| Posterior cerebral artery† | Complete or partial contralateral homonymous hemianopia, if midbrain involvement ipsilateral third nerve palsy with mydriasis and contralateral hemiparesis (Weber syndrome), (L with splenium of corpus callosum) alexia without agraphia. |
| Superior cerebellar artery | Ipsilateral limb and gait ataxia. |
| Anterior inferior cerebellar artery | Vertigo and ipsilateral deafness, possibly also ipsilateral facial weakness and ataxia. |
| Vertebral/posterior inferior cerebellar artery | Ipsilateral limb and gait ataxia; if lateral medullary involvement, may have ipsilateral fifth cranial nerve, cerebellar, nucleus ambiguous (hoarseness and dysphagia), vestibular nucleus dysfunction, Horner’s syndrome and contralateral hemisensory loss to pain and temperature (Wallenberg syndrome). |
| Basilar artery | Pontine localisation with impaired lateral gaze, horizontal diplopia and disconjugate gaze, non-localised hemiparesis, dysarthria; ‘locked-in syndrome’ with bilateral pontine infarction (intact vertical eye movements, anarthria, quadriplegia). |
Adapted from Southerland et al.27
*Targeted infarct of the precentral motor hand cortex (‘hand knob’) often associated with ipsilateral internal carotid stenosis, causing deficit involving only the contralateral hand, several fingers, or just the thumb.28
†Note the potential for paradoxical embolisation from the anterior to posterior territory in patients with fetal-origin posterior circulation arteries (posterior cerebral arteries arising from the distal internal carotid artery—a normal anatomical variant) and for a detailed review of the vascular supply of the thalamus, see Powell et al.29
L, left hemisphere; R, right hemisphere.