Common presentations and Lesions

Question 1

Ipsilateral third nerve palsy and contralateral hemiplegia

Answer 1

Weber’s syndrome (midbrain lesion)

Question 2

Ipsilateral third nerve palsy and contralateral involuntary movements

Answer 2

Benedikt’s Syndrome (lesion in the ventral portion of the mesencephalic tegmentum)

Question 3

Ipsilateral third nerve palsy and contralateral ataxia and tremor

Answer 3

Claude’s syndrome (lesion in the dorsal portion of the mesencephalic tegmentum)

Question 4

Ipsilateral seventh nerve palsy with contralateral hemiplegia

Answer 4

Millard-Gubler syndrome (lesion in the pons)

Question 5

Limited upward gaze, convergence retraction nystagmus, light-near dissociation, lid retraction and skew deviation of the eyes

Answer 5

Parinaud’s syndrome (lesion in the quadrigmeminal plate)

Question 6

Quadriplegia, inability to speak, limited horizontal gaze, with preserved consciousness, vertical gaze and blinking

Answer 6

Locked-in syndrome

Question 7

Vertigo, nystagmus, nausea, hiccups, hoarseness, dysphagia, ipsilateral paralysis of the palate and vocal cord, decreased gag reflex, impaired sensation on the ipsilateral hemiface, loss of sensation to pain and temperature in the contralateral hemibody, ipsilateral ataxia and lateropulsion, and ipsilateral Horner’s syndrome

Answer 7

Wallenberg’s syndrome: caused by a lateral medullary infarction (associated with posterior inferior cerebellar artery or vertebral artery occlusion)

Question 8

Ipsilateral hearing loss, vertigo, ipsilateral ataxia, ipsilateral Horner’s syndrome, sensory deficits in the ipsilateral hemiface and contralateral hemibody

Answer 8

Anterior inferior cerebellar artery infarct

Question 9

Contralateral hemibody sensory loss with subsequent development of pain, allodynia, and parasthesia

Answer 9

Dejerine- Roussy syndrome, results from a thalamic lesion

Question 10

Finger agnosia, right left disorientation, agraphia and acalculia

Answer 10

Gerstmann’s Syndrome - dominant parietal lobe infarct

Question 11

Normal variant with vascular supply to both medial thalami

Answer 11

Artery of percheron

Question 12

Deep branch from the ACA that supplies anterior limb of the internal capsule, inferior part of head of caudate nucleus, and anterior part of globus pallidus

Answer 12

recurrent artery of Heubner

Question 13

Caused by chronic hypertension, and associated with the pathogenesis of lacunar strokes

Answer 13

Lipohyallinosis

Question 14

Infarct between two vascular territories produces the “person in a barrel” syndrome characterized by proximal weakness

Answer 14

Watershed infarcts

Question 15

Behavioural abnormalities, altered level of consciousness, and abnormalities of ocular motion

Answer 15

Top of basilar syndrome -

Infarct in the posterior circulation from thrombus lodging in the distal basillar

Question 16

right hemiparesis, right homonoymous hemianopia and aphasia

Answer 16

Left MCA syndrome

Question 17

Left hemiparesis, left homonymous hemianopia and left hemineglect

Answer 17

Right MCA syndrome

Question 18

Thalamus, contralateral hemisensory loss

Answer 18

pure sensory lacunar syndrome

Question 19

Posterior limb of internal capsule, contralateral motor deficits. Also described with ventral pons lacunes

Answer 19

Pure motor lacunar syndrome

Question 20

Paramedian pons “clumsy hand” and dysarthria

Answer 20

clumsy hand dysarthria lacunar syndrome

Question 21

Pons, midbrain or internal capsule, weakness with ataxia out of proportion to weakness

Answer 21

Ataxic hemiparesis lacunar syndrome

Question 22

NOTCH3

Answer 22

CADASIL: cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy

Question 23

Dilated thin-walled vessels, with no smooth muscle of elastic fibers, and no intervening brain parenchyma (popcorn appearance on MRI)

Answer 23

Cavernous malformation

Question 24

Thin walled venous structure with normal intervening brain tissue

Answer 24

venous angioma

Question 25

Abnormally dilated capillaries, normal intervening brain tissue

Answer 25

Capillary telangiectasia

Question 26

Nidus, with arteries and veins communicating without intervening normal capillary bed in between

Answer 26

Arteriovenous malformation

Question 27

Haemorrhage in the putamen, caudate, thalamus, pons, cerebellum, and deep white matter - associated with lipohyalinosis and charcot bouchard microaneurysms

Answer 27

hypertensive intracranial haemorrhage

Question 28

Lobar haemorrhages Multiple microhaemorrhages on MRI gradient echo Congo-red positive amyloid material, seen as apple-green birefringence with polarized light

Answer 28

cerebral amyloid angiopathy

Question 29

"Puff of smoke"

Answer 29

Extensive collateral circulation seen in Moyamoya disease, in which there is bilateral stenosis of the distal internal carotid arteries and intracranial arteries of the circle of Willis

Question 30

Internal carotid artery

Answer 30

Ipsilateral retinal ischemia (amaurosis) | Sensorimotor dysfunction similar to involvement of middle and anterior cerebral artery territories

Question 31

Middle cerebral artery, M1 segment

Answer 31

contralateral face and arm (more than leg) weakness Aphasia (dominant hemisphere) Contralateral sensory loss Cortical sensory loss (nondominant hemisphere) Contralateral visual field defect gaze deviation ipsilateral to lesion

Question 32

Middle cerebral artery, anterior devision

Answer 32

``` Contralateral face and arm weakness Broca aphasia (dominant hemisphere) ```

Question 33

Middle cerebral artery, posterior division

Answer 33

``` contralateral sensory loss Wernickes aphasia (dominant hemisphere) Gerstmann syndrome (dominant hemisphere) Cortical sensory loss or neglect (non-dominant hemisphere) Contralateral visual field defect ```

Question 34

Anterior cerebral artery

Answer 34

Contralateral leg weakness Contralateral leg sensory loss Apraxia Abulia (bilateral)

Question 35

Anterior choroidal artery

Answer 35

Contralateral homonymous hemianopia (lateral geniculate body) Contralateral facial, arm, leg weakness (posterior limb of internal capsule) Contralateral facial, arm, leg sensory loss (thalamus)

Question 36

Posterior cerebral artery, precommunicating part

Answer 36

``` contralateral sensory loss (thalamus) Cognitive dysfunction (thalamus) Thalamic aphasia (rarely) Visual dysfunction as for postommunicating segment ```

Question 37

Posterior cerebral artery, posterior communicating part

Answer 37

contralateral homonymous hemianopia | Visual agnosias

Question 38

Posterior inferior cerebellar artery

Answer 38

``` Horners Ipsilateral hemiataxia Ipsilateral palatal weakness Hoarse voice Decreased pain and temperature on ipsilateral portion of face and contralateral limbs ```

Question 39

Anterior inferior cerebellar artery

Answer 39

ipsilateral deafness Ipsilateral facial weakness (LMN) Ipsilateral hemiataxia Contralateral sensory loss in limb

Question 40

Superior cerebellar artery

Answer 40

Ipsilateral ataxia Decreased sensation contralaterally Diplopia

Question 41

Basilar perforators, median and paramedian pontine perforators

Answer 41

contralateral limb weakness if unilateral, quadriparesis if bilateral Hemiataxia may develop (crossing pontocerebellar fibers) CNVI and VII (affecting nuclei or nerve fibers) palsies Internuclear opthalmoplegia

Question 42

Midbrain basilar, posterior cerebral artery perforators

Answer 42

Ipsilateral nuclear or fascicular CN III palsy Contralateral facial, arm, leg weakness (corticospinal tracts) Rubral tremor (red nucleus) may develop Ataxia (deccusation of superior cerebellar peduncle) may occur

Question 43

Anterior spinal and vertebral perforators to median and paramedian medulla

Answer 43

Ipsilateral tongue weakness (CNXII nucleus or nerve fibers) Contralateral arm and leg have reduced vibration sensation and proprioception (medial lemniscus) Contralateral arm and leg weakness (medullary pyramids)

Question 44

Weber syndrome

Answer 44

Medial midbrain PCA perforators Contralateral hemiparesis (cerebral peduncle) Isilateral CN III palsy (fascicles of CN III) Imparied ipsilateral pupillary reflex (CNIII) and dilated pupil

Question 45

Benedikt Syndrome

Answer 45

Midbrain tegmentum PCA perforators Ipsilateral CN III palsy, usually with dilated pupil Contralateral involuntary movements (red nucleus, subthalamic nucleus)

Question 46

Claude syndrome

Answer 46

Midbrain tegmentum (dorsal) PCA perforators Ipsilateral CN III palsy (CN III fascicles) contralateral hemiataxia and dysmetria (dentatothalamic fibers within the superior cerebellar peduncle) Contralateral tremor (red nucleus)

Question 47

Nothnagel syndrome

Answer 47

Midbrain PCA perforators Ipsilateral III CN palsy Contralateral hemiataxia (dentothalamic fibers in superior cerebellar peduncle)

Question 48

Millard Gubler Syndrome

Answer 48

Ventral Pons Basilar artery perforators, median and paramedian perforators ipsilateral lower motor neuron facial paralysis (CNVII) Ipsilateral abducens paralysis (CNVI fibres) Contralateral hemiparesis (corticospinal tract in basis pontis)

Question 49

Foville syndrome

Answer 49

Dorsal pons tegmentum Basilar artery perforators Ipsilateral LMN facial paralysis (nucleus or fascicles of CN VII) Ipsilateral gaze paralysis (nucleu abducens palsy) Contralateral hemiparesis (corticospinal tract in basis pontis)

Question 50

Ventral pontine syndrome

Answer 50

ventral pons Basilar artery, paramedian perforators Ipsilateral CN VI palsy Contralateral hemiparesis (corticospinal tract in basis pontis)

Question 51

Marie-Foix syndrome

Answer 51

Base of pons Basilar artery perforators Ipsilateral cerebellar ataxia (corticopontocerebellar fibers) Contralateral hemiparesis (corticospinal tract in basis pontis) Variable contralateral decrfease in pain and temperature sensation (spinothalamic tract involvement)

Question 52

Wallenberg Syndrome

Answer 52

Lateral medulla PICA Ipsilateral hemiataxia (inferior cerebellar peduncle) Dysphagia, hoarseness, ipsilateral palatal weakness (nucleus ambiguus), Horner syndrome (sympathetic) Decreased in pain and temperature sensation (spinal tract and nucleus of CN V and lateral spinothalamic tract) on ipsilateral portion of face, contralateral portion of body

Question 53

Dejerine syndrome

Answer 53

Medial medulla Vertebral artery perforators, anterior spinal artery Contralateral hemiparesis (medullary pyramid) Contralateral decrease in vibration or proprioception sensation in limbs (medial lemniscus) Ipsilateral CN XII palsy

Question 54

Internal capsule

Answer 54

pure motor hemiparesis (contralateral facial, arm, leg)

Question 55

corona radiata

Answer 55

pure motor hemiparesis (contralateral facial, arm, leg)

Question 56

Thalamus (ventral posterolateral and posteromedial nuclei)

Answer 56

pure sensory stroke contralateral facial, arm, leg sensory loss

Question 57

Thalamocapsular

Answer 57

Sensorimotor stroke - contralateral facial, arm, leg weakness and contralateral facial, arm, leg sensory loss

Question 58

Basis pontis, talamocapsular, corona radiata

Answer 58

ataxic hemiparesis stroke - hemiataxia and hemiparesis on same side of body

Question 59

Basis pontis

Answer 59

Clumsy hand dysarthria - facial weakness, dysarthria, slight hemiparesis