Stroke syndromes

of posterior circulations

Done By: Dana Marafie

Posterior Circulation
Posterior circulation
Arteries & structures they supply

• PCA: temopral & occipital lobes,

parts of thalamus & midbrain
• SCA: midbrain &superior
cerebellum
• AICA: pons & cerebellum
• PICA: medulla & cerebellum
• Basilar: pons , other braches
• Vertebral:
• Anterior spinal : upper 2/3 of ant.
Surface of spinal cord
 Specific supply
• Occipital lobe: PCA
• Temporal lobe: MCA (suerpior lateral ) &PCA
( rest)
• Midbrain: PCA( ant surface), SCA ( post surface)
• Pons: Basilar ( mainly), AICA
• Medulla: ant. Spinal , Vertebral & PICA . Small
region by ( post spinal)
• Thalamus: branches from PCA
• Cerebellum : SCA, AICA & PICA
 Posterior circulation strokes
• Form 20% of all ischemic strokes
• Mortalility is around 4% except for basilar artery occlusion where
it can be up to 90% !
• However, outcome is not very good
• Usually cause bilateral involvement
• severe headache, vomiting & Nausea are more common in
posterior circulation strokes
• Vertigo, Nystagmus , hemiplagia or quadriplegia, ocular eye
movements, ataxia & change in level of consciousness are also
seem
• When to expect Post circulation stroke in a patient?
• 1- different symptoms & different functions or str. Affected in a way
that can not be explained by a cortical region (many tracts or
cranial nerves involved)????
• 2- when patient is presented with vomiting ,Nystagmus, Nausea,
ocular movement disorders or vertigo along with the other
symptoms
 Arteries & Syndromes!
From SUPERIOR TO INFERIOR :
• PCA Occlusion :
• Basilar Artery Occlusion: Locked-in Syndrome
Branches;
• AICA Occlusion :
• PICA Occlusion : Wallenberg’s Syndrome
• Vertebral Occlusion :
• Anterior Spinal Artery Occlusion:

These Syndrome can be produced by occlusion of not just

mentioned artery but the other arteries as ,long as the same str
involved: However, there are commonly seen in case of
occlusion of the mentioned artery
 PCA occlusion

Lateral surface Medial surface

 PCA Occlusion
• contralateral
hemianopia ( with
macular sparing)
• memory deficit :
damage in
hippocampal
formation
(disconnection
syndrome )
• Bilateral PCA
occlusion =
Blindness +
inability to form
new memories
 Picture as seen in
Left homonymous hemianopia ( with macular sparing)
 PCA occlusion

T1 MRI of PCA infart

PCA ( al level of branches to midbrain)
(Weber’s syndrome)
• at level of midbrain ,
X
• specifically the BASE
 PCA ( al level of branches to midbrain)
(Weber’s syndrome)
• Manifestations: : at level of
midbrain
• Motor Weakness – contralateral
hemiplegia (upper and lower
extremity) : Corticospinal tract
• corticobulbar fibers in the cerebral
peduncle
• Ipsilateral Lateral gaze weakness
& diplopia :CN 3 fibers (LMN)
PE eye movements: patient is inable
to move eye up,down, or medially
in the epsilateral side
• pupillary dilitation: if Edinger-
Westphal nucleus are involved
 CASE!
• A 55 year old African woman had abdominal
surgery 2 weeks before suddenly remarking
to her husband that she was seeing double.
She also felt a weakness in her left arm and
leg. Her husband noticed that her right eyelid
was drooping.

• PE: Her general physical condition was good.

EYES: : right eyelid does not open fully.
right eye was deviated to the right
(laterally).
When asked to converge the eyes only
the left eye adducted showed pupillary
constriction ( right is dilated).
MOTOR SYSTEM: Motor strength was normal
on the right but was reduced on the left,
especially in the arm where there was an
increased biceps reflex and resistance to
passive stretch.
Basilar artery occlusion
(Locked-in Syndrome)
 Basilar artery occlusion
(Locked-in Syndrome)
•Manifestation :at the Level
of the Pons
•Weakness of both upper and lower extremity
(Quadriplegia): bilateral cortical spinal tracts
•Weakness of face - entire side :Bilateral
corticobulbar tracts
•If lesion is big,Horizonal gaze weakness:
Bilateral fascicles of CN VI ( ONLY vertical
gaze is possible!)
•Dysarthria: Bilateral corticobulbar tracts
•Death from respiratory failure is common
•PATEINT are alert, conscoius with normal
cognitive fuction
• IF VERY SEVERE, the only way to
communication may be blinking 
Patient is LOCKED-IN their bodies : Quadriplegic, with
dysarthria& facial weekness!
 Locked-in Syndome
A 62-year old woman with a history of hypertension
for 35 years developed left-sided hemiparesis. One
week later she became tetraplegic and unable to
speak. However, she was able to communicate by
blinking. She died three months after the onset of
her neurological symptoms.

MRI after 19 days in hospital MRA after 19 days in hospital

After autopsy
 locked-in syndrome

A quadriplegic patient with locked-

in syndrome who managed to
survive ( less severe case)
 Labyrinthine Artery Syndrome
• labyrinthine or internal auditory
artery usually takes its origin
from AICA, but it can also take Labrinthine

origin from PICA or the basilar Artery

artery.
• It supplies the inner ear
• Occlusion of this artery can lead
to sudden tinnitus, vertigo or
even unilateral ipsilateral
deafness !!!
 PICA Occlusion
(Lateral Medullary syndrome Of Wallenberg )
At the level of dorso-
lateral part of
medulla
& Cerebellum
 PICA Occlusion
(Lateral Medullary syndrome Of Wallenberg )
• The commonest of brainstem strokes!

• Manifestation: At the level of dorso-lateral

medulla & Cerebellum

• Ipsilateral Sensory loss of face - pain and

• Temperature CN 5 spinal N
• Ipsilateral Facial pain CN 5 spinal N
• Ipsilateral Ataxia - arm and l Restiform body,
Ipsilateral cerebellum
• Ipsilateral Gait ataxia Restiform body,
cerebellum
• Ipsilateral Nystagmus Vestibular nucleus
• Ipsilateral Nausea / vomiting Vestibular nucleus
• Ipsilateral Vertigo Vestibular nucleus
• Ipsilateral Horseness Nucleus ambiguus
• Ipsilateral Dysphagia Nucleus ambiguus
• Ipsilateral Horner syndrome-Descending sympathetics
• Contralateral Hemisensory loss - pain and
Temperature Spinothalamic tract
• Hiccups  ( whatever you do, it does not go !!!)

Prognosis is generally quite good with full or near full recovery expected at 6 months.
CTscan showing lesion in Medulla & Cerebellum
in Wallenberg Syndrome
 Vertebral artery occlusion
• Can also give
Wallenberg’s
syndrome
 Thalamic infarction
(Dejerine-Roussy syndrome or central pain
synrome)
PCA Pentrating branches to thalamus
• Very sad syndrome
• Manifestation : pure sensory
loss without weakness :
due to lesion of
(CONTRLATERAL: WHY?
Crossing below thalamus)
PCA
- Hemilateral sensory loss of all
modalities
- Hemilateral pain
( hypersensitivity) :
if you touch their affected side, they
will shout !
 MRI
MRI of
of the
the patient
patient II day
day after
after

After death, autopsy

 Anterior Spinal Artery Occlusion
( Anterior Spinal Artery syndrome)
• Complete sensory &
motor loss below the
level of occlusion
except for
proprioception
 Anterior Spinal Artery syndrome
• Manifestations:
• Loss of motor function below level of
damage : due to damage of
corticospinal tracts ( ant & post)
• Bilateral anesthesia ( loss of
sensation below the level of damage )
: damage of spinothalamic
• Loss of bladder & bowel control :
damage of descending autonomic
tracts;
• Proprioception is intact due to sparing
of dorsal system
• motor & sensory function in face can
be intact
 Note
• Keep in mind that these are not the only
syndromes we see in posterior circulation
• There are many other syndrome that are seen in
infartions affecting other regions of brain stem
• EG of other syndromes of :
• Midbain :Claude, Benedict ,Nothnagel,Parinaud
Syndromes
• Pons: Millard-Gubler and Raymond-Foville
• Medulla: Medial medullary syndrome
 Quiz ! 
Alia :Overall mortality for posterior
circulation strokes is:
a. 5%
b. 20%
c. 40%
d. 70%
e. 90%
• Wadha :
1- Locked-in Syndrome consists of:
a. Coma with quadriplegia
b. Bilateral upper extremity weakness
greater than lower extremity weakness
c. Quadriplegia, bilateral facial and
oropharyngeal palsy but preservation of
cortical function and vertical gaze
d. Cranial nerve findings contralateral to motor
and sensory findings
• Lastly, Sulaiman  :In Weber Syndome:

a .Ipsilatral 3rd nerve palsy & hemiplgia

b. Ipsilateral hearing loss
c. vertigo, vomiting , ipsilateral ataxia &
facial sensory loss & contralateral sensery
loss of limbs
d.Ipsilatral 3rd nerve palsy & crossed
hemiplgia