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Neuroradiology Unit, S P Institute of
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Monday, 24 September 2012

Ischemic stroke and Vascular territories of

Brain
MCA Superior Division Infarction

MRI axial FLAIR images of Brain show an infarct involving left frontal lobe
anterior to sylvian ssure.Area of involvement corresponds to left MCA
Superior Division territory.

The internal carotid artery (ICA) terminates in middle cerebral artery

(MCA) and anterior cerebral artery (ACA). The MCA main stem runs
laterally towards Sylvian ssure, giving o the lenticulostriate vessels.
Thelenticulostriate vessels are thesmall perforators supply the basal
ganglia. The MCA main stem then bifurcates into superior and inferior
divisions. The superior division supplies the lateral frontal and superior
parietal lobes, whereas the inferior division predominantly supplies the
lateral temporal and inferior parietal lobes.
The superior division of the MCA is one of the most common locations
for embolic stroke, either from carotids or from heart. MCA superior
division territory infarctions typically result in a contralateral
hemiparesis aecting the lower face and upper extremity more than the
leg;similar distributioncontralateral hemisensory loss; contralateral
visual eld decit predominantly aecting the lower elds; and often a
gaze preference to the ipsilateral side. Dominant hemisphere infarct is
often associated expressive aphasia where as non-dominant infarct is
associated with neglect syndrome.

MCA Inferior Division Infarction

MRI axial Flair image of brain shows an infarct involving the left temporal
lobe below the Sylvian ssure. Area of involvement corresponds to left
MCA Inferior Division territory.

CT study of brain shows an infarct involving the left temporal lobe below
the Sylvian ssure. Area of involvement corresponds to left MCA Inferior
Division territory.

The inferior division of the MCA is less commonly aected by emboli

than the superior division because the superior division is larger and
carries more blood compared to inferior division and hence, it is
statistically more likely for emboli to travel there. Inferior
divisionterritoryinfarct do NOT cause any weakness or sensory loss.
They are typically associated with contralateral visual eld decit
predominantly aecting the upper elds i.e. "pie in the sky" decit .
Dominant hemisphere infarct is often an associated receptive i.e.
Wernicke's aphasia where as non-dominanthemisphereinfarct is
associated with behavioral disturbance and impairment of visuospatial
skills like drawing, copying, dressing and often misdiagnosed initially
with primary psychiatric disorder.

MCA Distal main stem territory Infarction

CT study of Brain shows an infarct involving involving right peri sylvian
cerebral cortex and adjacent insular cortex. Right basal ganglion
isspared.Area of involvement corresponds to right MCA distal main stem
(superior as well as inferior division) territory.

Distal Stem Middle Cerebral Artery (MCA) Infarction involve the

distribution of both, superior as well as inferior division of the middle
cerebral artery with sparing of basal ganglia, results when an embolus
blocks theMCAdistal main stem after the take-o of the lenticulostriate
vessels which supply basal ganglia.Distal MCA stem occlusion infarct
result in contralateral hemiplegia aecting the lower face and arm more
than the leg,similar distributioncontralateral hemisensory loss and a
contralateral visual eld decit. Dominant hemisphere infarct often
associated with global aphasia that is expressive and receptive where as
non-dominant hemisphere infarct ischaracterizedby neglect syndrome
and impairment of visuospatial skills like drawing, copying, dressing.

MCA Proximal Stem Infarction

CT study of Brain shows an infarct involving involving left peri sylvian

cerebral cortex, adjacent insular cortex and leftbasal ganglia.Area of
involvement corresponds to left MCA proximal main stem (superior
division, inferior division as well aslenticulostriate) territory.

Proximal Stem Middle Cerebral Artery infarct involves deeper basal

ganglia in addition. The involvement of the basal ganglia denotes that
the block has occurred at the proximal middle cerebral artery, before the
take o of lenticulo striate perforators that supply basal
ganglia.Occlusion of the proximal main stem of the MCA aect the
superior division, inferior division as well as the lenticulostriate
perforators. Proximal MCA territory infarct result in a contralateral
hemiplegia, contralateral hemisensory loss and a contralateral visual
eld decit. Dominant hemisphereinvolvement result inan associated
global aphasia where as non-dominant hemispheric infarct is associated
with a neglect syndrome.The major clinical dierence between a
proximal and distal MCA stem occlusion is that with a proximal lesion
the leg is plegic as well. This occurs because the lenticulostriates are
involved, which results in infarction of the internal capsule, which
contains bers to the leg, arm and face.

CT study of Brain shows bilateral MCA proximal main stem terriotry

infarct.

MCA cortical branch Infarction

MRI Axial FLAIR images of brain shows an infarct involving left pre
central cortex - a left MCA cortical branch occlusion infarct.
A single MCA branch infarction is nearly always secondary to an
embolus.

CT images of brain shows an infarct involving right frontal pre central

cortex - a right MCA cortical branch occlusion infarct.
MRI Axial FLAIR images of Brain shows multiple cortical branch occlusion
infarcts.

Unlike multiple cardiac emboli that typically aect multiple vascular

distributions, here multiple infarcts are in the same vascular territory i.e.
ICA - MCA.

Anterior Cerebral Artery Infarction

CT study of brain shows infarct involving right para sagittal frontal lobe.
Area of involvement corresponds to right ACA territory.

CT study of brain shows infarct involving left para sagittal frontal lobe.
Area of involvement corresponds to left ACA territory.
CT and MRI Axial FLAIR Brain shows a focal infarctinvolving leftmedial
frontal lobe. The infarct is caused by a branch occlusion of the left
anterior cerebral artery.

As the anterior cerebral artery supplies the medial frontal lobe, an

infarct in this distribution predominantly results in weakness of the
contralateral leg.

MCA - ACA Combined (Distal Internal Carotid Artery) Infarction

Axial CT study of Brain shows a sub acute ischemic infarct in the

distribution of the left middle cerebral artery (MCA) and anterior cerebral
artery (ACA).

This type of infarction occurs when the clot is located at the top of the
carotid artery and there is no collateral ow from the contralateral side
through Acom.Occlusions of the distal ICA aect both the superior and
inferior divisions of the MCA, as well as the lenticulostriates, resulting in
a contralateral hemiplegia (face, arm and leg); contralateral
hemisensory loss; a contralateral visual eld decit, and often a gaze
preference to the ipsilateral side. With an infarct in the dominant
hemisphere, there is often an associated global aphasia (expressive and
receptive); with a non-dominant infarct, there is often a neglect
syndrome and impairment of visuospatial skills (e.g., drawing, copying,
dressing).

Posterior Cerebral Artery Infarction

PCA cortical branch Infarction

CT study of brain shows an infarct involving left occipital lobe. Area of

involvement corresponds to left PCA territory.

PCA territory infarct is most often caused by a cardiac embolus or an

embolus from an occluded or stenotic proximal vertebral or basilar
artery.
The basilar artery bifurcates into right and left PCAs at its termination,
which then course around the midbrain in the ambient and
quadrigeminal cisterns to supply the medial / inferior temporal lobe and
the medial occipital lobe. Small perforators arise from the proximal
PCAs, which supply the cerebral peduncle as well as the thalamus (the
latter known as thalamoperforators).
Infarctions in the territory of the PCA most often result in a contralateral
hemianopsia. Other signs and symptoms depend on whether the
infarction involves the thalamoperforator territory. Proximal PCA
involvement results in coexistent infarction of the lateral thalamus, with
contralateral hemisensory ndings. Infarction of either PCA may result
in impaired memory (verbal on the left; spatial on the right). In addition,
left PCA lesions are sometimes associated with alexia without agraphia
(patients can write, but cannot read what they have written);
transcortical sensory aphasia (a receptive aphasia similar to Wernicke's
aphasia except that repetition is relatively spared); and Gerstmann's
syndrome (a combination of acalculia, nger agnosia, agraphia, and
right/left confusion). With right sided PCA lesions, patients may have a
visual neglect. They may also have prosopagnosia, an inability to
recognize familiar faces.

Proximal PCA Infarction

MRI Axial FLAIR images of Brain shows infarct involving right thalamus,
right medial occipital and medial temporal lobe. Area of involvement
corresponds to right proximal PCA territory.

Proximal PCA territory infarct show an associatedinfarction in the

thalamus result with an embolus to the proximal posterior cerebral
artery as small perforating arteries to the thalamus arise from the
proximal posterior cerebral artery.
The basilar artery bifurcates into two PCAs at its termination, which
then course around the midbrain in the ambient and quadrigeminal
cisterns to supply the medial / inferior temporal lobe and the medial
occipital lobe. Small perforators arise from the proximal PCAs, which
supply the cerebral peduncle as well as the thalamus (the latter known
as thalamoperforators). Infarctions in the territory of the PCA most
often result in a contralateral hemianopsia. Other signs and symptoms
depend on whether the infarction involves the thalamoperforator
territory, and whether the infarction is left vs. right sided. Proximal PCA
involvement results in coexistent infarction of the lateral thalamus, with
contralateral hemisensory ndings. Infarction of either PCA may result
in impaired memory (verbal on the left; spatial on the right). In addition,
left PCA lesions are sometimes associated with alexia without agraphia
(patients can write, but cannot read what they have written);
transcortical sensory aphasia (a receptive aphasia similar to Wernicke's
aphasia except that repetition is relatively spared); and Gerstmann's
syndrome (a combination of acalculia, nger agnosia, agraphia, and
right/left confusion). With right sided PCA lesions, patients may have a
visual neglect. They may also have prosopagnosia, an inability to
recognize familiar faces.

MCA - PCA Combined Infarction

Axial CT study of brain shows aninfarct in the distribution of the left

middle cerebral (MCA) and posterior cerebral (PCA) arteries, such infarct
possible with Fetal PCA.

Simultaneousinfarction in the distribution of MCA and PCA arteriescan

occur from multiple emboli which is possible but un common; It is more
likely that a single occlusion caused this lesion. A number of individuals
have a normal anatomic variant known as a persistent fetal circulation,
wherein the PCA arises directly from the posterior communicating artery
o the internal carotid artery. In this case, an embolus at the top of the
internal carotid artery can then infarct the middle cerebral and posterior
cerebral artery territories. In this case, the anterior cerebral artery
territory is spared, presumably because of an intact anterior
communicating artery whereby blood can ow from the contra lateral
side.

Watershed (Border zone) Infarction

MRI Axial Diusion Brain shows infarcts with restricted diusion involving
fronto parietal and parietal cortex on either side.Area of involvement
corresponds to ACA - MCA watershed (cortical border zone) anteriorly
and MCA - PCA watershed (cortical border zone) posteriorly.

The area between two vascular territories is known as a watershed

(border zone). Watershed infarcts typically occur following reduced
perfusion pressure, often secondary to cardiac events or severe
bleeding and they are often bilateral.When a watershed infarct is seen
unilaterally is due to hemodynamic narrowing of a proximal artery.
A hemodynamically signicant ICA stenosis, ischemia rst occurs along
the border zone between the ACA - MCA or MCA - PCA territory on that
side.

The anterior watershed territory between ACA - MCA corresponds to the

shoulder and hip girdle muscles on the motor homunculus, leading to a
characteristic clinical decit, weakness of the shoulder and hip girdle
muscles bilaterally often referred to as "the man in the barrel"
distribution of weakness. The posterior watershed territory infarct
between the MCA - PCA result in bilateral cortical visual abnormalities,
among them cortical blindness, Anton's syndrome that is cortical
blindness with denial/confabulation and Balint's syndrome that is
asimultagnosia, optic ataxia, and gaze apraxia. A deep watershed area
exists betweenlenticulostriates below and the cortical branches
abovecharacterizedby an infarct in basal ganglia and adjacent corona
radiata or para ventricular white matter.
CT study of brain shows an infarct involving left basal ganglia along deep
border zone.

Lacunar Infarction

MRI Axial Flair Brain shows a lacunar infarct in the region of the
posterior limb of the right internal capsule.

Lacunar infarct also known as small occlusion infarct, caused by

occlusion of the deep perforators, most commonly associated with
hypertension and diabetes.Classic lacunar syndromes include pure
motor hemiparesis, ataxic hemiparesis, clumsy hand-dysarthria
characterizedby lesions either in the internal capsule or basis pontis
and pure sensory loss caused by a lesion in thalamus.
Remember that lacunar strokes are NOT associated with cortical
ndings such as aphasia, apraxia, neglect or visual eld abnormalities.
Multiple Lacunar State

MRI Axial Flair images of brain show multiple lacunar infarcts in bilateral
peri ventricular white matter.

Multi lacunar state also known as Binswanger's disease often results in

a subcortical dementiacharacterizedby memory loss, altered mood and
cognition dysfunction along with focal motor and sensory changes.
Usually have chronic hypertension and / or diabetes. Other prominent
features of the disease include urinary incontinence, a slow unstable
gait, tremors, clumsiness, behavioral and personality changes, lack of
facial expression and speech diculties.

Medial Medullary Infarction

MRI axial Diusion show an acute infarct in medial portion of right half of
medulla with restricted diusion

Medial medullary infarction result in classic "crossed" neurological

syndromecharacterizedby an ipsilateral hypoglossal nerve palsy with a
contralateral hemiparesis. The medial medulla is typically supplied by a
branch of the anterior spinal artery which arises from the vertebral
arteries.

Lateral Medullary Infarction

MRI Axial Flair Brain shows an infarct in lateral portion of right half of
Medulla.

Lateral medullary infarction result from occlusion of the vertebral artery

or PICA results in a Wallenberg's syndromecharacterizedby nausea,
vomiting, and vertigo along with ipsilateral facial numbness, weakness
of the ipsilateral soft palate, ipsilateral ataxia, and contralateral
numbness of the body. An ipsilateral Horner's syndrome (ptosis, miosis,
anhidrosis) may be present.

Inferior Cerebellar Infarction

MRI Axial FLAIR Brain shows an infarct involving caudal portion of right
cerebellar hemisphere. Area of involvement corresponds toposterior
inferior cerebellar artery (PICA) territory.

Lateral Medulla and Inferior Cerebellar Infarction

MRI Axial FLAIR Brain shows a left Lateral Medullary and Inferior
Cerebellar Infarction.Area of involvement corresponds to the posterior
inferior cerebellar artery (PICA).

PICA territory infarct result in a Wallenberg's syndromecharacterizedby

nausea, vomiting, and vertigo, ipsilateral facial numbness, weakness of
the ipsilateral soft palate, ipsilateral ataxia, contralateral numbness of
the body and ipsilateral Horner's syndrome (ptosis, miosis, anhidrosis).

Mid brain Infarction

MRI Axial FLAIR Brain shows an infarct in right half of mid brain, a recent
infarct with restricted diusion. Area of involement corresponds to the
distribution of one perforating branch of the basilar artery.

These lesions are usually caused by the occlusion of one paramedian

basilar branch seen with aging, diabetes and
hypertensives.Occasionally associated with intrinsic disease of the
basilar or an embolus to the basilar. Clinically present withWeber's
syndrome characterized by aclassic "crossed" neurology syndrome of
an ipsilateral 3rd nerve palsy and a contralateral hemiparesis.

Pontine Infarction
MRI Axial FLAIR Brain shows an in right half of Pons, area of involvement
corresponds to one perforating branch of the basilar artery.

The lesion is usually caused by the occlusion of one of perforating

branch from basilar seen with aging, diabetes and hypertensives.

Pontine and Mid brain Infarction

MRI Axial FLAIR brain shows an infarct involving entire pons and
midbrain, corresponds to the territory of the main basilar artery.

Basilarterritoryinfarctresult from either intrinsic basilar artery disease

or an embolus to the basilar artery.The cerebellum is spared
presumably due to collateral ow from PICA, AICA and SCA.

Cerebellar and Posterior Cerebral Artery Infarctions

MRI axial Diusion shows involving caudal portion of right cerebellar

hemisphere in right PICA territory and left medial occipital lobe in
Posterior Cerebral Artery territoryconsistent with an embolus to the
posterior circulation territories.

Reference : My most favorite"Neuroimaging in Neurology by David C

Preston, MD,Professor of Neurology andBarbara E Shapiro, MD,
PhD,Associate Professor of Neurology"
Dr Balaji Anvekar at 12:11 am

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10 comments:

Anonymous 26 February 2013 at 20:37

Thanks
Reply

Anonymous 26 May 2013 at 19:43

This is an excellent reference. Thanks for the eort.
Reply

Anonymous 18 November 2013 at 04:17

very good. thks
Reply

hari 5 September 2014 at 23:17

Very nice sir
Reply

Anonymous 5 September 2014 at 23:18

Thank u so much it is very nice sir
Reply

Anonymous 24 September 2014 at 11:34

So wonderful! Thanks so much
Reply

Anonymous 13 October 2014 at 10:58

Keep up the gud work.. many thanks
Reply
 Anonymous 28 April 2015 at 09:08
Very good and accurate
Reply

Anonymous 17 March 2016 at 20:32

awesome sir
thank you
Reply

Anonymous 30 April 2016 at 19:19

excellent reference
Reply

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