STROKE SYNDROMES

DJADJANG SUHANA

Vertebrobasilar arteries syndromes

I. Clinical syndromes of the midbrain
Midbrain (mesencephalic) disturbances :

1. Webers syndrome - Lesions of ventral portion of midbrain 2. Benedikts syndrome - lesions of tegmentum 3. Parinauds syndrome - Lesions of superior culliculi of the tectum

Webers syndrome
Clinical manifestations :
- Ipsilateral ophthalmoplegia - results from oculomotor nucleus interruption - Contralateral hemiparesis - involvement of corticospinal tract in cerebral peduncle

Benedikts syndrome
Clinical manifestations :
- Ipsilateral ophthalmoplegia - results from lesion of tegmentum that destroys the oculomotor nerve - Contralateral hyperkinesia (tremor, chorea, athetosis) - Lesion of tegmentum destroys red nucleus (nucleus of rubra) on one side.

Perinauds syndrome
Clinical manifestations :
- Upward gaze paralysis - Disorders of the quadrigeminal plate of mid brain (superior culliculi) - Etiologies are : - compressed by pineal body tumor - Lesion of posterior commissure

II. Clinical syndromes of the Pons

1. Raymonds syndrome 2. Millard-Gubler syndrome 3. Fovilles syndrome 4. Raymond-Cestan syndrome (Cestan-Chenais syndrome) 5. Pontocerebellar Angle Tumor Syndrome 6. Alternating trigeminal hemiplegia

Raymonds syndrome
Clinical manifestations :
- Alternating abducent hemiplegia - ipsilateral lateral rectus muscle paresis - contralateral hemiparesis

Due to infarction of paramedian area of pons involves the abducens nerve and corticospinal tract

Millard-Gubler syndrome
Clinical manifestations :
- Alternating facial hemiplegia - ipsilateral facial palsy - contralateral hemiparesis - sometime the VI - nerve is also involved (internal strabismus)

- Due to pontine lesion

Fovilles syndrome
Clinical manifestations :
- contralateral hemiparesis - ipsilateral VII-nerve palsy - ipsilateral paralysis of lateral conjugate gaze

- Due to pontine lesion

Raymond-Cestan syndrome
(Cestan-Chenais syndrome) Clinical manifestations :
- Quadriplegia - Anesthesia - Nystagmus - Due to atherothrombotic of the branches of basilar artery supplying this region

- Involvement of pyramidal tract, medial lemniscus and medial longitudinal fasciculus

Alternating Trigeminal Hemiplegia

Clinical manifestations :
- contralateral hemiparesis - ipsilateral paralysis of jaw muscle (masseter and temporal muscles paralysis) - Ipsilateral hypesthesia of facial region
Site of lesion : - Result from lesion of ventral pons involving :

- corticospinal tract - fibers of adjacent trigeminal nerve

III. Clinical syndromes of the medulla oblongata

A. Bulbar and radicular syndomes 1. Avellis syndrome ( X and Bulbar XI ) 2. Schmidts syndrome ( X and all of XI ) 3. Jacksons syndrome ( X, XI and XII ) 4. Tapias syndrome ( X and XII ) 5. Babinski-Nageotte Bulbar Syndrome (IX, X, Bulbar portion of XI and Part of V ) 6. Wallenbergs syndrome 7. Cestan-Chenais syndrome

8. Bonniers syndrome ( VIII, IX and X ) 9. Hypoglossal hemiplegia alternans ( XII )

III. Clinical syndromes of the medulla oblongata

A. Syndromes caused by peripheral lesions 1. Vernets syndrome ( IX, X and XI ) 2. Villarets syndrome (Collets or Sicards syndrome)

1.Avellis syndrome ( X and Bulbar XI )

Clinical manifestations :
- ipsilateral partalysis of soft palate, pharynx and larynx ( dysarthria, dysphagia, hypesthesia of pharynx and larynx ) - Contralateral dissociate hemihypesthesia (spinbothalamic tract) : - loss of pain and temperature senses, - sparing touch and pressure sense
Caused by lesion of nucleus ambiguus, tractus solitarius, and adjacent spinothalamicus tract affecting : - X-nerve, internal branch of the accessory nerve and ascending sensory nerve

2. Schmidts syndrome ( X and all of XI )

Clinical manifestations :
- ipsilateral paralysis of soft palate, pharynx, larynx, and hypesthesia of pharynx and larynx (X and bulbar portion of XI) - Ipsilateral sternocleidomastoid and trapezius muscle paralysis
Site of lesion : Lesion of vagal nuclei and both bulbar and spinal nuclei of accessory

3.Jacksons syndrome ( X, XI and XII )

Clinical manifestations :
- ipsilateral paralysis of soft palate, pharynx and larynx (X) - ipsilateral paralysis of sternocleidomastoid and trapezius muscle (XI) - Ipsilateral paralysis and atrophy of tongue (XII)

Site of lsion : Nuclear lesion of vagus, accessory and hypoglossal

4.Tapias syndrome ( X and XII )

Clinical manifestations :
- ipsilateral paralysis of pharynx and larynx (X) - Ipsilateral paralysis and atrophy of tongue (XII)

Site of lesion : - Nuclear lesion of vagus and hypoglossal

5. Wallenbergs syndrome
Clinical manifestations :
- ipsilateral loss of taste on posterior third of tongue - ipsilateral Horners syndrome (miosis, ptosis and enophthalmos) - Ipsilateral loss of pain and temperature sense of the face - ipsilateral asynergia and atxia (tendency to fall to side of lesion)
Site of lesion : - Atherothrombosis of Posterior inferior cerebellar artery

6.Bonniers syndrome ( VIII, IX and X )

Clinical manifestations :
- ipsilateral loss of taste on posterior third of tongue - ipsilateral Horners syndrome (miosis, ptosis and enophthalmos) - Ipsilateral loss of pain and temperature sense of the face - ipsilateral asynergia and atxia (tendency to fall to side of lesion)
Site of lesion : - Atherothrombosis of Posterior inferior cerebellar artery