Let’s take a look at
ischemic stroke syndromes.
Pure motor hemiplegia.
Contralateral pons or
internal capsule lacunar.
In a vascular pathology,
you’re going to have these larger
arteries that are affected.
Let it be the middle cerebral artery,
anterior cerebral artery, so on and so forth
or there’s something
called a lacunar infarct.
Let’s say that your patient has
had long-term hypertension.
Remember we said that hypertension
is an extremely common risk
for stroke taking place.
And if the hypertension is taking
place over a long period of time,
you can only imagine that there is really
no blood vessel that is left safe, right?
So they’re all vulnerable
to some type of pathology.
And say that you have a little blood
vessels that are now undergoing compromise
damage and injury.
And at some point in time, maybe
there’s an aneurysm that takes place
and this aneurysm could be something
like a Charcot-Bouchard aneurysm.
And that particular aneurysm would be
one in which little blood vessels,
deep penetrating blood vessels of
the brain that are being affected.
So imagine that these little blood vessels
especially around the internal capsule,
which is responsible for motor functioning
on the contralateral side, right?
So think about that from
And at some point in time,
as the aneurysm gets bigger,
we know that any time, there’s
an aneurysm taking place.
You’re always worried about
rupture, aren’t you?
And so therefore, when there’s
a rupture that takes place,
and you can only imagine now the little
blood vessels, well, they’re infarcted.
And you call this a lacunar infarct.
And many times, patients with
hypertension will have lacunar infarct.
But if that part of the brain is not
significant in terms of proper functioning
and then the patient
may be asymptomatic.
But if it is an internal
capsule that’s been affected
such as a caudate or putamen or even
the thalamus or a subthalamus, huh?
Then you will have motor type of
issues and this would be a pure motor,
contralateral type of
hemiplegia, would it?
And so maybe therefore, those interesting
gaits that you’ve talked about earlier
where the arm might be adducted
and the hand might be flexed
and then you have circumduction
that’s taking place of the leg
and you have internal rotation
of the ankle and so forth,
and you have that particular gait.
And so that’s referring
to what’s known as your
pure motor type of hemiplegia,
Let’s take another one.
Pure sensory stroke.
The contralateral thalamus.
Here once again, little blood
vessels that might undergo
strokes and lacunar
type of infarct.
Now, maybe it’s a big blood
vessel that has been affected.
All right, middle cerebral artery.
So think about that, please.
So this is an artery
that’s been affected.
And then you know about your
watershed areas, right?
And by watershed, I’m referring to two
blood vessels that are coming together.
And when they do it, it’s that particular
tissue that is now susceptible to damage.
And so for example, middle cerebral
artery and anterior cerebral artery
would be an area in which
you call that watershed.
And I told you earlier, middle
cerebral artery would be
supplying the lateral aspect
of the parietal lobe,
responsible for sensations and
activity in the upper extremity,
maybe the head and neck.
Well, let’s say that there
is an MCA type of issue
and there is an atherosclerotic type
of ischemic stroke taking place.
And please understand that the
hemiparesis will be taking place
in the face and the arm much
more so than the leg, right?
because of the homunculus
and the representation.
There might be aphasia
if it’s a dominant side.
There might be hemianopsia
or eye deviation
if there’s enough damage
of your MCA taking place.
Keep that in mind, aphasia.
More or less, you’re referring
to the dominant side.
How do you know what side of the
brain is dominant in your patient?
You’re going to be looking
for clues as to what arm
your patient is more
Right or left?
And then obviously,
the contralateral hemisphere is
going to be the dominant side.
Anterior cerebral artery,
what about this syndrome?
Well, here, think about the
anterior cerebral artery, please.
And you are supplying the
medial aspect of your brain
and so therefore this then represents
your legs and lower extremity.
So lower extremity
weakness, sensory loss.
Maybe even perhaps
incontinence or limb apraxia.
What does that mean to you?
You’re not able to carry out those
learned, motor type of functioning.
Anterior cerebral artery.
Where are you?
The medial aspect of the brain.
What about the posterior cerebral artery?
Well the posterior cerebral artery,
more or less, think of it as being part
of your occipital lobe posteriorly.
You should be thinking
There might be
There might be sensory loss as well.
Then you have from the circle of Willis,
think about the posterior
inferior cerebellar artery, okay?
So we have PICA.
And here, how is your
patient going to present?
I’m going to present
with this, doc.
So there might be hoarseness
that’s taking place.
Doc, I’m having a hard time eating.
So there might be dysphagia
that’s taking place, right?
So if there’s a couple of things
that you want to take out of
what’s known as Wallenberg
syndrome in your PICA.
And you must keep in mind the big symptoms
such as dysphagia, such as hoarseness.
So you might have ataxia, Horner syndrome,
ipsilateral loss of face sensation,
contralateral loss of body
sensation if it’s PICA.
This is referred to as being
your Wallenberg syndrome.
Now, with PICA,
would you call this a medial
medullary type of syndrome?
Or would you call this a lateral
medullary type of syndrome?
Keep that in mind.
I’ll answer that question in just a minute.
Won’t you come back and
spend some time with me.