Brainstem Cerebrovascular Accident

Aka: Brainstem Cerebrovascular Accident, Brainstem CVA, Brain Stem CVA, Brainstem Stroke, Brainstem Infarction, Brain Stem Infarction, Brain Stem Stroke, Pons CVA, Pontine Stroke, Pontine Infarction, Brainstem Syndrome, Wallenberg Syndrome, Lateral Medullary Syndrome, Dejerine Syndrome, Medial Medullary Syndrome, Lesions in the medullary tegmentum, Avellis' Syndrome, Jackson's Syndrome, Schmidt's Syndrome, Cestan-Chenais Syndrome, Raymond-Cestan Syndrome, Pierre Marie-Foix Syndrome, Artery of Percheron Stroke, Locked-In Syndrome, Artery of Percheron Stroke, Weber Syndrome, Benedikt Syndrome, Benedict Syndrome, Nothnagel Syndrome, Nothnagel's Syndrome, Foville Syndrome, One and A Half Syndrome, Parinaud Syndrome, Dorsal Midbrain Syndrome, Claude Syndrome, Top of the Basilar Syndrome, Rostral Brainstem Infarction, Millard-Gubler syndrome

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II. Findings

  1. See Posterior Circulation CVA

III. Associated Conditions: Medulla - Wallenberg's Syndrome (Lateral Medullary Syndrome)

  1. Results from Vertebral ArteryOcclusion
  2. Lesion in the lateral Medulla
    1. Occlusion of the Posterior Inferior Cerebellar Artery
    2. Often results from Vertebral Artery thrombosis
  3. Findings
    1. Presents with Ataxia, Vertigo, Nystagmus and Vomiting
    2. Dysphagia and Dysarthria are also present
    3. Decreased pain and TemperatureSensation
      1. Ipsilateral face
      2. Contralateral body
    4. Ipsilateral Horner Syndrome
      1. Ptosis
      2. Miosis
      3. Anhidrosis

IV. Associated Conditions: Medulla - Dejerine Syndrome (Medial Medullary Syndrome)

  1. Lesion in the medial Medulla
    1. Occlusion of the Vertebral Artery or the Anterior Spinal Artery
  2. Findings
    1. Ipsilateral Tongue weakness
    2. Contralateral Hemiparesis
    3. Contralateral proprioception and vibratory sense loss may be present

V. Associated Conditions: Medulla - Medullary Tegmentum Lesions

  1. Lesions in the medullary tegmentum
  2. Avellis' Syndrome
    1. Ipsilateral weakness of the Palate and Vocal Cords
  3. Jackson's Syndrome (or Schmidt's Syndrome)
    1. Ipsilateral flaccid weakness of the Soft Palate, pharynx and Vocal Cords
    2. Ipsilateral Sternocleidomastoid Muscle flaccid weakness and atrophy
    3. Ipsilateral Tongue weakness
    4. Ipsilateral partial weakness of the trapezius Muscle

VI. Associated Conditions: Medulla - Cestan-Chenais Syndrome

  1. Vertebral Artery Occlusion below the PICA origin
    1. Nucleus Ambiguous
    2. Corticospinal tract
    3. Medial Lemniscus
    4. Inferior cerebellar peduncles
    5. Sympathetic System
  2. Findings
    1. Ipsilateral weakness of the Soft Palate, pharynx and Vocal Cords
    2. Cerebellar Ataxia
    3. Ipsilateral Horner's Syndrome
    4. Contralateral Hemiparesis
    5. Contralateral Posterior Column effects (e.g. proprioception)

VII. Associated Conditions: Pons - Millard-Gubler syndrome

  1. Lesion in the caudal pons (ventral base of the pons)
  2. Findings
    1. Ipsilateral Cranial Nerve 7 palsy (facial palsy)
    2. Ipsilateral Cranial Nerve 6 Palsy (abducens palsy) may be present
    3. Contralateral Hemiparesis (pyramidal tract involvement)

VIII. Associated Conditions: Pons - Foville Syndrome

  1. Lesion in the facial colliculus (caudal pontine tegmentum)
    1. Occlusion of the Basilar Artery perforating branches to the pons
  2. Findings
    1. Ipsilateral Cranial Nerve 6 Palsy (lateral Gaze Palsy)
    2. Ipsilateral Cranial Nerve 7 palsy (upper and lower facial weakness)
    3. Contralateral Hemiparesis may be present

IX. Associated Conditions: Pons - Raymond-Cestan Syndrome

  1. Occlusion of the Basilar Artery Long Circumferential Branch
    1. Cranial Nerve 6
    2. Corticospinal tract
  2. Findings
    1. Ipsilateral Cranial Nerve 6 Palsy (abductor palsy)
    2. Contralateral Hemiparesis

X. Associated Conditions: Pons - Pierre Marie-Foix Syndrome

  1. Occlusion of the Anterior Inferior Cerebellar Artery (AICA)
    1. Cranial Nerve 6
    2. Cranial Nerve 7
    3. Horner's Syndrome
  2. Findings
    1. Ipsilateral Cranial Nerve 6 Palsy (abductor palsy)
    2. Ipsilateral Cranial Nerve 7 Palsy
    3. Contralateral Hemiparesis

XI. Associated Conditions: Pons - Locked-In Syndrome

  1. Causes
    1. Basilar ArteryOcclusion at pons
    2. Pontine Hemorrhage
    3. Central Pontine Myelinolysis
  2. Findings
    1. Complete motor paralysis with two exceptions
      1. Diaphragmatic breathing unaffected
      2. Vertical eye movements unaffected
    2. Neurologic function otherwise intact
      1. Awake, alert and lucid
      2. Cognitive function remains intact
      3. Intact Sensation

XII. Associated Conditions: Pons - One and A Half Syndrome

  1. Lesion in the paramedian pons (pontine reticular formation, Medial Longitudinal Fasciculus)
    1. Occlusion of the Basilar Artery perforating branches to the pons
  2. Findings
    1. Ipsilateral Cranial Nerve 6 Palsy (lateral Gaze Palsy)
    2. Bilateral Internuclear Ophthalmoplegia

XIII. Associated Conditions: Midbrain - Weber Syndrome

  1. Lesion in the medial Midbrain or cerebral peduncle
    1. Occlusion of deep penetrating artery from Posterior Cerebral Artery
  2. Findings
    1. Ipsilateral Cranial Nerve 3 palsy
    2. Contralateral Hemiparesis including the lower face

XIV. Associated Conditions: Midbrain - Benedikt Syndrome

  1. Lesion in the ventral Midbrain with red nucleus involvement
    1. Occlusion of deep penetrating artery from Posterior Cerebral Artery OR
    2. Occlusion Paramedian penetrating Basilar Artery branches
  2. Findings
    1. Ipsilateral Cranial Nerve 3 palsy
    2. Contralateral involuntary movements (e.g. hemichorea, hemiathetosis, Intention Tremor)

XV. Associated Conditions: Midbrain - Nothnagel Syndrome

  1. Lesion in the superior cerebellar peduncle
    1. Occlusion of deep penetrating artery from Posterior Cerebral Artery
  2. Findings
    1. Ipsilateral Cranial Nerve 3 palsy
    2. Contralateral dysmetria
    3. Contralateral limb Ataxia

XVI. Associated Conditions: Midbrain - Parinaud Syndrome (Dorsal Midbrain Syndrome)

  1. Lesion in the dorsal Midbrain (may also be caused by a neoplasm such as a pinealoma, or demyelinating disease)
  2. Findings
    1. Fixed pupils unresponsive to light
    2. Eyelid retraction (Collier's sign)
    3. Convergence-retraction Nystagmus (Nystagmus when looking up)
    4. Limited upward gaze

XVII. Associated Conditions: Midbrain - Claude Syndrome

  1. Lesion in the Midbrain tegmentum (red nucleus, brachium conjunctivum)
  2. Findings
    1. Ipsilateral Cranial Nerve 3 Palsy
    2. Contralateral Hemiparesis
    3. Contralateral Ataxia
    4. Contralateral Hemiplegia of the lower face, Tongue, and Shoulder
    5. Tremor

XVIII. Associated Conditions: Midbrain - Top of the Basilar Syndrome (Rostral Brainstem Infarction)

  1. Lesion in the Midbrain, Thalamus, inferior Temporal Lobes and Occipital Lobes
    1. Top or distal Basilar ArteryOcclusion
  2. Findings
    1. Cranial Nerve 3 Palsy (oculomotor palsy)
    2. Cranial Nerve 4 Palsy (trochlear palsy)
    3. Pupils with slow or no response to light
    4. Convergence-retraction Nystagmus
    5. Limited upward gaze

XIX. Associated Conditions: Midbrain- Artery of Percheron Stroke

  1. Occlusion of the thalamic perforating artery originating from proximal Posterior Cerebral Artery (PCA)
  2. Findings
    1. Altered Level of Consciousness
    2. Vertical Gaze Palsy
    3. Memory Impairment

XX. References

  1. Baloor and Nayak (2018) Exam Preparatory Manual for Undergraduate Medicine, Jaypee Brothers Medical Publication
  2. Southerland (2017) Continuum 23(1):40-61 [PubMed]
    1. https://www.researchgate.net/publication/313593321_Clinical_Evaluation_of_the_Patient_With_Acute_Stroke

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