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, Locked-In Syndrome, Weber Syndrome, Benedikt Syndrome, Benedict Syndrome, Nothnagel Syndrome, Nothnagel's Syndrome, Foville Syndrome, One and A Half Syndrome, Dejerine 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: Wallenberg's Syndrome (Vertebral ArteryOcclusion)

  1. Lesion in the lateral Medulla
    1. Occlusion of the Posterior Inferior Cerebellar Artery
    2. Often results from Vertebral Artery thrombosis
  2. 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: 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

V. Associated Conditions: 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

VI. Associated Conditions: 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)

VII. Associated Conditions: 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

VIII. Associated Conditions: 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: 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

X. Associated Conditions: Dejerine 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

XI. Associated Conditions: 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

XII. Associated Conditions: 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

XIII. Associated Conditions: 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

XIV. Associated Conditions: 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)

XV. References

  1. 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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