Color Atlas of Neurology

			Intracranial Pressure
		ICP (mm Hg)
70			Compliance = V V/ V P
60
50			Elastance = V P/ V V
40
30					VP
20
			V V
10
		Pressure-volume curve				Volume
		(green, compensation;
		red, decompensation)
			Communicating hydrocephalus
Sinus			Venous sinus
thrombosis			Subarach-
			noid space
			Brain
		Obstructive	Ventricular
		hydrocephalus	system
Etiology of hydrocephalus (right: normal state)						Arteries
	Supratentorial mass
	Subfalcine herniation
	Ventricular compression
	Transtentorial
	herniation
	Edema of astrocytes/
	endothelial cells
						Upward
Space-occupying lesion (mass)						posterior
						fossa her-
						niation

				Trans en-							Infraten-
				dothelial					torial mass
				diffusion
											Tonsillar
									herniation
							Pontomesencephalic
								compression,
Open zonula
								hemorrhages
occludens
(tight junction)						Astrocyte
Pinocytotic transport
				Cerebral edema (left, vasogenic; right, cytotoxic)

Intracranial Pressure

163

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164

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3 Neurological Syndromes

!Brain Disorders

!Spinal Disorders

!Peripheral Neuropathies

!Myopathies

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Stroke

Central Nervous System

A stroke is an acute focal or global impairment of brain function resulting from a pathological process (e. g. thrombus, embolus, vessel rupture) of the blood vessels. Its causes, in order of decreasing frequency, are ischemia (80%), spontaneous intracerebral or intraventricular hemorrhage (15%), and subarachnoid hemorrhage (5%). The signs and symptoms of stroke are usually not specific enough to enable identification of its etiology without further diagnostic studies. CT, MRI, cerebrovascular ultrasonography, ECG, and laboratory testing are usually needed.

Symptoms and Signs

The clinical manifestations of stroke persist, by definition, for more than 24 hours, and are often permanent, though partial recovery is common. The duration of symptoms and signs seems not to be correlated with the etiology of stroke.

Type of Deficit

Clinical Manifestations

Ischemia. A transient ischemic attack (TIA) differs from a stroke (by definition) in that its symptoms and signs resolve completely within 24 hours. The vast majority of TIAs resolve within one hour, and only 5% last longer than 12 hours. Patients with crescendo TIAs (a rapid succession of TIAs) have a high risk of developing a (completed) stroke, which can cause neurological deficits that are either minor (minor stroke) or major (disabling stroke, major stroke). A stuttering, fluctuating, or progressive course of stroke development (stroke in evolution) is uncommon.

Hemorrhage. Nontraumatic intracerebral hemorrhages usually cause acute neurological deficits that persist thereafter. If deficits worsen after the initial hemorrhage, the cause is either recurrent hemorrhage or a complication of the initial hemorrhage (cerebral edema, electrolyte imbalance, or heart disorder).

Weakness	Acute hemi-, mono-, or quadriparesis/quadriplegia (ca. 80–90%); loss of coordination
(pp. 46 ff, 70)	and balance; hyperkinesia (during or after stroke), e. g. hemichorea, hemiballism, or
	(rarely) dystonia
Sensory loss	Injury of postcentral cortex or subcortical area distal sensory (often also motor) defi-
(pp. 70 ff, 106)	cit in contralateral limbs. Paresthesiae and loss of stereognosis, graphesthesia,
	topesthesia, and acrognosis are prominent
Oculomotor and	Conjugate horizontal eye movements, disjugate gaze, nystagmus, diplopia. Visual field
visual disturbances	defects (p. 82), transient monocular blindness (= amaurosis fugax)
(pp. 70, 82 ff)
Headache (p. 182)	May be caused by subarachnoid hemorrhage, temporal arteritis, venous sinus thrombo-
	sis, arterial dissection, cerebellar hemorrhage, massive intracerebral hemorrhage (rare)
Impairment of con-	TIA and stroke generally do not impair consciousness (exception: brainstem stroke,
sciousness (pp. 116,	massive supratentorial stroke with bilateral cortical dysfunction)
204)
Behavioral changes	Aphasia, confusion (must be distinguished from aphasia), impairment of memory, neg-
(p. 122 ff)	lect, impaired affect control (compulsive crying and/or laughing), apraxia. Mental
	changes, especially depression and anxiety disorders, are common after stroke
Dysarthria and	Severe dysarthria is often accompanied by coughing, difficulty chewing, and dysphasia.
dysphagia (pp. 102,	Pseudobulbar palsy loss of voluntary motor control (e. g., swallowing, speaking,

130)tongue movement) with preservation of involuntary movements (e. g., yawning, coughing, laughing)

Dizziness (p. 58)	Cerebellum, brainstem (vertigo, nausea, nystagmus)
Epileptic seizures	Simple partial, complex partial, or generalized tonic-clonic seizures may occur during
(p. 192 ff)	or after a stroke

Respiratory disorders Hiccups (singultus) often occur in stroke, particularly in lateral medullary infarction.

(p. 150) Central hyperventilation is associated with a poor prognosis. Bihemispheric lesions may cause Cheyne–Stokes respiration (p. 118)

166Minor complications of stroke: Mild unilateral arm paresis, moderate sensory loss, mild dysarthria; these patients can care for themselves. Major complications: Aphasia, spastic hemiplegia, and hemianopsia; these patients generally need nursing care.

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Stroke

Stroke

(right hemiplegia, aphasia, conjugate gaze deviation to left)

Persistent deficit

		Progressive deficit
TIA		Time course

Territorial infarct		Territorial infarct	Territorial infarct
(anterior + middle cerebral a., CT)		(anterior cerebral a., CT)	(posterior inferior cerebellar a., CT)

Intracerebral hemorrhage	Subarachnoid hemorrhage (CT)	Aneurysm
(brain stem, CT)		(internal carotid a., MRI)
	Causes of stroke

Central Nervous System

167

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Stroke: Ischemia

Stroke Syndromes: Carotid Artery

Territory

! Brachiocephalic Trunk

Brachiocephalic trunk occlusion by emboli from the aortic arch has the same clinical manifestations as internal carotid artery (ICA) occlusion. Patients with adequate collateral flow remain asymptomatic.

		! Common Carotid Artery (CCA)
	System	CCA occlusion is very rare and, even when it oc-
		curs, is usually asymptomatic, because of an ade-
		quate collateral supply. When symptoms do
	Nervous	occur, they are the same as those of ICA occlusion.
		artery (MCA) more often than the anterior cere-
		! Internal Carotid Artery (ICA)
		Territorial infarcts affect the middle cerebral
	Central	bral artery (ACA). If the ICA is occluded and col-
		lateral flow via the circle of Willis is inadequate,
		extensive infarction occurs in the anterior two-
		thirds of the hemisphere, including the basal
		ganglia. Symptoms include partial or total blind-
		ness in the ipsilateral eye, impairment of con-
		sciousness (p. 116), contralateral hemiplegia
		and hemisensory deficit, homonymous hemi-
		anopsia, conjugate gaze deviation to the side of
		the lesion, and partial Horner syndrome. ICA in-
		farcts in the dominant hemisphere produce
		global aphasia. The occipital lobe can also be af-
		fected if the posterior cerebral artery (PCA)
		arises directly from the ICA (so-called fetal
		origin of the PCA). Border zone infarcts occur in
		distal vascular territories with inadequate col-
		lateral flow. They affect the “watershed” areas
		between the zones of distribution of the major
		cerebral arteries in the high parietal and frontal
		regions, as well as subcortical areas at the inter-
		face of the lenticulostriate and leptomeningeal
		arterial zones.
		Ophthalmic artery. Occlusion leads to sudden
		blindness (“black curtain” phenomenon or cen-
		tripetal shrinking of the visual field), which is
		often only temporary (amaurosis fugax = tran-
		sient monocular blindness). Thorough diagnostic
		evaluation is needed, as the same clinical syn-
		drome can be produced by other ophthalmo-

168logical diseases (Table 22a, p. 372).

Anterior choroidal artery (AChA). Infarction in

the AChA territory, depending on its precise lo-

cation and extent, can produce contralateral motor, sensory, or mixed deficits, hemiataxia, homonymous quadrantanopsia (both upper and lower), memory impairment, aphasia, and hemineglect.

Anterior cerebral artery (ACA). Contralateral hemiparesis is usually more distal than proximal, and more prominent in the lower than in the upper limb (sometimes only in the lower limb). Infarction in the territory of the central branches of the ACA (A1 segment, recurrent artery of Heubner) produces brachiofacial hemiparesis, sometimes accompanied by dystonia. Bilateral ACA infarction (when the arteries of both sides share a common origin) and infarctions of the cortical branches of the ACA produce abulia (p. 120), Broca aphasia (dominant hemisphere), perseveration, grasp reflex, palmomental reflex, paratonic rigidity (gegenhalten), and urinary incontinence. Lesions in the superior and medial frontal gyri or the anterior portion of the cingulate gyrus cause bladder dysfunction. Disconnection syndromes due to lesions of the corpus callosum are characterized by ideomotor apraxia, dysgraphia, and tactile anomia of the left arm.

Middle cerebral artery (MCA). Main trunk (M1) occlusion produces contralateral hemiparesis or hemiplegia with a corresponding hemisensory deficit, homonymous hemianopsia, and global aphasia (dominant side) or contralateral hemineglect with limb apraxia (nondominant side). Occlusion of the posterior main branch produces homonymous hemianopsia or quadrantanopsia as well as Wernicke or global aphasia (dominant side) or apraxia and dyscalculia (nondominant side); central main branch occlusion produces contralateral brachiofacial weakness and sensory loss; anterior branch occlusion on the dominant side additionally produces Broca aphasia. Occlusion of peripheral branches produces monoparesis of the face, hand, or arm. Occlusions of the lenticulostriate arteries, depending on their precise location, produce (purely motor) hemiparesis/hemiplegia, or hemiparesis with ataxia (lacunar infarct, p. 172).

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Stroke: Ischemia

Visual		Anterior	Lenticulostriate	Anterior/middle		Ophthalmic a.
distur-		cerebral a.	arteries (end	cerebral a.	(amaurosis fugax)
bance			zone)	(border zone)

Middle
cerebral a.
Internal carotid a.				Middle/posterior cerebral a.						Anterior choroidal a.
(brachiocephalic trunk,				(border zone)
common carotid a.)				Internal carotid a.				Internal carotid a. (terminal branches)
				(terminal branches)
						Callosomarginal a.				A. of central sul-
				Middle			Frontopolar a.			cus (rolandic a.)
				cerebral a.						Pericallosal a.
				Basal ganglia						A. of
										angular
				Anterior						gyrus
				cerebral a.
				Thalamus		Anterior
						cerebral
				Lenticulo-		a.				Temporal
				striate a.		Ophthalmic a.				aa.
										Posterior
				Internal
						Anterior				cerebral a.
				carotid a.		choroidal a.				Basilar a.
						Internal carotid a.				Vertebral a.
Internal carotid a. (branches)							Leptomeningeal arterial anastomoses
Terminal
branches
Central						Terminal branches
branches
							Central
							branches
			Anterior cerebral a.							Middle cerebral a.

Central Nervous System

169

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Stroke: Ischemia

		Stroke Syndromes: Vertebrobasilar				clusion causes impairment of consciousness
		Territory				(ranging from somnolence to coma), mental
		! Subclavian Artery				syndromes (hallucinations, confabulation, psy-
						choses), quadriparesis, and oculomotor dis-
		High-grade subclavian stenosis or occlusion				orders (diplopia, vertical or horizontal gaze
		proximal to the origin of the vertebral artery				palsy). Apical BA occlusion (p. 359) is caused by
		may cause a reversal of blood flow in the verte-				cardiac or arterial emboli. Pontine infarction
		bral artery, which worsens with exertion of the				sparing the posterior portion of the pons (teg-
		ipsilateral arm (subclavian steal). Rapid arm				mentum) produces quadriplegia and mutism
		fatigue and pain often result; less common are				with preservation of sensory function and verti-
		vertigo and other brain stem signs. The arterial				cal eye movements (locked-in syndrome, pp. 120,
	System	blood pressure is measurably different in the				359).
		two arms.				Paramedian infarction in the BA territory usu-
		! Vertebral Artery (VA)				ally affects the pons (pp. 72, 359 ff).
						Dorsolateral infarction affects the cerebellum,
	Nervous	VA occlusion produces variable combinations of				with a corresponding clinical picture. Occlusion
		symptoms and signs, including homonymous				of the labyrinthine artery (a branch of the AICA)
		hemianopsia,	dysarthria,	dysphagia,	unilateral	produces rotatory vertigo, nausea, vomiting and
		or bilateral	limb paralysis with or		without	nystagmus.
	Central	sensory deficit, ataxia, drop attacks (due to				! Posterior Cerebral Artery (PCA)
		medullary ischemia), and impairment of con-
		sciousness. Unilateral VA occlusion (e. g., due to				PCA occlusion is rare and produces symptoms
		dissection) can lead to infarction in the territory				and signs similar to those of MCA infarction.
		of the posterior inferior cerebellar artery.				Unilateral occlusion of a cortical branch pro-
		! Cerebellar Arteries				duces homonymous hemianopsia with sparing
						of the macula (supplied by the MCA), while bi-
		Large cerebellar infarcts can cause brain stem				lateral occlusion produces cortical blindness
		compression and hydrocephalus.				and, occasionally, Anton syndrome (p. 132). Cen-
		Posterior inferior cerebellar artery (PICA). Dor-				tral branch occlusion leads to thalamic infarc-
		solateral medullary infarction produces (usually				tion (p. 106; Dejerine–Roussy		syndrome), re-
		incomplete)	Wallenberg	syndrome	(p. 361).	sulting in transient contralateral hemiparesis,
		Often, only branches to the cerebellum are af-				spontaneous pain (“thalamic pain”), sensory
		fected ( vertigo, headache, ataxia, nystagmus,				deficits, ataxia,	abasia,	choreoathetosis,
		lateropulsion).				“thalamic hand” (flexion of the metacar-
		Anterior inferior cerebral artery (AICA). AICA oc-				pophalangeal joints with hyperextension of the
		clusion is rare. It produces ipsilateral hearing				interphalangeal	joints), and	homonymous
		loss, Horner syndrome, limb ataxia, and disso-				hemianopsia. If branches to the midbrain are af-
		ciated facial sensory loss, as well as contralateral				fected, an ipsilateral CN III palsy results, accom-
		dissociated sensory loss on the trunk and limbs				panied by variable contralateral deficits includ-
		(mainly the upper limbs) and nystagmus.				ing hemiparesis/hemiplegia, (rubral) tremor,
		Superior cerebellar artery (SCA). SCA occlusion				ataxia, and nystagmus. Isolated hemihypesthe-
		can produce ipsilateral Horner syndrome, limb				sia is associated with thalamic lacunar infarc-
		ataxia, dysdiadochokinesia, and CN VI and VII				tion.
		palsy, as well as contralateral hypesthesia and
		hypalgesia.

! Basilar Artery (BA)

Basilar artery occlusion. Thrombotic occlusion

170of the BA may be heralded several days in advance by nonspecific symptoms (unsteadiness,

dysarthria, headache, mental changes). BA oc-

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				Stroke: Ischemia
Ophthalmic			Medulla (dorsolateral branch)
a.
		Basilar a.
		External carotid a.
Internal		Vertebral a.
carotid a.
		Subclavian a.	Cerebellar hemisphere (medial branch)		System
		occlusion	Posterior inferior cerebellar a.
Craniocervical collaterals		Pericallosal a.		Caudate nucleus	Nervous
(Example: subclavian steal)				Capsula interna
				Putamen
				Posterior cerebral a.
				Superior cerebellar a.	Central
Middle	Internal			V
cerebral a.	capsule			VII, VIII
Anterior	Caudate	Anterior
cerebral	nucleus	cerebral a.
a.
		Anterior
		communicating a.
		Ventricle		Posterior
		Internal carotid a.	Basilar a.	inferior cerebellar a.
				Anterior
		Hypothalamus
				inferior cerebellar a.
		Posterior
		communicating a.		Vertebrobasilar vessels
		External capsule
		Thalamus
		Putamen
Vessels of basal ganglia		Posterior cerebral a.
(schematic)				Central
Paramedian				branches
pontine
infarct
				Terminal
	Dorsolateral infarct			branches	171
Basilar a.		MRI (sagittal)		Posterior cerebral a.

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Central Nervous System

172

Stroke: Pathogenesis of Infarction

! Risk Factors

The risk of stroke increases with age and is higher in men than in women at any age. Major risk factors include arterial hypertension (!140 mmHg systolic, !90 mmHg diastolic), diabetes mellitus, heart disease, cigarette smoking, hyperlipoproteinemia (total cholesterol

!5.0 mmol/l, LDL !3 mmol/l, HDL "0.9–1.2 mmol/l), elevated plasma fibrinogen, and obesity. Symptomatic or asymptomatic carotid artery stenosis, elevated plasma homocysteine levels, erythrocytosis, anti-phospholipid antibodies, alcohol abuse (#60 g of alcohol 75 cl of wine per day in men, #40 g in women). Drug abuse (amphetamines, heroin, cocaine), a sedentary lifestyle, and low socioeconomic status (unemployment, poverty) also increase the risk of stroke.

!Causes

Embolism (ca. 70%) is the most common cause of stroke. Emboli arise from local atheromatous lesions (atheromatous thromboembolism) on the walls of large arteries (macroangiopathy) of the brain or heart (cardiac embolism in atrial fibrillation, valvular heart disease, ventricular thrombus, and myxoma).

Thrombosis (ca. 25%). Occlusion of a small endartery (microangiopathy, small vessel disease) causes lacunar infarction. The cause is hyaline (lipohyalinosis)orproximalsclerosisofpenetrating arteries (lenticulostriate, thalamoperforating or pontine arteries, central branches). Causal factors include hypertension, diabetes, and blood– brain barrier disruption leading to deposition of plasma proteins in the arterial wall. Microan- giopathy-related hemodynamic changes sometimes cause hemodynamic infarction.

Rare causes (ca. 5%) include hematological diseases (e. g., coagulopathy, abnormal blood viscosity, anemia, leukemia) and arterial processes (dissection, vasculitis, migraine, fibromuscular dysplasia, moyamoya, vasospasm, amyloid angiopathy, and CADASIL = cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy).

! Infarct Types

infarcts in the subcortical periventricular region or brain stem. Classic lacunar syndromes include purely motor hemiparesis (internal capsule, corona radiata, pons), contralateral purely sensory deficit (thalamus, internal capsule), ataxic hemiparesis (internal capsule, corona radiata, pons), and dysarthria with clumsiness of one hand (= clumsy hand–dysarthria syndrome; internal capsule, pons). The presence of multiple supratentorial and infratentorial lacunes is termed the lacunar state (“état lacunaire”) and is clinically characterized by pseudobulbar palsy (p. 367), small-step gait (“marche à petit pas”), urinary incontinence, and affective disorders (compulsive crying). For leukoaraiosis, see p. 298.

Territorial infarcts are those limited to the distribution of the ACA, MCA, or PCA. With the exception of striatocapsular infarcts (internal capsule, basal ganglia), these infarcts are predominantly cortical. Embolic territorial infarcts often undergo secondary hemorrhage (“hemorrhagic conversion”).

End zone infarcts. Low-flow infarction in the subcortical white matter is due to extracranial high-grade vessel stenosis and/or inadequate collateral flow.

Border zone infarcts (p. 168) also result from hemodynamic disturbances due to microangiopathy. They are found at the interface (“watershed”) between adjacent vascular territories, and can be either anterior (MCA–ACA contralateral hemiparesis and hemisensory deficit, mainly in the lower limb and sparing the face, with or without aphasia) or posterior (MCA– PCA contralateral hemianopsia and cortical sensory deficit, with or without aphasia).

Global cerebral hypoxia/ischemia. The causes include cardiac arrest with delayed resuscitation, hemorrhagic shock, suffocation, and carbon monoxide poisoning. Global cerebral hypoxia/ischemia causes bilateral necrosis of brain tissue, particularly in the basal ganglia and white matter.

Lacunar infarcts (“small deep infarcts”). Lacunes are small ($1.5 cm in diameter), round or oval

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