Basilar artery penetrating artery occlusions

From WikiCNS

  1. Top of the basilar syndrome – due to occlusion of the rostral basilar artery causing ischemia to the midbrain, subthalamus, thalamus, and portions of the temporal and occipital lobes
    1. symptoms: visual field defect, disorder of vertical gaze and convergence (Parinaud’s), pupillary constriction, somnolence, hallucinations, bilateral weakness, ataxia, sensory loss in the extremities
  2. basilar artery or basilar artery branch occlusions
    1. symptoms: nystagmus, internuclear ophthalmoplegia, gaze paresis, abducens palsy, ocular bobbing, constricted pupils, somnolence, loss of consciousness, weakness, hypesthesia of face and limbs, vertigo, nausea, vomiting, ataxia
    2. characteristic syndromes:
      1. medial superior pons
        1. ipsilateral cerebellar ataxia (pontocerebellar fibers), internuclear ophthalmoplegia (medial longitudinal fasciculus), myoclonus of palate, pharynx, vocal cords, face, oculomotor (central tegmental bundle)
        2. contralateral paralysis of face, arm and leg (corticobulbar and corticospinal tracts), occasionally touch, vibration, and position (medial lemniscus)
      2. lateral superior pons
        1. ipsilateral ataxia (superior cerebellar peduncle), dizziness, nystagmus (vestibular nuclei), Horner’s (descending sympathetic fibers)
        2. contralateral impaired pain and temperature sense (spinothalamic), impaired touch, vibration and position (medial lemniscus)
      3. medial midpontine
        1. ipsilateral ataxia (middle cerebellar peduncle)
        2. contralateral paralysis (corticobulbar and corticospinal), impaired touch and proprioception (medial lemniscus)
      4. lateral midpontine
        1. ipsilateral ataxia (middle cerebellar peduncle), paralysis of mastication (motor nucleus of CN 5), impaired sensation over face (sensory nucleus of CN 5)
      5. medial inferior pons
        1. ipsilateral paralysis of conjugate gaze to side of lesion (paramedian pontine reticular formation (PPRF)), nystagmus (vestibular nuclei), ataxia of limbs (middle cerebellar peduncle), diplopia (abducens)
        2. contralateral paralysis (corticobulbar and corticospinal), impaired tactile and proprioception (medial lemniscus)
      6. lateral inferior pons
        1. ipsilateral horizontal and vertical nystagmus (vestibular nucleus), facial paralysis, paralysis of conjugate gaze (PPRF), deafness (cochlear nucleus), ataxia (middle cerebellar peduncle), impaired sensation over face (sensory nucleus of CN 5)
        2. contralateral impaired pain and temperature sensation over half of body (spinothalamic tract)
  3. superior cerebellar artery occlusion
    1. ipsilateral cerebellar ataxia (middle and superior cerebellar peduncles), nausea and vomiting, slurred (pseudobulbar) speech
    2. contralateral pain and temperature sensation (spinothalamic)
  4. anterior inferior cerebellar artery occlusion
    1. ipsilateral deafness (cochlear nucleus), facial weakness (facial nucleus), cerebellar ataxia (middle or inferior cerebellar peduncle), Horner’s syndome (descending sympathetics), paresis of conjugate lateral gaze (PPRF)
    2. contralateral loss of pain and temperature (spinothalamic tract) along with vertigo, nausea, vomiting, nystagmus, and tinnitus
  5. vertebral artery occlusions
    1. PICA occlusion producing Wallenberg syndrome:
      1. Ipsilateral pain and numbness over half of face (nucleus of CN 5), ataxia, vertigo and nystagmus (vestibular nuclei), Horner’s (descending sympathetic tract), dysphagia (CN 9 and 10 nuclei), numbness of ipsilateral arm, trunk or leg (cuneate and gracile nuclei), hiccups
      2. Contralateral impaired pain and thermal sense (spinothalamic)
      3. PICA has 5 segments that supply the choroid plexus of the fourth ventricle, medulla, vermis tonsil, and posteroinferior surface of the cerebellar hemisphere
        1. Occasionally PICA arises outside the foramen magnum
    2. medial medullary infarct –
      1. ipsilateral paralysis and atrophy of half of tongue (hypoglossal nucleus)
      2. contralateral paralysis of arm and leg sparing face (pyramidal tract), impaired tactile and proprioception (medial lemniscus)
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