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Stroke syndromes by territory
The deficits that point to each arterial territory, from the cortical strokes to the crossed brainstem syndromes.
| Territory | Lesion site | Key deficits | Clues |
|---|---|---|---|
| MCA | Most of the lateral hemisphere — face and arm cortex, language areas | Contralateral weakness and sensory loss of the face and arm more than the leg; contralateral homonymous hemianopia; gaze deviation toward the lesion | Dominant (left): aphasia. Nondominant (right): hemineglect, anosognosia. The most common territory |
| ACA | Medial frontal and parietal lobes — leg and foot cortex, bladder control | Contralateral leg more than arm weakness and sensory loss | Urinary incontinence, abulia or personality change |
| PCA | Occipital lobe, inferior temporal lobe, thalamus | Contralateral homonymous hemianopia with macular sparing | Visual agnosia; dominant PCA + splenium → alexia without agraphia; thalamic involvement → sensory loss |
| Lacunar (deep penetrating arteries) | Internal capsule, thalamus, basis pontis | Pure motor hemiparesis (face, arm and leg equally), pure sensory, sensorimotor, ataxic hemiparesis, dysarthria–clumsy hand | No cortical signs (no aphasia, neglect or field loss); chronic hypertension and diabetes |
| Weber (PCA/paramedian branches) | Ventral midbrain | Ipsilateral CN III palsy + contralateral hemiparesis | Crossed signs = brainstem |
| AICA (vertebrobasilar) | Lateral pons | Ipsilateral facial palsy, hearing loss, vertigo, ataxia and facial sensory loss; contralateral body pain and temperature loss | Vertigo + sudden unilateral hearing loss |
| PICA or vertebral (Wallenberg) | Lateral medulla | Ipsilateral face and contralateral body pain/temperature loss; dysphagia, hoarseness, reduced gag; ipsilateral Horner syndrome; vertigo, nystagmus; ipsilateral limb ataxia | No limb weakness; hiccups |
| Anterior spinal artery (medial medullary) | Medial medulla | Contralateral hemiparesis, contralateral loss of proprioception and vibration, ipsilateral tongue deviation (CN XII) | Pyramid + medial lemniscus + hypoglossal |
| Basilar | Ventral pons and brainstem | Coma or locked-in syndrome (quadriplegia and anarthria with vertical eye movements and blinking preserved); pinpoint pupils | Emergency CTA and thrombectomy |
Crossed signs (an ipsilateral cranial nerve deficit with contralateral limb signs) localize to the brainstem.
Posterior circulation strokes cause the 5 Ds — dizziness, diplopia, dysarthria, dysphagia, dystaxia — and are easily missed on CT; MRI is the test.