Anterior cerebral artery stroke syndromes

Jorge Moncayo-Gaete MD (Dr. Moncayo-Gaete of the International University of Ecuador has no relevant financial relationships to disclose.)
Julien Bogousslavsky MD (Dr. Bogousslavsky of the Swiss Medical Network has no relevant financial relationships to disclose.)
Steven R Levine MD, editor. (Dr. Levine of the SUNY Health Science Center at Brooklyn has received honorariums from Genentech for service on a scientific advisory committee and a research grant from Genentech as a principal investigator.)
Originally released May 30, 2002; last updated March 5, 2017; expires March 5, 2020

This article includes discussion of anterior cerebral artery stroke syndromes, weakness, extrapyramidal symptoms, sensory symptoms, gait apraxia, incontinence, neglect, akinetic mutism and abulia, mood disturbance, aphasia, callosal disconnection syndromes, and pathological grasp phenomena and alien hand. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.

Overview

Contralateral monoplegia with mild upper-extremity involvement is an unusual condition classically described as occurring when ischemia involves the anterior cerebral artery territory. A broad spectrum of complex cognitive, behavioral, and emotional disorders accompanied by other patterns of motor and sensory deficits may also be observed in the setting of infarcts in this territory or its branches. In this article, the authors provide a comprehensive description of the clinical manifestations, topographical distribution, etiology, and outcome of anterior cerebral artery stroke.

Key points

 

• Up to 3% of cerebral infarcts involve the anterior cerebral artery territory.

 

• Classically, weakness and sensory loss predominate in the contralateral leg.

 

• Cognitive, behavioral, and emotional disorders may also be prominent clinical findings.

 

• Etiology may differ according to ethnic origin; internal carotid artery atherosclerosis and cardiac embolism predominate in western populations whereas intrinsic anterior cerebral artery disease is the leading cause in Asian populations.

Historical note and terminology

The vascular anatomy and syndromes associated with infarction of the anterior cerebral arteries were first described by Foix and Hillemand and by Critchley in the first half of the 20th century (Foix and Hillemand 1925; Critchley 1930a; Critchley 1930b). Indeed, in Critchley's review on this topic presented in the Proceedings of the Royal Society of Medicine, he acknowledged that “we owe to Charles Foix and his pupils the foundations of our knowledge of cerebrovascular topography, and though they possibly err on the side of over-simplification, Foix has undoubtedly opened a new chapter in clinical neurology.”

In the same review, Critchley described the primary motor symptom of a stroke in the anterior cerebral artery distribution as a “crural monoplegia – or hemiplegia with crural predominance,” although he allows that with “rare cases of occlusion of Heubner's artery” there may be “a severe degree of contralateral hemiplegia affecting particularly…the face, tongue and shoulder.” Other symptoms described were ideomotor apraxia, the “phenomena of forced grasping and groping,” and rare “aphasic speech defects.” These observations remain relevant today.

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