Stroke syndromes and their anatomic localization

Karen D Orjuela MD (Dr. Orjuela of University of Colorado Medical Center in Denver has no relevant financial relationships to disclose.)
Camilo R Gomez MD (Dr. Gomez of Loyola University Chicago, Stritch School of Medicine, 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 10, 2004; last updated April 27, 2017; expires April 27, 2020

Overview

The original description of stroke syndromes followed the phenomenologic approach to clinical diagnosis that characterized classical neurology; accurate diagnostic localization of injuries or lesions of the nervous system required clinicians to piece together the different deficits into well-defined, recognizable, and predictable syndromes based on pattern recognition. Stroke syndromes had the singular advantage of directly relating to specific vessels and their branches. The introduction of advanced imaging techniques improved our understanding of how clinical syndromes relate to specific vascular processes, incorporating elements of mechanism (ie, pathogenesis), causation (ie, etiology), and prognosis (ie, outcome) into the cerebrovascular clinical evaluation. In this article, the authors describe a process by which the recognition of stroke syndromes is linked to relevant diagnostic and therapeutic choices destined to optimize outcomes.

Key points

 

• Because the vascular supply to different brain regions is predictable, the identification of stroke syndromes, by inference, allows cerebrovascular localization diagnosis.

 

• The evolution of increasingly sophisticated imaging techniques provides certainty about the anatomic relationship between each stroke syndrome and its underlying pathologic substrate.

 

• Stroke syndrome recognition allows inference of the mechanism (ie, pathogenesis) and causation (ie, etiology) of the stroke and facilitates management decisions.

 

• Stroke syndromes optimize benefit versus risk assessment of therapeutic interventions by providing perspective of the natural history of the stroke.

Historical note and terminology

The traditional approach to neurologic diagnosis is centered on the use of bedside neurologic findings to localize the brain lesions responsible for them. The most frequent scenario for the application of such a paradigm is the care of stroke patients, and it is not surprising that stroke syndromes drove the progress of localization diagnosis in both neurology and neurosurgery (McHenry 1981; Ljunggren and Fodstad 1991). The 19th century witnessed an exponential growth in clinical neurology, and it is within this period that a number of the classic stroke syndromes were first described. However, the idea that lesions in specific areas of the brain could produce discrete yet predictable neurologic deficits was still a subject of controversy. It gained importance in large part due to the efforts of Charcot, who introduced a 2-part approach to the study of neurologic diagnosis; the méthode anatomoclinique (anatomoclinical method) involved cataloging patients based on their neurologic deficits and then correlating the lesions found at autopsy with those deficits (Goetz 2002). His pathologic characterization of cerebral infarctions led to the concept of neurologic localization becoming widely accepted.

Advances in stroke localization during the earlier part of the 20th century followed the work of Foix, who was considered by many to be the first modern stroke neurologist (Caplan 1990). His contributions included detailed descriptions of the vascular supply of specific cerebral arteries, together with the clinical syndromes resulting from their occlusion. Later in the 20th century, many of his original ideas were further defined by C Miller Fisher, who introduced definitions for transient ischemic attack, lacunar syndromes, and the etiopathogenic importance of extracranial carotid atherosclerosis (Fisher 2001). In parallel, advances in neuroimaging provided a more dynamic dimension to the day-to-day application of the anatomoclinical method of Charcot, arguably becoming the equivalent to bedside neuropathology.

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