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MAJOR CATEGORIES OF NEUROLOGIC DISEASE
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Supplementary motor area
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Motor area for foot, leg, and urinary bladder Sensory area for foot and leg
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Pericallosal A Calloso-marginal A Artery of splenium Fronto-polar A Parieto-occipital branch
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Visual cortex with striate area along calcarine sulcus Medial orbito-frontal A Ant cerebral A Post cerebral A Calcarine A Post temporal A Ant temporal A Figure 34-6 Diagram of a cerebral hemisphere, medial aspect, showing the branches and distribution of the anterior cerebral artery and the principal regions of cerebral localization Below is a list of the clinical manifestations of infarction in the territory of this artery and the corresponding regions of cerebral damage Also shown is the course of the main branch of the posterior cerebral artery on the medial side of the hemisphere
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Signs and symptoms Paralysis of opposite foot and leg A lesser degree of paresis of opposite arm Cortical sensory loss over toes, foot, and leg Urinary incontinence Contralateral grasp re ex, sucking re ex, gegenhalten (paratonic rigidity), frontal tremor Abulia (akinetic mutism), slowness, delay, lack of spontaneity, whispering, motor inaction, re ex distraction to sights and sounds Impairment of gait and stance (gait apraxia ) Mental impairment (perseveration and amnesia) Miscellaneous: dyspraxia of left limbs Tactile aphasia in left limbs Cerebral paraplegia
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Note: Hemianopia does not occur; transcortical aphasia occurs rarely (page 423)
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Structures involved Motor leg area Involvement of arm area of cortex or bers descending therefrom to corona radiata Sensory area for foot and leg Posteromedial part of superior frontal gyrus (bilateral) Medial surface of the posterior frontal lobe ( ) Uncertain localization probably superomedial lesion near subcallosum Inferomedial frontal striatal ( ) Localization unknown Corpus callosum Corpus callosum Motor leg area bilaterally (due to bilateral occlusion of anterior cerebral arteries)
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in the neck With severe atherosclerotic stenosis at the level of the carotid sinus, with or without a superimposed thrombus, auscultation frequently discloses a bruit, best heard with the bell of the stethoscope held against the skin just tightly enough to create a seal (excessive pressure creates a diaphragm of the skin and lters the low-pitched frequencies that are typical of the bruit of carotid stenosis) Occasionally a bruit is due to stenosis at the origin of the external carotid artery or is a radiated murmur from the aortic valve and can then be misleading If the bruit is loudest at the angle of the jaw, the stenosis usually lies at the proximal internal carotid; if heard lower in the neck, it is in the common carotid or subclavian artery Rarely, stenosis in vertebral arteries or vascular malforma-
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tions at the base of the brain may produce bruits heard posteriorly in the neck The duration and quality of the bruit are relevant bruits that extend into diastole and are high-pitched are almost invariably associated with a tight stenosis (lumen l5 mm) An additional though infrequent sign of carotid occlusion is the presence of a bruit over the opposite carotid artery, heard best by placing the bell of the stethoscope over the eyeball (ocular bruit) As pointed out by Pessin and colleagues (1983), this murmur is often due to augmented circulation through the patent vessel but there are as many instances in our experience when a bruit over the eye instead re ects a stenosis in the intracranial portion of the carotid artery on
CEREBROVASCULAR DISEASES
that side Pulsation may be palpably reduced or absent in the common carotid artery in the neck, in the external carotid artery in front of the ear, and in the internal carotid artery in the lateral wall of the pharynx, but these are among the least dependable signs of carotid disease and too vigorous compression risks dislodging plaque material Also, in the presence of a unilateral internal carotid occlusion, compression of the normal common carotid should be avoided because it may precipitate neurologic symptoms Central retinal artery pressure is reduced on the side of a carotid occlusion or severe stenosis; this can be appreciated by gentle pressure on the globe while viewing the vessels emanating from the optic nerve head A diastolic retinal pressure (determined by ophthalmic dynamometry) of less than 20 mmHg usually means that the common or internal carotid artery is occluded These and other tests for assessing carotid ow have been largely supplanted by ultrasound insonation and MRI imaging of the carotid artery, but retinal examination remains highly valuable in that it may demonstrate emboli within retinal arteries, either shiny white or reddish in appearance; this is another important sign of carotid disease (crystalline cholesterol is sloughed from an atheromatous ulcer) Additional signs of carotid occlusion include pulseless arms (as in Takayasu disease, see page 732); faintness on arising from the horizontal position or recurrent loss of consciousness when walking; headache and sometimes ocular, retro-orbital, and neck pain; transient blindness, either unilateral or bilateral; unilateral visual loss or dimness of vision with exercise, after exposure to bright light, or on assuming an upright position; retinal atrophy and pigmentation; atrophy of the iris; heterochromia of the iris (differing coloration on the two sides is a sign of carotid occlusion early in life); leukomas (corneal scars); peripapillary arteriovenous anastomoses in the retinae; optic atrophy; and claudication of jaw muscles The cardinal clinical sign of stenoses, ulcerations, and dissections of the internal carotid artery near its origin from the common carotid artery are TIAs It is a subject of debate whether these are the result of brin platelet emboli or a reduction in blood ow TIAs are discussed further on, but here it can be stated that TIAs and severe stenosis of the vessel represents an important risk factor for stroke
the distal internal carotid and proximal to its bifurcation An occlusion here blocks the ow in the small deep penetrating vessels as well as in super cial cortical branches; alternatively, an occlusion at the distal end of the stem blocks the ori ces of the divisions of the artery in the sylvian sulcus but leaves unaffected the more proximal deep penetrating vessels The picture of total occlusion of the stem is one of contralateral hemiplegia (face, arm, and leg), hemianesthesia, and homonymous hemianopia (due to infarction of the lateral geniculate body), with deviation of the head and eyes toward the side of the lesion; in addition, there is a variable but usually global aphasia with left hemispheric lesions and anosognosia and amorphosynthesis with a right-sided ones (see Chap 22) In the beginning, the patient may be dull or stuporous because of an ill-de ned effect of widespread paralysis of neurologic function Once fully established, the motor, sensory, and language deficits remain static or improve very little as months and years pass If the patient is globally aphasic for a prolonged period of time, he seldom ever again communicates effectively (see Chap 23 on the aphasic disorders) Occlusion of branches of the middle cerebral artery gives rise to only parts of the symptom complex If there are adequate collateral vessels over the surface of the hemisphere, only those component of the stroke referable to the deep structures are evident (mainly hemiplegia encompassing the contralateral limbs and face, as discussed below, under Deep MCA Territory Occlusion ), the cortical elements then being absent or mild (aphasia, agnosia, etc) Occlusion of the stem of the middle cerebral artery by a thrombus, contrary to conventional teaching, is relatively infrequent (less than 10 percent of middle cerebral artery occlusions in our experience); cerebral embolism is a more common cause Pathologic studies over the years have shown that most carotid occlusions are thrombotic, whereas most middle cerebral occlusions are embolic (Fisher, 1975; Caplan, 1989) The emboli tend to lodge in the stem or, more often, drift into super cial cortical branches; not more than 1 in 20 will enter deep penetrating branches that originate in the stem The middle cerebral artery may, however, become stenotic from atherosclerosis In several series of such cases, the permanent stroke was preceded by TIAs, producing a picture resembling that of carotid stenosis (see Day; Caplan) MCA Branch (Superior and Inferior Division) Occlusion Superior Division An embolus entering the middle cerebral artery most often lodges in one of its two main branches, the superior division (supplying the rolandic and prerolandic areas) or the inferior division (supplying the lateral temporal and inferior parietal lobes) Major infarction in the territory of the superior division causes a dense sensorimotor de cit in the contralateral face, arm, and, to a lesser extent, leg as well as ipsilateral deviation of the head and eyes; ie, it mimics the syndrome of stem occlusion except that the foot is spared and the leg is less involved than the arm and face ( brachiofacial paralysis ); there is no impairment of alertness If the occlusion is lasting (not merely transient ischemia with disintegration of the embolus), there will be slow improvement; after a few months, the patient will be able to walk with a spastic leg, while the motor de cits of the arm and face remain The sensory de cit may be profound, resembling that of a thalamic infarct (pseudothalamic syndrome of Foix), but more often it is less severe than the motor de cit, taking the form of stereoanesthesia, agraphesthesia, impaired position sense, tactile localization, and two-point discrimination as well as variable changes in touch, pain,
Middle Cerebral Artery (MCA)
This artery has super cial and deep hemispheral branches Through its cortical branches, it supplies the lateral (convexity) part of the cerebral hemisphere (Fig 34-4) Its cortical territory encompasses (1) cortex and white matter of the lateral and inferior parts of the frontal lobe including motor areas 4 and 6, contraversive centers for lateral gaze and motor speech area of Broca (dominant hemisphere); (2) cortex and white matter of the parietal lobe, including the sensory cortex and the angular and supramarginal convolutions; and (3) superior parts of the temporal lobe and insula, including the sensory language areas of Wernicke The deep penetrating or lenticulostriate branches of the middle cerebral artery supply the putamen, part of the head and body of the caudate nucleus, the outer globus pallidus, the posterior limb of the internal capsule, and the corona radiata (Fig 34-5) The size of both the middle cerebral artery and the territory that it supplies is larger than those of the anterior and posterior cerebral arteries MCA Stem (M1) Occlusion The middle cerebral artery may be occluded in its stem (the term M1 is used by radiologists to denote this portion of the vessel), the portion that is distal to its origin at
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