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PART 4
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and temperature sense With left-sided lesions there is initially a global aphasia, which changes gradually to a predominantly motor (Broca) aphasia, with improvement in comprehension of spoken and written words and the emergence of an effortful, hesitant, grammatically simpli ed, and dysmelodic speech (Chap 23); or there is a Broca aphasia from the outset Embolic occlusion limited to one of the branches of the superior division, perhaps the most common stroke seen in clinical practice, produces a more circumscribed infarct that further fractionates the above described syndrome With occlusion of the ascending frontal branch, the motor de cit is limited to the face and arm with little or no affection of the leg, and the latter, if weakened at all, soon improves; with left-sided lesions, there is dys uent and agrammatic speech, with normal comprehension (page 418) Embolic occlusion of the rolandic branches results in sensorimotor paresis with severe dysarthria but little evidence of aphasia A cortical-subcortical branch occlusion may give rise to a brachial monoplegia Embolic occlusion of ascending parietal and other posterior branches of the superior division may cause no sensorimotor de cit but only a conduction aphasia (page 421) and bilateral ideomotor apraxia There are many other limited stroke syndromes or combinations of the aforementioned syndromes relating to small regions of damage in the frontal, parietal, or temporal lobes Most of these are discussed in Chap 22, on lesions in particular parts of the cerebrum Improvement can be expected within a few weeks to months but often some remnant of the original problem remains in place As indicated earlier, the distal territory of the middle cerebral artery may also be rendered ischemic by failure of the systemic circulation, especially if the carotid artery is stenotic; this may simulate embolic branch occlusions Inferior Division Occlusion of the inferior division of the middle cerebral artery is slightly less frequent than occlusion of the superior one, but again is nearly always due to embolism The usual result in left-sided lesions is a Wernicke aphasia, which generally remains static for days or weeks, or a month or two, after which some improvement can be expected (page 419) In less extensive infarcts from branch occlusions (superior parietal, angular, or posterior temporal), the de cit in comprehension of spoken and written language may be especially severe Again, after a few months, the de cits usually improve, often to the point where they are evident only in self-generated efforts to read and copy visually presented words or phrases With either right- or left-hemispheric lesions, there is usually a superior quadrantanopia or homonymous hemianopia and, with right-sided ones, a left visual neglect and other signs of amorphosynthesis; rarely, an agitated confusional state, presumably from temporal lobe damage, may be a prominent feature of dominant hemispheral lesions and sometimes of nondominant ones Deep MCA ( MCA Stem, M1) Territory Occlusion (Striatocapsular Infarction) A number of interesting syndromes occur with deep lesions in the territory of the penetrating vessels of the middle cerebral artery (Figs 34-5 and 34-7) Most are attributable to emboli to the stem of the middle cerebral artery, although imaging studies show a patent vessel in half of the cases; a few are presumably atherothrombotic There have been few adequate pathologic studies Although centered in the deep white matter, most of these lesions are fragments of the cortical-subcortical stroke patterns described above The most common type in our experience has been a large striatocapsular infarction, similar to that described by Weller and colleagues All of their patients had some degree of hemiparesis and one- fth had aphasia or hemineglect
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Aphasia, when it occurs, tends to be a limited form of the Broca type and, in our experience, has been short-lived With deep small strokes, we have most often encountered incomplete motor syndromes affecting only the arm and hand, without language disturbance or neglect; these are quite dif cult to differentiate from small embolic cortical strokes The lesions in the corona radiata are larger than typical lacunes (see further on) but probably have a similar pathophysiology Foix and Levy, who described the clinical effects of deep capsular-basal ganglionic lesions and of more super cial cortical-subcortical ones, found few important differences in the degree and pattern of the hemiplegia and sensory disorder Homonymous hemianopia may occur with posterior capsular lesions, but it must be distinguished from visual hemineglect of contralateral space Bilateral cerebral infarctions involving mainly the insular-perisylvian (anterior opercular) regions manifest themselves by a facio-glossopharyngo-masticatory diplegia (anarthria without aphasia; see Mao et al)
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