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Signs and symptoms 1 Medial midpontine syndrome (paramedian branch of midbasilar artery) a On side of lesion (1) Ataxia of limbs and gait (more prominent in bilateral involvement b On side opposite lesion (1) Paralysis of face, arm, and leg (2) Deviation of eyes (3) Variably impaired touch and proprioception when lesion extends posteriorly Usually the syndrome is purely motor 2 Lateral midpontine syndrome (short circumferential artery) a On side of lesion (1) Ataxia of limbs (2) Paralysis of muscles of mastication (3) Impaired sensation over side of face

Middle cerebellar peduncle Motor bers or nucleus of fth nerve Sensory bers or nucleus of fth nerve

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As mentioned, in the ventral pons, the lacunar syndrome may be one of pure motor hemiplegia, mimicking that of internal capsular infarction except for relative sparing of the face and the presence of an ipsilateral paresis of conjugate gaze in some cases; or there is a combination of dysarthria and clumsiness of one hand; in the latter case the lacune is located in the paramedian midpons on the side opposite the clumsy limb Occasionally a lacunar infarction of the pons, midbrain, internal capsule, or parietal white matter gives rise to a hemiparesis with ataxia on the same side as the weakness (Fisher; Sage and Lepore) Some of the brainstem syndromes may blend with basilar branch syndromes There are many other, less frequent lacunar syndromes, too numerous to tabulate here Multiple lacunar infarcts, involving the corticospinal and corticobulbar tracts, are by far the most common cause of pseudobulbar palsy Undoubtedly, an accumulation of lacunes deep in both hemispheres can give rise to gait disorders and also to mental dulling sometimes referred to as multi-infarct dementia (see further on and pages 373, 691, and 707) The main differential diagnostic considerations are then normal-pressure hydrocephalus (Chap 31) and degenerative brain conditions that affect the frontal lobes and basal ganglia (Chap 39)

In all these cases of lacunar infarction, the diagnosis depends essentially on the occurrence of the aforementioned unique stroke syndromes of limited proportions: to recapitulate, pure motor hemiplegia, pure sensory stroke, clumsy-hand with dysarthria, and ataxic hemiparesis are the main ones As mentioned above, MRI is more reliable than CT scanning in demonstrating the lacunes Initially, lacunes are seen on the MRI as deep oval or linear areas of T2, FLAIR, and especially, diffusion weighted signal abnormality; later they become cavitated The EEG may be helpful in a negative sense; in the case of lacunes in the pons or the internal capsule, there is a notable discrepancy between the unilateral paralysis or sensory loss and the negligible electrical changes over the affected hemisphere

In classifying the cerebrovascular diseases, it is most practical, from the clinical viewpoint, to preserve the classic division into thrombosis, embolism, and hemorrhage The causes of each of the

Signs and symptoms 1 Medial superior pontine syndrome (paramedian branches of upper basilar artery) a On side of lesion (1) Cerebellar ataxia (2) Internuclear ophthalmoplegia (3) Rhythmic myoclonus of palate, pharynx, vocal cords, respiratory apparatus, face, oculomotor apparatus, etc b On side opposite lesion (1) Paralysis of face, arm, and leg (2) Rarely touch, vibration, and position senses are affected 2 Lateral superior pontine syndrome (syndrome of superior cerebellar artery) a On side of lesion (1) Ataxia of limbs and gait, falling to side of lesion (2) Dizziness, nausea, vomiting (3) Horizontal nystagmus (4) Paresis of conjugate gaze (ipsilateral) (5) Loss of optokinetic nystagmus (6) Skew deviation (7) Miosis, ptosis, decreased sweating over face (Horner syndrome) b On side opposite lesion (1) Impaired pain and thermal sense on face, limbs, and trunk (2) Impaired touch, vibration, and position sense, more in leg than in arm (there is a tendency to incongruity of pain and touch de cits)

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Middle and superior cerebellar peduncles, superior surface of cerebellum, dentate nucleus Vestibular nuclei Territory of descending branch to middle Vestibular nuclei cerebellar peduncle (occlusion of Uncertain superior cerebellar artery) Uncertain Uncertain Descending sympathetic bers

Spinothalamic tract Medial lemniscus (lateral portion)

big three, along with the criteria for diagnosis and the con rmatory laboratory tests for each, are considered here in separate sections This classi cation has the disadvantage of not providing for disorders such as reversible ischemia, hypertensive encephalopathy, and venous thrombosis; these are considered in separate sections later in the chapter