Examqo › Examqo library › Neurology › Cerebrovascular disease · IMLE
Stroke syndromes by territory — where is the occlusion?
Each arterial territory produces a fixed combination of signs: middle cerebral artery — face and arm with aphasia or neglect; anterior — leg; posterior — visual field; lacunar — a "pure" deficit without cortical signs; and brainstem — crossed signs.
Why it matters in the exam
Many stroke questions do not ask about treatment but about location: which artery is blocked, on which side, and whether it is a large vessel suitable for thrombectomy. Classic syndromes are tested: Wallenberg (lateral medullary) with reduced pain sensation in the face on the same side and the body on the other side, Horner, hoarseness and vertigo without weakness; Weber (midbrain) with a 3rd nerve palsy and weakness on the opposite side; and alexia without agraphia in a left posterior cerebral artery infarct. HINTS is also tested in a patient with continuous vertigo: a normal head impulse test, direction-changing nystagmus or vertical skew suggest stroke rather than vestibular neuritis. A common distractor is blaming vertigo with ataxia on the ear, or thinking a lacunar infarct affects language.
Key points
- MCA: face and arm more than leg, gaze towards the lesion, aphasia or neglect.
- ACA: leg more than arm; PCA: hemianopia with macular sparing.
- Lacunar: a pure deficit without cortical signs.
- Wallenberg: pain and temperature loss in the face on the same side and the body on the opposite side, Horner and hoarseness, no weakness.
- Continuous vertigo with central HINTS requires MRI for posterior circulation stroke.
Summary table
| Territory | Main findings | Distinguishing clue |
|---|---|---|
| Middle cerebral artery (MCA) | Weakness and numbness of face and arm more than leg on the opposite side; gaze deviation towards the lesion; hemianopia | Dominant hemisphere — aphasia; non-dominant — neglect |
| Anterior cerebral artery (ACA) | Leg weaker than arm on the opposite side | Abulia, urinary incontinence |
| Posterior cerebral artery (PCA) | Homonymous hemianopia on the opposite side with macular sparing | On the left — alexia without agraphia |
| Lacunar | Pure motor (internal capsule), pure sensory (thalamus), ataxic hemiparesis, dysarthria and clumsy hand | No aphasia, neglect or hemianopia |
| Brainstem | Wallenberg: pain and temperature loss in the face on the same side and the body on the opposite side, Horner, hoarseness, ataxia, no weakness; Weber: 3rd nerve on the same side and weakness on the opposite side | Basilar artery occlusion — coma or "locked-in" |
| Cerebellum | Vertigo, vomiting, ataxia, nystagmus | Central HINTS; risk of oedema and hydrocephalus |
Free exam questions
במקרה של שבץ מוחי במנגנון של תס חיף, איזה מהעורקים הבאים עלול להיחסם בשכיחות הגבוהה ביותר? (the question as examined, in Hebrew)
- א. MIDDLE CEREBRAL ARTERY
- ב. INTERNAL CAROTID ARTERY
- ג. THALAMO PERFORATE ARTERY
- ד. LATERAL LENTICULOSTRIATE ARTERY
בן 25 ( , בבדיקתו נראה כתם אדום port wine ) באזור עפעף עליון שמאלי. מה המאפיינים הקליניים הנלווים למצב זה? (the question as examined, in Hebrew)
- א. החזרים ירודים בגפיים איפסילטרלית לכתם
- ב. פרכוס פוקלי
- ג. רעד במנוחה בגפיים
- ד. סימנים צרבלרים
In the full version for subscribers
- A simple algorithm
- Memory aid
- Exam traps
- 5 review cards
- Enough for IMLE
The full version is open to subscribers of: Neurology, Medical licensing exam (IMLE), Internal medicine, Emergency medicine, Geriatrics.
Subscriber? Read the full topic Plans and prices 25 free questions
Sources
- AHA/ASA Guidelines for the Early Management of Patients With Acute Ischemic Stroke, 2019 — Clinical assessment and stroke scales
- HINTS to Diagnose Stroke in the Acute Vestibular Syndrome (Kattah et al., Stroke), 2009 — Bedside eye examination
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.