Clinical Neurology · Stroke & Vascular Neurology

Brainstem Stroke Syndromes

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Named vascular syndromes of the brainstem — affected structures (cranial nerves, nuclei, tracts), vascular supply, and clinical presentation, organized by level (midbrain, pons, medulla).

Midbrain

Syndrome	Vascular	Structures affected	Presentation
Weber (superior alternating hemiplegia)	Paramedian branch of PCA	CN: 3rd Nuclei: Tracts: CST	Ipsilateral: 3rd palsy Contralateral: Hemiplegia
Benedikt’s (Paramedian midbrain)	Paramedian branch of PCA	CN: 3rd Nuclei: Red nucleus Tracts: CST	Ipsilateral: 3rd palsy Contralateral: Hemiplegia, rubral tremors, chorea
Claude	Paramedian branch of PCA	CN: 3rd Nuclei: Red nucleus Tracts: CST - SCP	Ipsilateral: 3rd palsy Contralateral: Ataxia
Nothnagel	Midbrain tumors	3rd CN - Sup cerebellar ped.	Bilateral 3rd palsy Cerebellar ataxia
Parinaud (dorsal midbrain)	Tectal lesion: Pineal tumor – MS – Stroke – Obstructive HCP	CN: Nuclei: upward gaze center (riMLF) – Edinger Westphal Tracts:	Triad of: Upward gaze palsy (Supranuclear) Pupillary light near dissociation (accommodates, doesn’t react to light) Convergence-retraction nystagmus (attempts for upward gaze causes convergence)

Pons

Syndrome	Vascular	Structures affected	Presentation
Millard Gubler (Ventral Pontine)	Penetrating of Basilar	CN: 6th – 7th Nuclei: Tracts: CST	Ipsilateral: 6th – 7th palsy Contralateral: hemiplegia
Foville (Inferior medial pontine)	Penetrating of Basilar	CN: 6th – 7th Nuclei: PPRF Tracts: MLB – ML – CST	Ipsilateral: 7th palsy - horizontal gaze palsy Contralateral: hemiplegia – hemihypothesia - INO
Lateral Pontine (Marie Foix)	AICA	CN: Spinal 5th - 7th – 8th Nuclei: cochlear – vestibular, lateral reticular nucleus (cause Horner) Tracts: LSTT – Cerebellar peduncle – Descending sympathetic	Ipsilateral: Spinal 5th (all facial sensations) – 7th (facial weakness) – 8th (hearing loss) – Ataxia – Horner’s – falling to same side (vestibular) Contralateral: pain and temp loss – contralateral beating nystagmus
Avellis’		9th - 10th - CST	9th + 10th palsy Crossed hemiplegia
Jackson		9th - 10th - 11th - 12th - CST	9th, 10th, 11th, 12th palsy Crossed hemiplegia

Medulla

Syndrome	Vascular	Structures affected	Presentation
Wallenberg (Lateral medullary)	PICA	9th, 10th, 11th, spinal 5th LSTT, spinocerebellar tract	9th, 10th, 11th, spinal 5th palsy Ipsilateral Cerebellar ataxia Contralateral pain & temp loss.
Medial medullary		12th CN – CST – Medial lemniscus	12th palsy Crossed hemiplegia & deep sensory loss
Top of basilar	Rostral basilar	Midbrain, thalamus, temporo-occipital	Hemianopia or cortical blindness Impaired vertical gaze Loss of initiative (abulia)
Locked in		Bilateral ventral pontine lesion	Quadriplegic – intact consciousness – aphasia – preserved vertical eye movement and blinking

Notes

There is a lot of overlap between brainstem syndromes; presented here are the main characteristic.
Supranuclear upgaze paralysis: means loss of voluntary upgaze but preserved with doll’s head maneuver.
AICA vs PICA: AICA involves ipsilateral facial weakness and hearing loss.

Ahmed Koriesh, MD