Localization of paralysis in stroke

What do you need to know about the paralysis of your patient to shorten the list of possible stroke locations?

  • Is the paralysis proportionately affecting arm and leg (brachiocrural) or more brachially or crurally or even a monoparesis?
  • Does it affect proximal or distal muscles or both?
  • How much and in what form is the face affected? Is the face afflicted during volontary and/or emotional innervation?
  • Is it purely motor? Is an associated sensory disturbance ipsi- or contralateral? Dissociated?
  • What cranial nerves are involved?

We discuss the anatomy of the corticospinal and corticobulbar (in particular the corticofacial) tracts, moving through the various levels

  • Cortical: primary motor cortex, sensory cortex, premotor cortex
  • Subcortical
  • Internal capsule
  • Cerebral peduncle
  • Pons
  • Medulla

We spend some time on the anatomy of the internal capsule – here, the centuries-old descriptions have been reconfirmed in tractography studies.

Some pearls

  • Monoparesis is rarely if ever capsular or subcapsular.
  • Pure motor proportionate paralysis tends to be capsular.

As for references, I highly recommend Brazis’ Localization book (the first chapter), complemented by the recently edited Stroke Syndromes book (aka the bible).

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