Brainstem stroke syndrome

Overview

Brainstem stroke syndrome refers to a group of clinical conditions caused by interrupted blood flow to the brainstem, the area of the brain that connects the cerebrum to the spinal cord. The brainstem controls many vital functions, including breathing, heart rate, blood pressure, balance, and consciousness, as well as sensory and motor pathways. A stroke in this region can result in severe neurological deficits or death, depending on the location and extent of the damage. Brainstem strokes may be ischemic (caused by blockage of blood flow) or hemorrhagic (caused by bleeding).

Causes

Brainstem stroke syndrome occurs when there is a disruption of blood supply to the brainstem. Common causes include:

• Ischemic stroke – due to blood clots or narrowing of arteries supplying the brainstem, such as the basilar artery or vertebral arteries

• Hemorrhagic stroke – caused by rupture of a blood vessel, often due to hypertension or aneurysm

• Atherosclerosis – buildup of plaque in the arteries reducing blood flow

• Embolism – a clot or debris traveling from the heart or other vessels to the brainstem

• Arterial dissection – tearing of an artery wall, particularly in younger patients

• Small vessel disease – affecting perforating arteries in the brainstem

Symptoms

The symptoms of a brainstem stroke can vary widely based on the specific area of the brainstem involved (midbrain, pons, or medulla) and whether the stroke is unilateral or bilateral. Common symptoms include:

• Dizziness or vertigo

• Double vision or loss of vision

• Difficulty speaking (dysarthria) or swallowing (dysphagia)

• Facial weakness or numbness

• Weakness or paralysis in the limbs – can be one-sided or affect all four limbs

• Loss of coordination and balance (ataxia)

• Altered consciousness or coma

• Respiratory difficulties – in severe cases due to involvement of the respiratory centers

• Locked-in syndrome – a rare but devastating outcome involving paralysis of all voluntary muscles except those that control eye movement, with preserved consciousness

Diagnosis

Prompt diagnosis of brainstem stroke is critical for timely treatment. Diagnostic tools and steps include:

• Neurological examination – assessing cranial nerve function, reflexes, strength, and coordination

• Magnetic Resonance Imaging (MRI) – especially diffusion-weighted imaging (DWI) to detect ischemic changes in the brainstem

• Computed Tomography (CT) scan – to quickly assess for hemorrhage or mass effect

• CT angiography or MR angiography – to visualize blood vessels and detect blockages or dissections

• Electrocardiogram (ECG) and echocardiography – to evaluate cardiac sources of emboli

• Blood tests – including clotting profile, glucose, lipid levels, and inflammatory markers

Treatment

Treatment of brainstem stroke depends on the cause (ischemic or hemorrhagic), severity, and time of presentation. Management may include:

• Ischemic stroke treatment:

  • Thrombolytic therapy (tPA) – if given within the treatment window (usually 4.5 hours from symptom onset)

  • Mechanical thrombectomy – in certain cases to remove a clot from a large artery

  • Antiplatelet or anticoagulant medications – to prevent further clotting

• Hemorrhagic stroke treatment:

  • Blood pressure control and reversal of anticoagulation

  • Surgical intervention if indicated (e.g., to relieve pressure or repair aneurysms)

• Supportive care:

  • Airway management and ventilation if breathing is compromised

  • Feeding support via nasogastric or PEG tube for dysphagia

  • Rehabilitation – including physical, occupational, and speech therapy

Prognosis

The prognosis for brainstem stroke syndrome varies depending on the location, size, and type of stroke, as well as the timeliness of treatment. Some patients recover with minimal deficits, especially with early intervention and rehabilitation. However, severe strokes involving the brainstem can lead to profound disability, including locked-in syndrome, or may be fatal. Long-term outcomes also depend on the presence of complications such as aspiration pneumonia, recurrent stroke, and secondary infections. With advances in acute stroke care and rehabilitation, functional recovery is possible, though many patients require long-term support and follow-up care.