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Given the complexity of this request (CVA long case assessment + all 12 cranial nerves with courses + LMN/UMN differentiation), I'll build this as a comprehensive, structured guide. Let me search the medical library in parallel across all major sections.

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Now I have enough from textbooks to deliver a thorough, structured guide. Here it is:

CVA (Cerebrovascular Accident) - Complete Long Case Assessment Guide

PART 1: APPROACH TO THE PATIENT (HOW TO WALK IN)

Before you touch the patient, observe:

Posture - hemiplegic posture (arm flexed, leg extended = Wernicke-Mann)
Facial asymmetry at rest (nasolabial fold flattening, drooping angle of mouth)
Gaze deviation - "patient looks toward the stroke" (frontal lobe lesion drives eyes ipsilaterally)
Drool or salivation on one side
Nasogastric tube, catheter, IV line - clues to severity
Speech attempt - dysarthria, aphasia even before formal testing
Limb posture - hemiplegia, contractures if chronic
Consciousness level - is patient alert? Following commands?

PART 2: HISTORY TAKING - DETAILED

A. Presenting Complaint

Ask about the main deficit the patient or family noticed first.

B. History of Presenting Illness (HPI)

Ask these questions specifically:

Question	What you are looking for
What happened exactly?	Nature of deficit
What were you doing when it started?	(Exertional - hemorrhage; at rest/sleep - thrombosis; sudden maximal - embolism)
Was onset sudden or gradual?	Sudden = embolism/hemorrhage; stepwise = thrombosis
Did it reach maximum immediately or progress?	Embolism = immediate max; thrombosis = may progress over hours
Duration of symptoms?	TIA <24 hours (classically <1 hour); stroke persists
Any previous similar episode that resolved?	Prior TIA = major red flag
Headache?	Severe sudden "thunderclap" = SAH; moderate/progressive = hemorrhage
Loss of consciousness?	Hemorrhage, posterior circulation
Seizure at onset?	Hemorrhage more likely
Vomiting?	Raised ICP, posterior fossa, hemorrhage
Neck stiffness?	SAH, meningitis

Specific deficits to ask about:

Weakness of face/arm/leg (which side?)
Numbness/tingling (same or opposite side to weakness?)
Difficulty speaking - can they understand but not speak (Broca's)? Can they speak but not understand (Wernicke's)?
Slurred speech (dysarthria - bilateral cortical or posterior fossa)
Swallowing difficulty (dysphagia - posterior circulation, bilateral)
Vision change - blurred in one eye (amaurosis fugax = ICA), loss of half visual field (homonymous hemianopia), double vision (brainstem)
Dizziness/vertigo (posterior circulation)
Incoordination/unsteady gait (cerebellar)
Headache location and character

C. Past Medical History

Ask specifically about each:

Hypertension - duration, control, medications, compliance
Diabetes mellitus - duration, control, HbA1c if known
Atrial fibrillation - known? on anticoagulation?
Valvular heart disease - rheumatic, prosthetic valve
Ischemic heart disease / MI - increases cardioembolic risk
Previous TIA or stroke - where, when, any residual
Hyperlipidemia - on statins?
Carotid artery disease - known carotid bruit, stenosis, endarterectomy
Peripheral vascular disease
Migraine with aura (risk factor, can mimic stroke)
Coagulopathy - antiphospholipid syndrome, Factor V Leiden, protein C/S deficiency

D. Drug History

Anticoagulants - warfarin (INR?), DOACs
Antiplatelets - aspirin, clopidogrel
Antihypertensives - compliance?
OCP / HRT - in women (increases risk)
Statins
Any recent drug changes

E. Social History

Smoking - pack-years
Alcohol - units per week (heavy alcohol - hemorrhage risk)
Recreational drugs - cocaine (vasospasm), amphetamines
Occupation - important for disability assessment
Handedness - which is dominant (for aphasia localization)
Living situation - alone? stairs? home modifications needed?
Who is carer? Any dependents?

F. Family History

Stroke, MI, hypertension, diabetes, hyperlipidemia in first-degree relatives
Young family members with stroke (think CADASIL, MELAS, antiphospholipid)

G. Systems Review (Important Negatives to Ask)

No chest pain / palpitations (AF, MI)
No recent head trauma (subdural)
No fever / neck stiffness (meningitis, endocarditis)
No weight loss (malignancy with hypercoagulable state)
No recent surgery / immobility (DVT/PE)
No oral contraceptive use

PART 3: EXAMINATION - SYSTEMATIC APPROACH

Step 1: General Examination (before neurological)

Vitals: BP both arms (difference >20 mmHg = aortic dissection), HR (irregular = AF), SpO2, temperature
Cardiovascular: irregular rhythm (AF), murmurs (valvular source of emboli), carotid bruits
Signs of risk factors: xanthelasma, corneal arcus (hyperlipidemia), fundal changes (hypertensive retinopathy)
Neck: carotid bruit (auscultate lightly, both sides)

Step 2: Level of Consciousness

Use GCS (E+V+M) or describe alert/drowsy/stuporous/comatose

Step 3: Higher Mental Functions

Orientation - time, place, person
Aphasia testing:
- Ask to name objects (anomia)
- Ask to follow commands ("close your eyes, touch your nose")
- Listen to spontaneous speech - fluent or non-fluent?
- Ask to repeat a phrase ("no ifs, ands, or buts")
Attention - serial 7s or days of week backwards
Memory - immediate and delayed recall
Neglect - line bisection, bilateral simultaneous stimulation
Apraxia - "show me how to comb your hair"
Agnosia - recognizing objects by touch or sight

Step 4: Cranial Nerve Examination (detailed below - see Part 4)

Step 5: Motor System

Examine in this order:

Inspection:

Wasting/atrophy (LMN or chronic)
Fasciculations (LMN - anterior horn)
Posture - hemiplegic posture

Tone:

Passive movement of limbs
UMN = spasticity (velocity-dependent increase, clasp-knife)
LMN = flaccidity
Test upper limbs: pronate/supinate, flex/extend wrist and elbow
Test lower limbs: roll leg on bed, sudden knee flexion (watch heel rise)

Power (MRC grading 0-5):

Test in a pyramidal distribution pattern:
- UMN weakness: upper limb extensors and lower limb flexors are weaker
- Upper limb: shoulder abduction, elbow extension, wrist extension, finger extension, finger spread
- Lower limb: hip flexion, knee flexion, ankle dorsiflexion

Reflexes:

Biceps (C5,6), Triceps (C7), Supinator (C5,6)
Knee (L3,4), Ankle (S1,2)
UMN = hyperreflexia + clonus
LMN = hyporeflexia/absent

Plantar response (Babinski):

Stroke lateral sole from heel forward
Normal = flexion (toes flex)
UMN lesion = extension (big toe up, other toes fan out) = positive Babinski

Coordination:

Finger-nose test (cerebellar - ipsilateral limb ataxia)
Heel-shin test
Rapid alternating movements (dysdiadochokinesia)

Step 6: Sensory System

Light touch (cotton wool)
Pinprick (spinothalamic - contralateral to lesion)
Vibration (posterior column - may be contralateral with thalamic/cortical lesion)
Proprioception (position sense)
Cortical sensation: two-point discrimination, graphesthesia, stereognosis
Hemibody sensory loss contralateral to lesion (thalamic or cortical)
Dissociated sensory loss in brainstem syndromes

Step 7: Gait (if able)

Circumduction gait (hemiplegic)
Ataxic gait (cerebellar)
Tandem gait

PART 4: CRANIAL NERVE EXAMINATION - EACH NERVE IN DETAIL

CN I - OLFACTORY NERVE

Memory hook: "ONE nose, ONE smell" - purely sensory, no motor

Course: Olfactory receptor cells in nasal mucosa → olfactory filia pass through cribriform plate of ethmoid → synapse in olfactory bulb → olfactory tract → primary olfactory cortex (uncus of temporal lobe) - bypasses thalamus (unique among CNs)

Clinical test:

Close eyes, occlude one nostril
Ask to identify mild smell (coffee, vanilla, peppermint)
NOT ammonia - it stimulates trigeminal, not olfactory

What to ask in history:

Loss of smell (anosmia)?
Distorted smell (parosmia)?
Smell hallucinations (uncinate fits - temporal lobe)?

Findings in CVA: Not typically affected in MCA stroke; uncal herniation may compress it

Abnormalities:

Anosmia - cribriform plate fracture, meningioma, Parkinson's, COVID

CN II - OPTIC NERVE

Memory hook: "TWO eyes see" - purely sensory

Course: Retinal ganglion cells → optic nerve → optic chiasm (nasal fibers cross, temporal stay ipsilateral) → optic tract → lateral geniculate nucleus (thalamus) → optic radiation → primary visual cortex (occipital lobe, calcarine cortex)

Clinical test:

Visual acuity: Snellen chart, each eye separately (with glasses)
Color vision: Ishihara plates (optic neuritis - early color loss)
Visual fields by confrontation: Examiner faces patient ~60 cm away, compare each quadrant, both eyes separately and together
Fundoscopy: optic disc (papilledema, pallor), retinal vessels (AV nicking, hemorrhages in hypertension)
Pupillary light reflex (see CN III below) - afferent limb is CN II

What to ask in history:

Sudden painless monocular blindness (amaurosis fugax = TIA of retinal artery)?
Visual field loss?
Blurred vision?

Visual field defects and localization:

Lesion site	Field defect
Optic nerve (unilateral)	Monocular blindness
Optic chiasm	Bitemporal hemianopia
Optic tract	Contralateral homonymous hemianopia
Temporal optic radiation	Superior quadrantanopia ("pie in the sky")
Parietal optic radiation	Inferior quadrantanopia ("pie on floor")
Occipital cortex	Homonymous hemianopia with macular sparing

In CVA: MCA infarct → contralateral homonymous hemianopia. PCA infarct → hemianopia with macular sparing

CN III - OCULOMOTOR NERVE

Memory hook: "III does most, EXCEPT SO4 and LR6" (Superior Oblique = CN IV, Lateral Rectus = CN VI)

Course: Oculomotor nucleus in midbrain (at level of superior colliculus) → passes through red nucleus → exits midbrain between PCA and SCA → runs along tentorium → enters cavernous sinus → superior orbital fissure → orbit → parasympathetic fibers travel on outside (important clinically)

Muscles supplied: SR, MR, IR, IO (all except SO and LR), levator palpebrae

Parasympathetic: Edinger-Westphal nucleus → pupil constriction, lens accommodation

Clinical test:

Inspect: ptosis? pupil size and symmetry?
Pupillary light reflex: direct and consensual
Test all eye movements in H-pattern: ask patient to follow your finger
Accommodation: ask patient to follow finger moving toward nose (pupils constrict)

What to ask in history:

Drooping eyelid (ptosis)?
Double vision (diplopia)?
Which direction is worse?

Key clinical distinction:

Surgical CN III palsy (compressive - aneurysm): pupil DILATED and unreactive (parasympathetics on outside compressed first); ptosis + eye "down and out"
Medical CN III palsy (diabetes, hypertension - ischemia): pupil SPARED (ischemia affects central fibers, spares outer parasympathetics); ptosis + "down and out" but normal pupil

In CVA: Ipsilateral CN III palsy + contralateral hemiplegia = Weber syndrome (midbrain)

CN IV - TROCHLEAR NERVE

Memory hook: "SO4 - Superior Oblique, CN4" / "Trochlear wraps around like a pulley (trochlea)"

Course: Only CN to exit from dorsal aspect of brainstem; decussates in the anterior medullary velum; longest intracranial course; exits midbrain → passes around to orbit

Muscle supplied: Superior oblique → intorts and depresses the eye (most important action when eye is adducted)

Clinical test:

Ask patient to look down and in
Patient complains of vertical diplopia, worse going down stairs or reading
Head tilt test: patient tilts head to opposite shoulder to compensate

What to ask in history:

Vertical double vision?
Difficulty reading or going down stairs?

In CVA: Midbrain infarct; often isolated CN IV palsy is from trauma

CN VI - ABDUCENS NERVE

Memory hook: "LR6 - Lateral Rectus, CN6" / "Six abducts, six-pack = lateral"

Course: Nucleus in pons → long course through subarachnoid space → tip of petrous temporal bone (vulnerable to raised ICP - false localizing sign) → cavernous sinus → superior orbital fissure → lateral rectus

Clinical test:

Ask patient to look laterally to affected side - eye cannot abduct
Results in convergent squint (esotropia) at rest
Horizontal diplopia, worse on gaze toward affected side

What to ask in history:

Horizontal double vision?

In CVA: Pontine infarct → ipsilateral CN VI palsy + contralateral hemiplegia = Millard-Gubler syndrome

CN V - TRIGEMINAL NERVE

Memory hook: "FIVE branches for Face sensation; V1 V2 V3 = Ophthalmic Maxillary Mandibular. Motor = Mastication Muscles"

Course:

Sensory: peripheral receptors → trigeminal ganglion (Gasserian, in Meckel's cave) → 3 branches → brainstem
- V1 (ophthalmic): forehead, cornea, upper nose
- V2 (maxillary): cheek, upper lip, upper teeth, palate
- V3 (mandibular): lower jaw, lower teeth, anterior 2/3 tongue sensation
Motor: motor nucleus in mid-pons → V3 → muscles of mastication (masseter, temporalis, pterygoids, tensor tympani, tensor veli palatini, anterior digastric, mylohyoid)

Clinical test:

Sensation: test all 3 divisions with cotton wool and pinprick on each side of face
Corneal reflex: afferent CN V1 → efferent CN VII; touch cornea lightly with wisp of cotton → bilateral blink
Motor: ask to clench teeth (palpate masseter), open jaw against resistance; if pterygoid weak, jaw deviates to weak side
Jaw jerk: tap on chin with jaw relaxed; exaggerated in bilateral UMN lesion (pseudobulbar palsy)

What to ask in history:

Facial numbness (which part)?
Facial pain (trigeminal neuralgia)?
Difficulty chewing?
Loss of taste in tongue (anterior 2/3 - chorda tympani from CN VII passes through V3 territory but not V itself)

CN VII - FACIAL NERVE

Memory hook: "Seven = Face moves; B: Bell's palsy, BELLS mnemonic: Brow, Eye, Lip, Lower face, Smile"

Course: Motor nucleus in pons → nerve loops around CN VI nucleus (forming facial colliculus) → exits at cerebellopontine angle → internal auditory meatus → facial canal (petrous temporal bone) → gives off: Greater petrosal nerve (lacrimation), Nerve to stapedius, Chorda tympani (taste anterior 2/3 tongue + submandibular/sublingual glands) → exits via stylomastoid foramen → parotid gland → terminal branches (temporal, zygomatic, buccal, marginal mandibular, cervical)

Clinical test:

Upper face: raise eyebrows (frontalis), wrinkle forehead, close eyes tightly (orbicularis oculi)
Lower face: show teeth (buccinator), puff cheeks, blow out cheeks, smile
Taste anterior 2/3 tongue (if needed)
Corneal reflex efferent limb

THE MOST IMPORTANT CLINICAL DISTINCTION IN CVA:

Feature	UMN Lesion (stroke)	LMN Lesion (Bell's palsy)
Forehead	SPARED (wrinkle preserved)	INVOLVED (cannot wrinkle)
Eye closure	Weak but can close	Cannot close at all (lagophthalmos)
Lower face	Weak (nasolabial fold flat, drooping)	Weak
Site	Contralateral cortex/internal capsule	Ipsilateral nerve/nucleus
Taste	Normal	May be lost (if lesion proximal to chorda tympani)
Lacrimation	Normal	May be reduced
Hyperacusis	Absent	Present (if nerve to stapedius affected)

Why is the forehead spared in UMN lesion? The frontalis (upper face) has bilateral cortical representation - both hemispheres supply it. So a unilateral cortical lesion still has input from the opposite side. Lower face has predominantly contralateral representation only.

CN VIII - VESTIBULOCOCHLEAR NERVE

Memory hook: "Eight = hearing and balance - two components" (Cochlear + Vestibular)

Course: Cochlear: hair cells of organ of Corti → spiral ganglion → cochlear nerve → cochlear nuclei in pons → bilateral representation above brainstem → auditory cortex (Heschl's gyrus, temporal lobe); Vestibular: hair cells in semicircular canals/utricle/saccule → vestibular ganglion → vestibular nuclei in pons/medulla

Clinical test:

Cochlear: whispered numbers in each ear (occlude other ear), Rinne (AC > BC = normal or SNHL; BC > AC = CHL), Weber (lateralizes to deaf ear = CHL; lateralizes to good ear = SNHL)
Vestibular: Romberg test (eyes open OK, eyes closed falls = posterior column or vestibular), HINTS exam (Head Impulse, Nystagmus, Test of Skew) for central vs peripheral vertigo, Dix-Hallpike

What to ask in history:

Deafness?
Tinnitus?
Vertigo (spinning)?
Unsteadiness?

In CVA: Lateral medullary (Wallenberg) syndrome - loss of pain/temp from ipsilateral face + contralateral body, dysphagia, vertigo, Horner's, ipsilateral limb ataxia

CN IX - GLOSSOPHARYNGEAL NERVE

Memory hook: "Nine = taste posterior 1/3 tongue + gag reflex afferent"

Course: Nucleus ambiguus + nucleus tractus solitarius in medulla → exits medulla → jugular foramen → supplies: stylopharyngeus (only motor), sensation posterior 1/3 tongue (taste and touch), pharynx (sensory), carotid sinus and body (baroreceptor afferents)

Clinical test:

Gag reflex (afferent CN IX, efferent CN X)
Ask about taste at back of tongue
Usually tested with CN X together

What to ask in history:

Difficulty swallowing?
Loss of taste at back of throat?
Throat pain?

CN X - VAGUS NERVE

Memory hook: "Vagus = Wandering nerve (latin: vagare = wander) - goes everywhere. Gag efferent, speech, swallowing, heart rate, gut"

Course: Dorsal motor nucleus (parasympathetics) + nucleus ambiguus (motor) + NTS (sensory) in medulla → jugular foramen → pharyngeal plexus → branches: superior laryngeal nerve (cricothyroid - pitch), recurrent laryngeal nerve (all other laryngeal muscles) → descends into thorax and abdomen (heart, lungs, gut to splenic flexure)

Clinical test:

Listen to voice: hoarse? (RLN palsy)
Ask to say "Aah" and watch palate rise - unilateral palsy = palate pulled to normal side (uvula deviates away from lesion)
Gag reflex
Swallowing - ask to swallow water

What to ask in history:

Hoarse voice?
Difficulty swallowing (dysphagia)?
Coughing or choking when drinking?
Change in voice?

In CVA (Wallenberg): Ipsilateral palate palsy, dysphagia, hoarseness

CN XI - ACCESSORY NERVE (SPINAL ACCESSORY)

Memory hook: "11 = Two muscles, two letters: SCM + Trapezius" / "Turn to TRAP, Shrug your SCM" (SCM turns head, trapezius shrugs)

Course: Spinal nucleus (C1-C5 anterior horn) → ascends through foramen magnum → joins cranial root briefly → exits via jugular foramen → supplies sternocleidomastoid (SCM) and trapezius

Clinical test:

SCM: ask patient to turn head against resistance - test SCM contralateral to direction of turn; in CVA, contralateral head turn weakened
Trapezius: ask patient to shrug shoulders against resistance; look for shoulder drop, winging of scapula
Inspect for wasting of either muscle

What to ask in history:

Difficulty turning head?
Shoulder weakness or pain?
Dropping shoulder?

In CVA: Contralateral weakness of SCM; ipsilateral weakness in nuclear/nerve lesion

CN XII - HYPOGLOSSAL NERVE

Memory hook: "12 = Tongue moves (hypoglossal). LICK the TWELVE" / "Tongue deviates TOWARD the lesion in LMN"

Course: Hypoglossal nucleus in medulla (floor of 4th ventricle) → exits medulla in pre-olivary sulcus → hypoglossal canal → under the tongue → intrinsic and extrinsic tongue muscles (genioglossus = main)

Clinical test:

Inspect tongue at rest on floor of mouth - wasting? fasciculations? (LMN)
Ask to protrude tongue: deviates toward weak side
Ask to push tongue into cheek and resist examiner's finger
Rapid movements: "la la la" (tongue), "pa pa pa" (lips/CN VII), "ka ka ka" (palate/CN X)

What to ask in history:

Slurred speech (dysarthria)?
Difficulty with eating and food manipulation in mouth?

UMN vs LMN:

UMN (CVA): tongue deviates CONTRALATERAL to lesion side (toward paralyzed side), no wasting, no fasciculations
LMN (nuclear/nerve): tongue deviates TOWARD lesion (toward the wasted side), wasting, fasciculations

PART 5: UMN vs LMN LESION - COMPLETE TABLE AND CLINICAL DIFFERENTIATION

The Classic Comparison

Feature	UMN Lesion	LMN Lesion
Weakness	Yes	Yes
Atrophy/Wasting	No (mild disuse only)	Yes (prominent, early)
Fasciculations	No	Yes (spontaneous twitching)
Tone	Increased (spasticity)	Decreased (flaccidity)
Reflexes	Increased (hyperreflexia)	Decreased/absent
Clonus	Present	Absent
Babinski	Positive (extensor plantar)	Absent (flexor plantar normal)
Distribution	Pyramidal pattern (whole limb)	Individual muscle groups / nerve distribution
Speed of onset	May be acute flaccid → later spastic	Usually flaccid from start

Important Caveat - ACUTE UMN (Spinal Shock / Early Stroke):

In the first hours to days after acute UMN lesion (e.g., fresh stroke), tone and reflexes are DECREASED, not increased - this is called "cerebral shock" or spinal shock
Over days to weeks, spasticity and hyperreflexia develop
Do not dismiss a diagnosis of UMN stroke just because reflexes are initially normal or reduced

Where is the Lesion?

Location	Type	Key Features
Motor cortex / corona radiata	UMN	Contralateral hemiparesis, may spare face
Internal capsule	UMN	Contralateral hemiplegia + hemisensory loss
Brainstem	Mixed	Ipsilateral CN palsy + contralateral hemiplegia = crossed syndrome
Spinal cord	UMN (below lesion)	Bilateral weakness, sensory level
Anterior horn cell	LMN	Weakness + wasting + fasciculations
Peripheral nerve	LMN	Follows nerve distribution
Neuromuscular junction	Neither	Fatigable weakness, no sensory
Muscle	Myopathic	Proximal weakness, no sensory loss, no reflex change early

Bedside Differentiation in Clinic

Step 1: Look - Is there wasting? Fasciculations? Posture?

Wasting + fasciculations = LMN
Hemiplegic posture (arm flexed, leg extended) = chronic UMN

Step 2: Tone - Is it increased or decreased?

Spasticity (clasp-knife, velocity-dependent) = UMN
Flaccidity = LMN or acute UMN

Step 3: Reflexes - Are they brisk or absent?

Brisk with spread (e.g., tapping patella also causes adductor jerk) = UMN
Absent = LMN

Step 4: Plantar - Up or down?

Extensor = UMN

Step 5: Distribution - Whole limb pyramidal pattern or individual nerve/root?

Pyramidal (extensors of arm weaker, flexors of leg weaker) = UMN
Dermatomal/myotomal = LMN (root), nerve territory = LMN (peripheral nerve)

PART 6: KEY CRANIAL NERVE COURSES - QUICK MEMORY TABLE

CN	Origin	Memory Hook	Key Exit	Key Clinical Point
I	Olfactory mucosa	"Cribriform = smell sieve"	Cribriform plate	Anosmia after head injury
II	Retina	"Optic = eye to brain"	Optic canal	Afferent pupil defect (RAPD)
III	Midbrain	"Three = most eye movements"	Superior orbital fissure	Pupil on outside: surgical vs medical palsy
IV	Dorsal midbrain	"Four = only dorsal exit"	Superior orbital fissure	Vertical diplopia, head tilt
V	Pons	"Five = face feeling"	Foramen rotundum (V2), foramen ovale (V3)	Corneal reflex afferent
VI	Pons	"Six = lateral look"	Superior orbital fissure	False localizing sign in raised ICP
VII	Pontomedullary junction	"Seven = smile/frown"	Stylomastoid foramen	UMN spares forehead; LMN involves all
VIII	Pons/medulla	"Eight = ear"	Internal auditory meatus	Rinne/Weber
IX	Medulla	"Nine = gag afferent"	Jugular foramen	Posterior tongue taste
X	Medulla	"Ten = wanders everywhere"	Jugular foramen	Uvula deviates away from lesion
XI	Medulla + C1-C5	"Eleven = SCM + Trap"	Jugular foramen	Shoulder shrug = CN XI
XII	Medulla	"Twelve = tongue"	Hypoglossal canal	Deviates TOWARD LMN lesion

PART 7: IMPORTANT CVA SYNDROMES AND WHAT TO LOOK FOR

Syndrome	Vessel	Key Findings
MCA territory	Middle cerebral artery	Contralateral hemiplegia (face/arm > leg), hemianesthesia, homonymous hemianopia; left = aphasia; right = neglect
ACA territory	Anterior cerebral artery	Contralateral leg > arm weakness, incontinence
PCA territory	Posterior cerebral artery	Homonymous hemianopia with macular sparing, thalamic pain, ±CN III palsy
Lacunar	Perforators	Pure motor (internal capsule), pure sensory (thalamus), ataxic hemiparesis, dysarthria-clumsy hand
Weber's (midbrain)	Basilar branches	Ipsilateral CN III palsy + contralateral hemiplegia
Millard-Gubler (pons)	Basilar branches	Ipsilateral CN VI + VII palsy + contralateral hemiplegia
Wallenberg (lateral medulla)	PICA	Ipsilateral: facial pain/temp loss, ataxia, Horner's, dysphagia; Contralateral: body pain/temp loss; NO hemiplegia
Benedikt's (midbrain tegmentum)	Basilar	Ipsilateral CN III + contralateral tremor/ataxia

PART 8: NEGATIVE HISTORY AND EXAMINATION - WHAT EXAMINERS EXPECT YOU TO STATE

Negative history points to mention:

No seizures at onset
No preceding headache / thunderclap headache (arguing against SAH)
No fever (against infectious/inflammatory)
No neck stiffness (against SAH/meningitis)
No visual loss before onset (against TIA-preceding event missed)
No cardiac symptoms (palpitations = AF)
No history of anticoagulant use / missed doses
No trauma

Negative examination findings to document:

No papilledema (against raised ICP)
No neck stiffness/Kernig's/Brudzinski (against SAH)
No carotid bruit on contralateral side
No cardiac murmurs suggesting valvular disease
No peripheral stigmata of infective endocarditis (splinter hemorrhages, Osler nodes, Janeway lesions)
No DVT signs (against cardiac embolism from DVT/PFO)
Contralateral limbs normal
Cognition preserved in contralateral domain (e.g., if left MCA - right hemisphere functions intact)
Bladder/bowel control intact (or note incontinence if present)

Sources: Adams and Victor's Principles of Neurology 12E; Neuroanatomy through Clinical Cases 3rd Edition (Blumenfeld); Bradley and Daroff's Neurology in Clinical Practice; Harrison's Principles of Internal Medicine 22E; Goldman-Cecil Medicine

---Here is your complete CVA long case guide - everything is above, but let me give you a clean summary of how it is organized so you can navigate it:

GUIDE STRUCTURE SUMMARY

The full guide above has 8 Parts:

Part 1 - How to Walk In: What to observe before you say a word - posture, gaze deviation, facial asymmetry, equipment in the room.

Part 2 - History Taking: Detailed questions for the presenting complaint (onset timing, progression, specific deficits), past medical history (HTN, DM, AF, valvular disease, TIA), drug history, social history, family history, and a list of important negative history points you must actively ask about.

Part 3 - Examination: Step-by-step from vitals/cardiovascular → consciousness (GCS) → higher mental functions (aphasia testing) → motor (inspection, tone, power, reflexes, Babinski, coordination) → sensory → gait.

Part 4 - All 12 Cranial Nerves: For each nerve:

Course from origin to end
Memory hook to remember it
Exactly what to test clinically
What history questions to ask
Relevant CVA findings

The most exam-critical CN point: CN VII (facial) - in a UMN (stroke) lesion the forehead is SPARED because the frontalis has bilateral cortical representation. In LMN (Bell's palsy) the entire face including forehead is involved. Examiners always ask this.

Part 5 - UMN vs LMN Table: Complete comparison with the acute UMN caveat (early stroke can be flaccid/hyporeflexic - do not miss it), plus a 5-step bedside differentiation approach.

Part 6 - Quick Cranial Nerve Course Memory Table: All 12 with foramina and key clinical point in one table.

Part 7 - CVA Syndromes: MCA, ACA, PCA, lacunar, Weber, Millard-Gubler, Wallenberg, Benedikt - what each looks like.

Part 8 - Negative Findings: Specific negative history and examination points you are expected to mention in a long case to show systematic thinking.

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