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Capsular and Pontine Warning Syndromes

Learning objectives

  • Understand what is the Capsular Warning Syndrome
  • Understand the clinical presentation
  • Know the characteristic radiological and other features
  • Understand current management


  • CWS was first described by Donnan in 1993
  • Repeated sensory and/or motor symptoms affecting at least two of the face, arm and leg, without cortical signs
  • Recurrent stereotyped lacunar TIAs with increased risk of developing stroke


  • Exact aetiology of the syndrome not clear
  • Presumed angiopathy of a lenticulostriate artery.
  • Might be large vessel syndrome restricting flow to perforator vessels
  • Possibly seen with pontine perforators too (pontine warning syndrome)
  • crescendo episodes of ischaemia restricted to the region of the internal capsule
  • Usually causing symptoms affecting face, arm, and leg.
  • Small vessel disease associated with hypertension, diabetes mellitus, and dyslipidemia


  • Repeated sensory and/or motor symptoms affecting at least two of the face, arm and leg, without cortical signs
  • Pontine warning syndrome : gaze palsies, dysarthria and ataxic hemiparesis


  • FBC, U&E, LFTs, Glucose, lipids
  • CT/CTA as needed
  • Carotid doppler
  • MRI may show a lacunar infarct in the internal capsule or the corona radiata. With a pontine warning syndrome evidence of infarction involving pontine corticospinal and sensory tracts may be seen
  • Consider MRA to look for vascular stenosis
  • EEG if seizure suspected

Differentials of repeated stereotypical negative neurology

  • Severe Carotid stenosis
  • Artery to artery embolisation
  • Migraine
  • Seizures


  • Reperfusion therapies where indicated - reperfusion of an MCA may increase flow to the lenticulostriate artery.
  • Admission to stroke unit
  • Aspirin 300 mg +/- Clopidogrel
  • Optimise BP control if hypertension and glucose control if diabetic
  • Statin to lower Cholesterol


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