1
|
Nakamura J, Nishimae T, Uchisawa H, Okada Y, Shiozaki T, Tanaka H, Ueta K, Fujita D, Tsujimoto N, Ikuno K, Shomoto K. Effects of postural-control training with different sensory reweightings in a patient with body lateropulsion: a single-subject design study. Physiother Theory Pract 2023:1-11. [PMID: 37916486 DOI: 10.1080/09593985.2023.2274943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 10/18/2023] [Indexed: 11/03/2023]
Abstract
INTRODUCTION Body lateropulsion (BL) is an active lateral tilt of the body during standing or walking that is thought to be affected by a lesion of the vestibulospinal tract (VST) and the subjective visual vertical (SVV) tilt. Interventions for BL have not been established. OBJECTIVE We examined the effects of postural-control training with different sensory reweighting on standing postural control in a patient with BL. METHODS The patient had BL to the left when standing or walking due to a left-side medullary and cerebellar infarct. This study was a single-subject A-B design with follow-up: Phase A was postural-control training with visual feedback; phase B provided reweighting plantar somatosensory information. Postural control, VST excitability, and SVV were measured. RESULTS At baseline and phase A, the patient could not stand with eyes-closed on a rubber mat, but became able to stand in phase B. The mediolateral center of pressure (COP) position did not change significantly, but the COP velocity decreased significantly during phase B and the follow-up on the firm surface. VST excitability was lower on the BL versus the non-BL side, and the SVV deviated to the right throughout the study. CONCLUSION Postural-control training with reweighting somatosensory information might improve postural control in a patient with BL.
Collapse
Affiliation(s)
- Junji Nakamura
- Department of Rehabilitation Medicine, Nishiyamato Rehabilitation Hospital, Nara, Japan
- Graduate School of Health Sciences, Kio University, Nara, Japan
| | - Takuma Nishimae
- Department of Rehabilitation Medicine, Nishiyamato Rehabilitation Hospital, Nara, Japan
| | - Hidekazu Uchisawa
- Department of Rehabilitation Medicine, Nishiyamato Rehabilitation Hospital, Nara, Japan
| | - Yohei Okada
- Graduate School of Health Sciences, Kio University, Nara, Japan
- Neurorehabilitation Research Center of Kio University, Nara, Japan
| | - Tomoyuki Shiozaki
- Department of Otolaryngology-Head and Neck Surgery, Nara Medical University, Kashihara-City, Nara, Japan
| | - Hiroaki Tanaka
- KMU Day-care Center Hirakata, Kansai Medical University Hospital, Hirakata-City, Osaka, Japan
- Department of Physical Medicine and Rehabilitation, Kansai Medical University, Osaka, Japan
| | - Kozo Ueta
- Graduate School of Health Sciences, Kio University, Nara, Japan
- Department of Rehabilitation Medicine, Shiga Hospital, Otsu-Shi, Shiga, Japan
| | - Daiki Fujita
- Department of Rehabilitation Medicine, Nishiyamato Rehabilitation Hospital, Nara, Japan
| | - Naohide Tsujimoto
- Department of Rehabilitation Medicine, Nishiyamato Rehabilitation Hospital, Nara, Japan
| | - Koki Ikuno
- Department of Rehabilitation Medicine, Nishiyamato Rehabilitation Hospital, Nara, Japan
- Graduate School of Health Sciences, Kio University, Nara, Japan
| | - Koji Shomoto
- Graduate School of Health Sciences, Kio University, Nara, Japan
| |
Collapse
|
2
|
Wüthrich M, Wang Z, Martinez CM, Carmona S, Mantokoudis G, Tarnutzer AA. Systematic review and meta-analysis of the diagnostic accuracy of spontaneous nystagmus patterns in acute vestibular syndrome. Front Neurol 2023; 14:1208902. [PMID: 37396773 PMCID: PMC10312004 DOI: 10.3389/fneur.2023.1208902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 06/05/2023] [Indexed: 07/04/2023] Open
Abstract
Objectives For the assessment of patients presenting with acute prolonged vertigo meeting diagnostic criteria for acute vestibular syndrome (AVS), bedside oculomotor examinations are essential to distinguish peripheral from central causes. Here we assessed patterns of spontaneous nystagmus (SN) observed in AVS and its diagnostic accuracy at the bedside. Methods MEDLINE and Embase were searched for studies (1980-2022) reporting on the bedside diagnostic accuracy of SN-patterns in AVS patients. Two independent reviewers determined inclusion. We identified 4,186 unique citations, examined 219 full manuscripts, and analyzed 39 studies. Studies were rated on risk of bias (QUADAS-2). Diagnostic data were extracted and SN beating-direction patterns were correlated with lesion locations and lateralization. Results Included studies reported on 1,599 patients, with ischemic strokes (n = 747) and acute unilateral vestibulopathy (n = 743) being most frequent. While a horizontal or horizontal-torsional SN was significantly more often found in peripheral AVS (pAVS) than in central AVS (cAVS) patients (672/709 [94.8%] vs. 294/677 [43.4%], p < 0.001), torsional and/or vertical SN-patterns were more prevalent in cAVS than in pAVS (15.1 vs. 2.6%, p < 0.001). For an (isolated) vertical/vertical-torsional SN or an isolated torsional SN specificity (97.7% [95% CI = 95.1-100.0%]) for a central origin etiology was high, whereas sensitivity (19.1% [10.5-27.7%]) was low. Absence of any horizontal SN was more frequently observed in cAVS than in pAVS (55.2 vs. 7.0%, p < 0.001). Ipsilesional and contralesional beating directions of horizontal SN in cAVS were found at similar frequency (28.0 vs. 21.7%, p = 0.052), whereas for pAVS a contralesional SN was significantly more frequent (95.2 vs. 2.5%, p < 0.001). For PICA strokes presenting with horizontal SN, beating direction was ipsilesional more often than contralesional (23.9 vs. 6.4%, p = 0.006), while the opposite was observed for AICA strokes (2.2 vs. 63.0%, p < 0.001). Conclusions (Isolated) vertical and/or torsional SN is found in a minority (15.1%) of cAVS patients only. When present, it is highly predictive for a central cause. A combined torsional-downbeating SN-pattern may be observed in pAVS also in cases with isolated lesions of the inferior branch of the vestibular nerve. Furthermore, in cAVS patients the SN beating direction itself does not allow a prediction on the lesion side.
Collapse
Affiliation(s)
| | - Zheyu Wang
- Division of Quantitative Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | | | - Sergio Carmona
- Fundación San Lucas para la Neurosciencia, Rosario, Argentina
| | - Georgios Mantokoudis
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Alexander Andrea Tarnutzer
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
- Department of Neurology, Cantonal Hospital of Baden, Baden, Switzerland
| |
Collapse
|
3
|
Molecular Organization and Patterning of the Medulla Oblongata in Health and Disease. Int J Mol Sci 2022; 23:ijms23169260. [PMID: 36012524 PMCID: PMC9409237 DOI: 10.3390/ijms23169260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/15/2022] [Accepted: 08/16/2022] [Indexed: 11/17/2022] Open
Abstract
The medulla oblongata, located in the hindbrain between the pons and the spinal cord, is an important relay center for critical sensory, proprioceptive, and motoric information. It is an evolutionarily highly conserved brain region, both structural and functional, and consists of a multitude of nuclei all involved in different aspects of basic but vital functions. Understanding the functional anatomy and developmental program of this structure can help elucidate potential role(s) of the medulla in neurological disorders. Here, we have described the early molecular patterning of the medulla during murine development, from the fundamental units that structure the very early medullary region into 5 rhombomeres (r7–r11) and 13 different longitudinal progenitor domains, to the neuronal clusters derived from these progenitors that ultimately make-up the different medullary nuclei. By doing so, we developed a schematic overview that can be used to predict the cell-fate of a progenitor group, or pinpoint the progenitor domain of origin of medullary nuclei. This schematic overview can further be used to help in the explanation of medulla-related symptoms of neurodevelopmental disorders, e.g., congenital central hypoventilation syndrome, Wold–Hirschhorn syndrome, Rett syndrome, and Pitt–Hopkins syndrome. Based on the genetic defects seen in these syndromes, we can use our model to predict which medullary nuclei might be affected, which can be used to quickly direct the research into these diseases to the likely affected nuclei.
Collapse
|
4
|
Liu G, Guo Y, Dang C, Peng K, Tan S, Xie C, Xing S, Zeng J. Longitudinal changes in the inferior cerebellar peduncle and lower limb motor recovery following subcortical infarction. BMC Neurol 2021; 21:320. [PMID: 34404371 PMCID: PMC8369783 DOI: 10.1186/s12883-021-02346-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 08/06/2021] [Indexed: 02/02/2023] Open
Abstract
Background The cerebellum receives afferent signals from spinocerebellar pathways regulating lower limb movements. However, the longitudinal changes in the spinocerebellar pathway in the early stage of unilateral supratentorial stroke and their potential clinical significance have received little attention. Methods Diffusion tensor imaging and Fugl-Meyer assessment of lower limb were performed 1, 4, and 12 weeks after onset in 33 patients with acute subcortical infarction involving the supratentorial areas, and in 33 healthy subjects. We evaluated group differences in diffusion metrics in the bilateral inferior cerebellar peduncle (ICP) and analyzed the correlation between ICP diffusion metrics and changes to the Fugl-Meyer scores of the affected lower limb within 12 weeks after stroke. Results Significantly decreased fractional anisotropy and increased mean diffusivity were found in the contralesional ICP at week 12 after stroke compared to controls (all P < 0.01) and those at week 1 (all P < 0.05). There were significant fractional anisotropy decreases in the ipsilesional ICP at week 4 (P = 0.008) and week 12 (P = 0.004) compared to controls. Both fractional anisotropy (rs = 0.416, P = 0.025) and mean diffusivity (rs = -0.507, P = 0.005) changes in the contralesional ICP correlated with changes in Fugl-Meyer scores of the affected lower limb in all patients. Conclusions Bilateral ICP degeneration occurs in the early phase of supratentorial stroke, and diffusion metric values of the contralesional ICP are useful indicators of affected lower limb function after supratentorial stroke. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-021-02346-x.
Collapse
Affiliation(s)
- Gang Liu
- Department of Neurology, The First Affiliated Hospital, Sun Yat-Sen University; Guangdong Provincial Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, No. 58, Zhongshan Road 2, Guangzhou, Guangdong, China.,Guangdong-Hong Kong-Macao Greater Bay Area Center for Brain Science and Brain-Inspired Intelligence, Guangzhou, Guangdong, China
| | - Yaomin Guo
- Department of Neurology, The First Affiliated Hospital, Sun Yat-Sen University; Guangdong Provincial Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, No. 58, Zhongshan Road 2, Guangzhou, Guangdong, China
| | - Chao Dang
- Department of Neurology, The First Affiliated Hospital, Sun Yat-Sen University; Guangdong Provincial Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, No. 58, Zhongshan Road 2, Guangzhou, Guangdong, China
| | - Kangqiang Peng
- Department of Medical Imaging, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Shuangquan Tan
- Department of Neurology, The First Affiliated Hospital, Sun Yat-Sen University; Guangdong Provincial Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, No. 58, Zhongshan Road 2, Guangzhou, Guangdong, China
| | - Chuanmiao Xie
- Department of Medical Imaging, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Shihui Xing
- Department of Neurology, The First Affiliated Hospital, Sun Yat-Sen University; Guangdong Provincial Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, No. 58, Zhongshan Road 2, Guangzhou, Guangdong, China
| | - Jinsheng Zeng
- Department of Neurology, The First Affiliated Hospital, Sun Yat-Sen University; Guangdong Provincial Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, No. 58, Zhongshan Road 2, Guangzhou, Guangdong, China.
| |
Collapse
|
5
|
Ramaswamy S, Rosso M, Levine SR. Body Lateropulsion in Stroke: Case Report and Systematic Review of Stroke Topography and Outcome. J Stroke Cerebrovasc Dis 2021; 30:105680. [PMID: 33652344 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105680] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 02/09/2021] [Accepted: 02/10/2021] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Body lateropulsion (BLP) is seen in neurological lesions involving the pathways responsible for body position and verticality. We report a case of isolated body lateropulsion (iBLP) as the presentation of lateral medullary infarction and conducted a systematic literature review. METHODS MEDLINE and EMBASE databases were searched up to December 3, 2020. INCLUSION CRITERIA age ≥ 18, presence of BLP, confirmed stroke on imaging. EXCLUSION CRITERIA age < 18, qualitative reviews, studies with inadequate patient data. Statistical analysis was performed using IBM® SPSS® Statistics 20. RESULTS A 64-year-old man presented with acute-onset iBLP. Brain MRI demonstrated acute infarction in the right caudolateral medulla. His symptoms progressed with ipsilateral Horner syndrome over the next 24 hours and contralateral hemisensory loss 10 days later. Repeat MRI showed an increase in infarct size. BLP resolved partially at discharge. Systematic review: 418 abstracts were screened; 59 studies were selected reporting 103 patients. Thirty-three patients had iBLP (32%). BLP was ipsilateral to stroke in 70 (68%) and contralateral in 32 (32%). The most common stroke locations were medulla (n = 63, 59%), pons (n = 16, 15%), and cerebellum (n = 16, 15%). Four strokes were cortical, 3 frontal and 1 temporoparietal (3%). The most common etiology was large-artery atherosclerosis (LAA) in 20 patients (32%), followed by small-vessel occlusion in 12 (19%). Seventeen (27%) had large-vessel occlusion (LVO), 12 involving the vertebral artery. Sixty (98%) had some degree of resolution of BLP; complete in 41 (70%). Median time-to-resolution was 14 days (IQR 10-21). There was no relationship between time-to-resolution and age, sex, side of BLP or side of stroke. CONCLUSION BLP was commonly seen with medullary infarction and was the isolated finding in one-third. LAA and LVO were the most common etiologies. Recovery of BLP was early and complete in most cases.
Collapse
Affiliation(s)
- Srinath Ramaswamy
- Department of Neurology, SUNY Downstate Health Sciences University, Brooklyn, NY 11203, USA.
| | - Michela Rosso
- Department of Neurology, SUNY Downstate Health Sciences University, Brooklyn, NY 11203, USA.
| | - Steven R Levine
- Departments of Neurology and Emergency Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY 11203, USA; Jaffe Stroke Center, Maimonides Medical Center, Brooklyn, NY 11219, USA; Department of Neurology, King's County Hospital Center, Brooklyn, NY 11203, USA.
| |
Collapse
|
6
|
Naoi T, Morita M, Kosami K, Mashiko T, Kameda T, Okada S, Hayashi Y, Kawakami T, Tanaka R, Fujimoto S. Clinical Characteristics and Clinical Course of Body Lateropulsion in 47 Patients with Brainstem Infarctions. J Stroke Cerebrovasc Dis 2020; 29:105183. [PMID: 32912551 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 07/17/2020] [Accepted: 07/19/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND In patients with lower lateral medullary infarction (LMI) located under the vestibular nucleus, proprioceptive impairment due to dorsal spinocerebellar tract (DSCT) is considered a pathological condition for body lateropulsion. In patients with brainstem infarction located at or above the level of the vestibular nucleus, other pathways, such as the crossed vestibulothalamic tract (CVTT), are considered responsible. RESEARCH QUESTION The clinical course of body lateropulsion between each anatomical level of infarction remains unclear. Further, whether body lateropulsion refers to a static or a dynamic symptom also remains unclear. METHODS We examined 47 patients who exhibited body lateropulsion and categorized them into four groups: lower LMI under the vestibular nucleus, LMI at the level of the vestibular nucleus, pontine infarction, and midbrain infarction. The patients' time to acquire static upright standing position and gait in a straight line were statistically analyzed by a log-rank test using the Kaplan-Meier method. RESULTS Body lateropulsion in the static upright position was less frequent in the lower LMI group than in the other groups. SIGNIFICANCE Lower LMI primarily affected body lateropulsion in gait. DSCT damage could affect ipsilateral hip joint or leg coordination, causing body lateropulsion in dynamic situation.
Collapse
Affiliation(s)
- Tameto Naoi
- Rehabilitation Center, Jichi Medical University Hospital, Tochigi, Japan.
| | - Mitsuya Morita
- Rehabilitation Center, Jichi Medical University Hospital, Tochigi, Japan; Division of Neurology, Department of Medicine, Jichi Medical University, Tochigi, Japan.
| | - Koki Kosami
- Department of Public Health, Jichi Medical University, Tochigi, Japan.
| | - Takafumi Mashiko
- Division of Neurology, Department of Medicine, Jichi Medical University, Tochigi, Japan.
| | - Tomoaki Kameda
- Division of Neurology, Department of Internal Medicine, Shin-Oyama City Hospital, Tochigi, Japan.
| | - Shunich Okada
- Division of Neurology, Department of Internal Medicine, Shin-Oyama City Hospital, Tochigi, Japan.
| | - Yuka Hayashi
- Division of Neurology, Department of Internal Medicine, Shin-Oyama City Hospital, Tochigi, Japan.
| | - Tadataka Kawakami
- Division of Neurology, Department of Internal Medicine, Shin-Oyama City Hospital, Tochigi, Japan.
| | - Ryota Tanaka
- Division of Neurology, Department of Medicine, Jichi Medical University, Tochigi, Japan.
| | - Shigeru Fujimoto
- Division of Neurology, Department of Medicine, Jichi Medical University, Tochigi, Japan.
| |
Collapse
|
7
|
Kim JS, Kim SH, Lim SH, Im S, Hong BY, Oh J, Kim Y. Degeneration of the Inferior Cerebellar Peduncle After Middle Cerebral Artery Stroke: Another Perspective on Crossed Cerebellar Diaschisis. Stroke 2019; 50:2700-2707. [PMID: 31446886 DOI: 10.1161/strokeaha.119.025723] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background and Purpose- Deafferentation of the cortico-ponto-cerebellar pathway has been proposed as a key mechanism of crossed cerebellar diaschisis. Although the cerebellum receives afferent stimuli from both cortico-ponto-cerebellar and spinocerebellar pathways, evidence on whether spinocerebellar deafferentation contributes to a hypofunctional cerebellum is lacking. Therefore, we aimed to determine whether changes in the spinocerebellar pathway occur after middle cerebral artery stroke. Methods- Twenty-three patients admitted to our inpatient rehabilitation facility and 23 age-matched healthy controls were retrospectively enrolled. Patients' functional ambulation category was determined and the Medical Research Council muscle scale test of the lower limb muscles was performed at admission and discharge. The fractional anisotropy (FA) values of the corticospinal tract and the inferior cerebellar peduncle (ICP), as the final route of the dorsal spinocerebellar pathway, were compared between the groups. The FA laterality indices of the ICP and corticospinal tract were calculated as follows: (FAaffected-FAunaffected)/(FAaffected+FAunaffected). Pearson correlation analysis and multivariate linear regression models were used to determine the associations between the FA laterality indices and ambulatory function. Results- The FAs of the corticospinal tract and ICP were lower in the patient group than in the control group. The FA laterality index of the corticospinal tract was not correlated with the functional ambulation category or Medical Research Council muscle scale score at admission or discharge. The FA laterality index of the ICP at the pontomedullary junction was positively correlated with the functional ambulation category and Medical Research Council muscle scale scores of all hemiplegic lower limb muscles at admission and discharge. The FA laterality index of the ICP at the pontomedullary junction was independently associated with the functional ambulation category according to the multivariate regression models. Conclusions- ICP degeneration occurs in the subacute and early chronic phase of middle cerebral artery stroke. The lower FA laterality index of the ICP was indicative of poorer ambulatory and lower limb function.
Collapse
Affiliation(s)
- Joon Sung Kim
- From the Department of Rehabilitation Medicine (J.S.K., S.H.L., B.Y.H.), St Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon
| | - Se-Hong Kim
- Department of Family Medicine (S.-H.K.), St Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon
| | - Seong Hoon Lim
- From the Department of Rehabilitation Medicine (J.S.K., S.H.L., B.Y.H.), St Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon
| | - Sun Im
- Department of Rehabilitation Medicine, Bucheon St Mary's Hospital, College of Medicine, The Catholic University of Korea (S.I.)
| | - Bo Young Hong
- From the Department of Rehabilitation Medicine (J.S.K., S.H.L., B.Y.H.), St Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon
| | - Jeehae Oh
- Rehabilitation Medicine, Independent Scholar, Seoul, Republic of Korea (J.O.)
| | - Youngkook Kim
- Department of Rehabilitation Medicine, Yeouido St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul (Y.K.)
| |
Collapse
|
8
|
Lateral medullary infarction with cardiovascular autonomic dysfunction: an unusual presentation with review of the literature. Clin Auton Res 2018; 28:569-576. [PMID: 29368226 DOI: 10.1007/s10286-018-0502-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 01/08/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE We report an unusual case of lateral medullary infarction presenting with orthostatic hypotension with pre-syncope without vertigo or Horner's syndrome. METHODS Case report with review of the literature. RESULTS A 67-year-old man presented with pre-syncope and ataxia without vertigo. Initial brain CT and MRI were normal. Neurological evaluation revealed right-beating nystagmus with left gaze, vertical binocular diplopia, right upper-extremity dysmetria, truncal ataxia with right axial lateropulsion, and right-facial and lower extremity hypoesthesia. Bedside blood pressure measurements disclosed orthostatic hypotension. He had normal sinus rhythm on telemetry and normal ejection fraction on echocardiogram. A repeat brain MRI disclosed an acute right dorsolateral medullary infarct. Autonomic testing showed reduced heart rate variability during paced deep breathing, attenuated late phase II and phase IV overshoot on Valsalva maneuver, and a fall of 25 mmHg of blood pressure at the end of a 10-min head-up tilt with no significant change in heart rate. These results were consistent with impaired sympathetic and parasympathetic cardiovascular reflexes. He was discharged to acute rehabilitation a week later with residual right dysmetria and ataxia. CONCLUSION Lateral medullary infarctions are usually reported as partial presentations of classical lateral medullary syndrome with accompanying unusual symptoms ranging from trigeminal neuralgias to hiccups. Pre-syncope from orthostatic hypotension is a rare presentation. In the first 3-4 days, absence of early DWI MRI findings is possible in small, dorsolateral medullary infarcts with sensory disturbances. Physicians should be aware of this presentation, as early diagnosis and optimal therapy are associated with good prognosis.
Collapse
|
9
|
Nishihira T, Suzuki K, Takekawa H, Nakamura T, Iwasaki A, Hirata K. [Lateral medullary infarction presenting with truncal lateropulsion and decreased pain and temperature sensation below T10 sensory level]. Rinsho Shinkeigaku 2014; 54:819-23. [PMID: 25342017 DOI: 10.5692/clinicalneurol.54.819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 45-year-old man noted a tendency to fall to the left side on standing following headache and vomiting. Neurological findings were unremarkable except for truncal lateropulsion to the left side. Brain magnetic resonance imaging (MRI) showed a small infarct in the left inferolateral part of medulla. Clinical and imaging findings suggested vertebral artery dissection as the cause of stroke. On hospital day 6, the patient developed decreased pain and temperature sensation in the right side below T10 sensory level and decreased sweating on the left side of the face with miosis of the left pupil. Brain MRI revealed an expanded lesion of the left inferolateral part of medulla. In our patient, the involvement of the spinocerebellar tract and the lateral spinothalamic tract likely contributed to the development of truncal lateropulsion and sensory disturbance below thoracic levels, respectively. Our case is clinically important in understanding a correlation between clinical symptoms and lateral medullary lesions.
Collapse
|
10
|
Jung SH. Rehabilitation for Brainstem Lesion: Non-Motor Symptoms. BRAIN & NEUROREHABILITATION 2014. [DOI: 10.12786/bn.2014.7.2.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Se Hee Jung
- Department of Rehabilitation Medicine, Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Korea
| |
Collapse
|