Medial medullary infarction with restricted sensory symptom

Medial medullary infarction with central sparing

A 35-year-old woman had cardiac arrest requiring treatment with a left ventricular assist device. After regaining consciousness, examination revealed upbeating nystagmus, otherwise normal bulbar function, left arm dysmetria, and numbness periorally and in areas she described as "a turtleneck of numbness with a T-shirt of sensation" (figure 1).

Hemi- and monoataxia in cerebellar hemispheres and peduncles stroke lesions: topographical correlations

Limb ataxia of sudden onset is due to a vascular lesion in either the cerebellum or the brainstem (posterior circulation, PC, territory). This sign can involve both the upper and the lower limb (hemiataxia) or only one limb (monoataxia). The topographical correlates of limb ataxia have been studied only in brainstem strokes. Therefore, it is not yet known whether this sign is useful to localize the lesion within the entire cerebellar system, both the cerebellar hemisphere and the cerebellar brainstem pathways. Limb ataxia was semi-quantified according to the International Cooperative Ataxia Rating Scale in 92 consecutive patients with acute PC stroke. Limb ataxia was present in 70 patients. Four topographical patterns based on magnetic resonance imaging findings were identified: picaCH pattern (posterior inferior cerebellar artery infarct); scaCH pattern (superior cerebellar artery infarct); CH/CP pattern (infarct involving both the cerebellum and the brainstem cerebellar pathways); and CP pattern (infarct involving the brainstem cerebellar pathways). Hemiataxia was present in (47/70; 67.1%) and monoataxia in (23/70; 32.9%) of patients. Monoataxia involved the upper limb in (19/70; 27.1%) and the lower limb in (4/70; 5.7%) of patients. Limb ataxia usually localized the lesion ipsilaterally (picaCH, scaCH, CH/CP, and CP patterns involving the medulla and sometimes the pons) (53/70; 75.7%), but it might be due also to contralateral (CP pattern involving the pons or midbrain) (16/70; 22.9%) or bilateral lesions (1/70). Limb ataxia usually localizes the lesion ipsilaterally but the infarct might be sometimes contralateral. The occurrence of monoataxia may suggest that the cerebellar system is somatotopically organized.

Crossed cheiro-oral syndrome

OBJECTIVES

Cheiro-oral syndrome is characterized by sensory impairment confined to perioral area and ipsilateral fingers/hand. It results from an involvement of the ascending sensory tracts above the pons. However, a crossed pattern of perioral and acral paresthesia was rarely reported before.

PATIENTS AND METHODS

This study reports the neuroanatomic relationship, course and clinical significance of perioral and contralateral acral paresthesia in four patients. We term it the crossed cheiro-oral syndrome.

RESULTS

All patients had lateral or dorsolateral medullary infarctions that were ipsilateral to their perioral paresthesia. The contributory origin is considered a diagonal lesion involving the par oralis fibers within the descending trigeminal sensory tract and acral portion of the lateral spinothalamic tract at the lateral portion of medulla oblongata. Despite of a restricted sensory disturbance at initial, progressive neurological disability terminated to Wallenberg's syndrome ensued in three patients and disabling deficits persisted in two of them.

CONCLUSION

The crossed cheiro-oral syndrome seems a mild form of Wallenberg's syndrome. Therefore, it predicts medullary involvement and is also a warning sign for progression.

Delayed-onset ipsilateral sensory symptoms in patients with central poststroke pain

Sensory symptoms almost always develop on the side contralateral to the cerebral lesion. Delayed occurrence of ipsilateral sensory symptoms after stroke has not been recognized. I describe 6 patients with unilateral stroke who initially developed painful sensory symptoms on the side contralateral to the lesion. The patients' central poststroke pain progressively worsened for a certain period of time when sensory symptoms also occurred on the side ipsilateral to the lesion. The delayed-onset ipsilateral sensory symptom was mild, unaccompanied by objective sensory deficits and developed at the body parts mirroring the site of the most severe central poststroke pain. Possible pathogenic mechanisms for this delayed-onset ipsilateral sensory symptom are discussed.