Chapter 8 - Ataxia in patients with brain infarcts and hemorrhages

https://doi.org/10.1016/B978-0-444-51892-7.00008-5Get rights and content

Abstract

Gait and limb incoordination and ataxia are most often found in patients with brainstem and cerebellar infarcts and hemorrhages. Lesions involving the thalamus and the deep portions of the cerebral hemispheres also may cause ataxia accompanied by weakness and sensory symptoms.

Patients who have lesions in the lateral medulla and inferior cerebellum often topple, lean, or veer when attempting to sit, stand, or walk. They list to the side or abruptly veer when walking. The affected limbs are often hypotonic. In pontine lesions, ataxia is accompanied by weakness and pyramidal tract signs as part of an ataxic hemiparesis syndrome. In lesions affecting the superior cerebellum and the brachium conjunctivum, limb dysmetria and overshoot and dysarthria predominate and gait ataxia is absent or slight and transient.

Infarcts affecting the thalamus can cause gait instability and astasia with ataxia. Lateral thalamic lesions are characterized by hemisensory symptoms, extrapyramidal limb postures and dysfunction, and gait ataxia. Lesions that affect the posterior limb of the internal capsule and its afferent and efferent projections may also cause an ataxic hemiparesis syndrome, often with accompanying hemisensory abnormalities.

Section snippets

Medullary infarcts

Lateral medullary infarcts often involve the inferior cerebellar peduncle (restiform body) and vestibular, medial lemniscal, and spinocerebellar afferent fibers that travel within the inferior cerebellar peduncle on their way to the cerebellum. These nuclei and tracts are located in the most dorsal and lateral regions of the medulla.

Vestibulocerebellar symptoms and signs are nearly always present in patients with lateral medullary ischemia. The vestibular nuclei and their connections with

Cerebral hemisphere lesions

Ataxia is not prominent in patients with infarcts and hemorrhages in the cerebral hemispheres. Although frontal lobe and parietal lobe tumors are well known to produce ataxia, very few cerebrovascular cerebral hemisphere lesions cause a true cerebellar-type ataxia. Probably the most common vascular lesions that are accompanied by ataxia are small deep lacunar-type infarcts that involve the posterior limb of the internal capsule (Fisher and Cole, 1965, Fisher, 1978, Iraqui and McCutchen, 1982).

References (86)

  • C.S. Kase

    Cerebellar Hemorrhage

  • J.J. Marx et al.

    Topodiagnostic implications of hemiataxia: an MRI-based brainstem mapping analysis

    Neuroimage

    (2008)
  • P. Amarenco et al.

    Anatomie des arteres cerebelleuses

    Rev Neurol

    (1989)
  • P. Amarenco et al.

    Cerebellar infarction in the territory of the anterior and inferior cerebellar artery

    Brain

    (1990)
  • P. Amarenco et al.

    Cerebellar infarction in the territory of the superior cerebellar artery: a clinicopathologic study of 33 cases

    Neurology

    (1990)
  • P. Amarenco et al.

    Infarction of the territory of the medial branch of the posterior inferior cerebellar artery

    J Neurol Neurosurg Psychiatry

    (1990)
  • P. Amarenco et al.

    Cerebellar infarctions

  • P. Amarenco et al.

    Anterior inferior cerebellar artery territory infarcts. Mechanisms and clinical features

    Arch Neurol

    (1993)
  • P. Amarenco et al.

    Causes and mechanisms of territorial and non-territorial cerebellar infarcts in 115 consecutive patients

    Stroke

    (1994)
  • A. Barth et al.

    The clinical and topographic spectrum of cerebellar infarcts: a clinical-magnetic resonance imaging correlation

    Ann Neurol

    (1993)
  • A. Barth et al.

    Infarcts in the territory of the lateral branch of the posterior inferior cerebellar artery

    J Neurol Neurosurg Psychiatry

    (1994)
  • C. Bassetti et al.

    Isolated infarcts of the pons

    Neurology

    (1996)
  • J. Bogousslavsky et al.

    Painful ataxic hemiparesis

    Arch Neurol

    (1984)
  • J. Bogousslavsky et al.

    Respiratory failure and unilateral caudal brainstem infarction

    Ann Neurol

    (1990)
  • J. Bogousslavsky et al.

    Pure midbrain infarction: clinical syndromes, MRI and etiologic patterns

    Neurology

    (1994)
  • J.V. Bowler et al.

    Ipsilateral cerebellar diaschisis following pontine infarction

    Cerebrovasc Dis

    (1991)
  • T. Brandt et al.

    Skew deviation with ocular torsion: a vestibular brainstem sign of topographic diagnostic value

    Ann Neurol

    (1993)
  • T. Brandt et al.

    Vestibular syndromes in the roll plane: topographic diagnosis from brainstem to cortex

    Ann Neurol

    (1994)
  • R. Brennan et al.

    Acute cerebellar hemorrhage: analysis of clinical findings and outcome in 12 cases

    Neurology

    (1977)
  • L.R. Caplan

    Intracranial branch atheromatous disease

    Neurology

    (1989)
  • L.R. Caplan

    Posterior Circulation Disease

    (1996)
  • L.R. Caplan

    Posterior circulation ischemia: then, now, and tomorrow. The Thomas Willis Lecture - 2000

    Stroke

    (2000)
  • L.R. Caplan et al.

    Lateral tegmental brainstem hemorrhages

    Neurology

    (1982)
  • L.R. Caplan et al.

    Lateral thalamic infarcts

    Arch Neurol

    (1988)
  • L.R. Caplan et al.

    New England Medical Center Posterior Circulation Registry

    Ann Neurol

    (2004)
  • L.R. Caplan et al.

    New England Medical Center Posterior Circulation Stroke Registry: I. Methods, data base, distribution of brain lesions, stroke mechanisms, and outcomes

    J Clin Neurol

    (2005)
  • L.R. Caplan et al.

    New England Medical Center Posterior Circulation Stroke Registry: II. Vascular lesions

    J Clin Neurol

    (2005)
  • C.J. Chaves et al.

    Cerebellar infarcts

  • C.J. Chaves et al.

    Cerebellar infarcts in the New England Medical Center Posterior Circulation Stroke Registry

    Neurology

    (1994)
  • C. Davison et al.

    The syndrome of the superior cerebellar artery and its branches

    Arch Neurol Psychiatry

    (1935)
  • J. Dejerine et al.

    Le syndrome thalamique

    Rev Neurol

    (1906)
  • C. Deluca et al.

    Limb ataxia and proximal intracranial territory brain infarcts: clinical and topographical correlations

    J Neurol Neurosurg Psychiatry

    (2007)
  • M.W. Devereux et al.

    Automatic respiratory failure associated with infarction of the medulla

    Arch Neurol

    (1973)
  • M. Dieterich et al.

    Wallenberg's syndrome: lateropulsion, cyclorotation, and subjective visual vertical in thirty-six patients

    Ann Neurol

    (1992)
  • M. Dieterich et al.

    Ocular torsion and tilt of subjective visual vertical are sensitive brainstem signs

    Ann Neurol

    (1993)
  • C.M. Fisher

    Ataxic hemiparesis

    Arch Neurol

    (1978)
  • C.M. Fisher et al.

    Basilar artery branch occlusion: a cause of pontine infarction

    Neurology

    (1971)
  • C.M. Fisher et al.

    Homolateral ataxia and crural paresis: a vascular syndrome

    J Neurol Neurosurg Psychiatry

    (1965)
  • C.M. Fisher et al.

    Lateral medullary infarction – the pattern of vascular occlusion

    J Neuropath Exp Neurol

    (1961)
  • C.M. Fisher et al.

    Acute hypertensive cerebellar hemorrhage: diagnosis and surgical treatment

    J Nerv Ment Dis

    (1965)
  • C. Foix et al.

    Irrigation de la protuberance

    Compt Rendu Soc Biol (Paris)

    (1925)
  • C. Foix et al.

    Les syndromes de la region thalamique

    Presse Med

    (1925)
  • S. Gilman et al.

    Disorders of the Cerebellum

    (1981)

    • Cited by (8)

    • Quantitative clinical proteomic study of autopsied human infarcted brain specimens to elucidate the deregulated pathways in ischemic stroke pathology

      2013, Journal of Proteomics
      Citation Excerpt :

      PDC deficiency due to mutations of PDHB or DLAT has been associated with lactic acidosis and neurological dysfunctions like ataxia and hypotonia [40]. This indicates that the presence of similar pathological (i.e. lactic acidosis) or neurological (i.e. ataxia) features in stroke patients may partially be related to PDC deficiency [41]. Ferritin is the major iron storage protein in healthy human brain and can sequester > 4000 iron atoms.

    • Contraversive saccadic hypermetria and ipsilateral limb ataxia: the brachium conjunctivum syndrome

      2023, Journal of Neurology

    • Comprehensive Assessment of Acute Isolated or Prominent Dysarthria in the Emergency Department: A Neuro-Emergency Expert’s Experience beyond Stroke

      2022, Brain Sciences

    • Biomechanical markers of impaired motor coordination

      2020, 15th International Conference Mechatronic Systems and Materials, MSM 2020

    • Concurrent leukoencephalomyelitis and polyneuritis in a maltese terrier: Resembling combined central and peripheral demyelination in humans

      2019, Journal of Veterinary Medical Science

    • A “matched” sensory reference can guide goal-directed movements of the affected hand in central post-stroke sensory ataxia

      2018, Experimental Brain Research
    View all citing articles on Scopus
    View full text
    Copyright © 2012 Elsevier B.V. All rights reserved.