Clinical Case
History
Joyce is a 76-year-old woman who has chronic hypertension.One morning, when she was walking in her house, she suddenly fell down and was taken to the emergency room. A computed tomography (CT) scan and magnetic resonance imaging scan (MRI) of her head and an angiogram of the cerebral vasculature were taken. She was subsequently transferred to the Neurology Service.
Examination
The neurologic examination revealed that Joyce had myoclonus (rapid movements of her hands), dysarthria, nystagmus, Horner’s syndrome, and some contralateral loss of pain and temperature.Shealso displayed a tremor of her right hand.The MRI scan of her head,angiogram of the cerebral vasculature, and neurologic evaluation revealed that Joyce had a stroke involving the right superior cerebellar artery.
Explanation
Major symptoms of the superior cerebellar artery syndrome are ipsilateral intention tremor, limb ataxia, Horner’s syndrome, some contralateral loss of pain and temperature, and nystagmus. The superior cerebellar artery supplies the superior cerebellar pedunde,dorsal surface of the cerebellum, the rostral part of the tegmentum of the pons, and parts of the midbrain, which include cranial nerves III and IV and the medial longitudinal fasciculus.
CT scan and MRI of the head were performed to determine whether there was an existing subarachnoid or intracerebral bleed.The presence of an ongoing bleed would have required Joyce to be referred to a neurosurgeon.The angiogram was taken to rule out an aneurysm. In this case,there was a short-term bleed that affected the dorsal part of the cerebellum, superior cerebellar peduncle, and rostral pons. After some time in the neurology ward, Joyce’s condition stabilized, and she was sent to the Rehabilitation Service. Because the disorder was limited to the superior cerebellar artery, the patient showed considerable recovery within 6 months and was able to return home.
SUMMARY TABLE
Vascular Syndromes
|
Syndrome |
Arterial Occlusion |
Lesion/Symptoms |
|
|
Cerebral Vascular Syndromes |
|
|
Anterior cerebral artery syndrome |
Anterior cerebral artery |
Occlusion of one artery: Damage to the precentral gyrus; contralateral paralysis of the leg Occlusion of both arteries: Bilateral paralysis of lower limbs; impaired sensation mainly of the leg |
|
Middle cerebral artery syndrome |
Middle cerebral artery |
Contralateral hemiplegia predominantly in the upper extremities and face; contralateral sensory loss— inability to discriminate between intensities of different stimuli; aphasia due to damage to the left hemisphere where the speech centers are located – |
|
Syndrome |
Arterial Occlusion |
Lesion/Symptoms |
|
|
Cerebral Vascular Syndromes |
|
|
Posterior cerebral artery syndrome; see also Weber’s syndrome |
Posterior cerebral artery (cal-carine branch supplying the visual cortex) |
Hemianopsia (loss of half the vision in both eyes) due to damage to the visual cortex; see other symptoms in Weber’s syndrome |
|
Midbrain Vascular Syndromes |
||
|
Weber’s syndrome (medial midbrain syndrome) |
Posterior cerebral artery (paramedian branches) |
Unilateral damage to the ventral region of midbrain; ipsilateral paresis of adduction and vertical gaze; pupillary dilation (damaged oculomotor nerve); paresis of the contralateral face, arm, and leg (damaged corticospinal and corticobulbar tracts) |
|
Claude’s syndrome |
Posterior cerebral artery (paramedian branches) |
Unilateral damage to the tegmental region of the midbrain; ipsilateral oculomotor paresis (damaged oculomotor nucleus), contralateral ataxia and tremor (damaged superior cerebellar peduncle) |
|
Parinaud’s syndrome (gaze palsy syndrome. Sylvian aqueduct syndrome, midbrain syndrome) |
Posterior cerebral artery (paramedian branches) |
Dorsal midbrain lesions; impaired upward vertical gaze, loss of the pupillary light reflex (damaged pretectal area) |
|
Benedikt’s syndrome |
Posterior cerebral artery (paramedian branches) |
Combined lesions of the ventral and lateral midbrain tegmentum; oculomotor paresis (damaged rootlets of oculomotor nerve), ataxia, and weakness (damaged red nucleus and superior cerebellar peduncle) |
|
Superior cerebellar artery syndrome |
Superior cerebellar artery |
Analgesia and thermoanesthesia on the ipsilateral side of the face (damaged nucleus and spinal tract of the trigeminal nerve),ipsilateral Horner’s syndrome (ipsilateral miosis, ptosis, and enophthalmos due to disruption of descending sympathetic pathways), contralateral loss of sensations of pain and temperature (damaged spinothalamic tract), ipsilateral limb and gait ataxia (damaged superior cerebellar peduncle) |
|
Pontine Vascular Syndromes |
||
|
Caudal basal pontine syndrome |
Paramedian pontine arteries and long circumferential arteries. |
Contralateral upper motor neuron paralysis (damaged corticospinal tract), ipsilateral facial weakness or paralysis (damaged facial nucleus), ipsilateral gaze paresis (damaged pontine gaze center and abducens nucleus) |
|
Locked-in syndrome |
Paramedian pontine arteries and short circumferential branches of basilar artery |
Lesion of the ventral half of the pons; paralysis of all motor activity (damaged corticospinal tract in the ventral pons), aphonia (damaged corticobulbar fibers passing through the basal pons); vertical gaze and blinking of eyes spared (patients can use these functions to communicate) |
|
Medial tegmental pontine syndrome |
Paramedian pontine branches of the basilar artery |
Damaged abducens nucleus and nerve (cranial nerve [CN] VI), genu of facial nerve and medial lemniscus; ipsilateral paralysis of CN VI, lateral gaze paralysis, ipsilateral facial paralysis, and contralateral loss of kineshtetic and discriminative touch senses |
|
Caudal tegmental pontine syndrome |
Paramedian branches of the basilar artery |
Lesions in the caudal pons; contralateral hemiparesis (damaged corticospinal tract),conjugate gaze palsy (damaged abducens nucleus), facial muscle weakness (damaged facial nucleus or nerve fibers) |
|
Syndrome |
Arterial Occlusion |
Lesion/Symptoms |
|
|
Pontine Vascular Syndromes |
|
|
One-and-a-half syndrome |
Paramedian branches of basilar artery supplying dorsal paramedian pontine tegmentum |
Ipsilateral gaze paralysis (damaged abducens nucleus), internudear ophthalmoplegia (paralysis of adduction of the eye ipsilateral to the lesion and nystagmus of the abducting eye due to damaged medial longitudinal fasciculus) |
|
Rostral basal pontine syndrome |
Long circumferential branches of the basilar artery and anterior inferior cerebellar artery |
Lesions in the rostral pons involving trigeminal nerve; ipsilateral trigeminal sensory and motor symptoms and contralateral upper motor neuron hemiplegia |
|
Dorsolateral tegmental pontine syndrome |
Anterior inferior cerebellar artery on one side, and posterior inferior cerebellar artery on the contralateral side |
Lesions of the dorsolateral pontine tegmentum on one side and dorsolateral medulla on the contralateral side; dissociated sensory loss (i.e., loss of pain and temperature sense but preservation of vibration and position sense) of the entire body; dissociated sensory loss due to bilateral damage to the trigeminal and spinothalamic tracts but sparing of medial lemniscus; ataxia of limbs and trunk (damaged fibers destined for the cerebellum) |
|
Rostral tegmental pontine syndrome |
Superior cerebellar artery and paramedian branches of the basilar artery supplying the rostral pons. |
Lesions in the rostral pons; damaged medial lemniscus, medial longitudinal fasciculus, spinothalamic and corticospinal tracts, and cerebellar fibers; ophthalmoplegia (damaged medial longitudinal fasciculus), contralateral hemiparesis (damaged corticospinal tract), hemisen-sory loss (damaged spinothalamic tract and medila lemniscus), ipsilateral ataxia (damaged cerebellar fibers) |
|
Medullary Vascular Syndromes |
||
|
Lateral medullary syndrome (Wallenberg’s syndrome). See also Chapter 10. |
Posterior inferior cerebellar artery |
Dysphagia (lack of coordination in speech), dysarthria (disturbance of articulation), and difficulty in swallowing (paralysis of the laryngeal muscles due to damaged nucleus ambiguus);analgesia and thermoanesthesia on the ipsilateral side of the face (damage to the nucleus and spinal tract of the trigeminal nerve); contralateral loss of pain and temperature (damage to the spinothalamic tract); vertigo, nausea, vomiting,and nystagmus (damage to the vestibular nuclei); ipsilateral Horner’s syndrome (damage to descending hypothalamospinal fibers); ipsilateral gait and limb ataxia (damage to the cerebellum) |
|
Medial medullary syndrome (Dejerine’s syndrome); see also Chapter 11 |
Anterior spinal artery or paramedian branches of the vertebral arteries |
Lesions in the pyramid, medial lemniscus,and hypoglossal nerve fibers; symptoms are loss of conscious proprioception,touch,and pressure sensations from the contralateral side of the body; upper motor neuron paralysis of limbs on the contralateral side; paralysis of the ipsilateral side of the tongue;and deviation of the tongue to the side ipsilateral to the lesion on protrusion |
|
Dorsal medullary syndrome; see also Chapters 10,14, and 17 |
Medial branch of posterior inferior cerebellar artery |
Lesions of the inferior cerebellar peduncle and vestibular nuclei; symptoms include nystagmus, vertigo, and vomiting (due to damage to the vestibular nuclei) and ataxia (due to damage to the afferent fibers arising in the spinal cord and brainstem regions |
