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Home , Anterior spinal artery, Aphasia, Astereognosis, Cerebellar artery, Cerebellar ataxia, Cerebellar hemisphere

I19 Postgrad Med J: first published as 10.1136/pgmj.29.329.119 on 1 March 1953. Downloaded from

- N/ THE OF THE OF THE AND, Part II By LESLIE G. KILOH, M.D., M.R.C.P., D.P.M. First Assistant in the Joint Department of Psychological Medicine, Royal Victoria Infirmary and University of Durham

The Vertebral (See also Cabot, I937; Pines and Gilensky, Each enters the foramen 1930.) magnum in front of the roots of the hypoglossal nerve, inclines forwards and medially to the The Posterior Inferior anterior aspect of the and unites The posterior inferior cerebellar artery arises with its fellow at the lower border of the to from the vertebral artery at the level of the lower form the basilar artery. border of the inferior olive and winds round the The posterior inferior cerebellar and the medulla oblongata between the roots of the hypo- Protected by copyright. anterior spinal arteries are its principal branches glossal nerve. It passes rostrally behind the root- and it sometimes gives off the posterior spinal lets of the vagus and glossopharyngeal nerves to artery. A few small branches are supplied directly the lower border of the pons, bends backwards and to the medulla oblongata. These are in line below caudally along the inferolateral boundary of the with similar branches of the fourth ventricle and finally turns laterally into the and above with the paramedian branches of the vallecula. basilar artery. Branches: From the trunk of the artery, In some cases of apparently typical throm- twigs enter the lateral aspect of the medulla bosis of the posterior inferior cerebellar artery, oblongata and supply the region bounded ventrally post-mortem examination has demonstrated oc- by the inferior olive and medially by the hypo- clusion of the entire vertebral artery (e.g., Diggle glossal nucleus-including the nucleus ambiguus, and Stcpford, 1935). In some of these the the and the restiform body. A thrombus has extended from the posterior inferior http://pmj.bmj.com/ cerebellar artery just before death but in others branch passes to the chorioid plexus of the fourth there is no doubt that it was the primary condition. ventricle, and in the majority of individuals it also In these it is usual to find that the basilar artery gives off the . A twig to the has commenced early in the region of the inferior is present in many individuals olive and supplies the median area of the medulla (Shellshear, I922). oblongata normally irrigated by the vertebral and The medial terminal branch ramifies over the ,anterior spinal arteries. vermis; the lateral terminal branch supplies the The usual result of vertebral artery thrombosis lower surface of the cerebellar hemisphere. on September 29, 2021 by guest. is simply a combination of those features which Occlusion of the posterior inferior cerebellar result from occlusion of the posterior inferior artery gives rise to the lateral medullary or cerebellar artery and of the medullary portion of Wallenberg's . Although credit for the the anterior spinal artery with all their variations earliest descriptions is usually given to Senator (q.v.). (I883) and Wallenberg (i895), a remarkably de- Several eponyrns have been attached to the tailed and personal account by Gaspard Vieusseux, syndrome of the vertebral artery. The common the Swiss physician, was published by Marcet in picture is sometimes known as the Babinski- I8I7. Nageotte syndrome. The syndrome of Cestan- The clinical picture of posterior inferior cere- Chenais is similar but weakness of the tongue and bellar artery thrombosis shows much variation, involvement of the descending root of the fifth though the main features are reasonably constant nerve and of the spinothalamic tract are absent. and diagnostic. MEDICAL March POSTGRADUATE JOURNAL 1953Postgrad Med J: first published as 10.1136/pgmj.29.329.119 on 1 March 1953. Downloaded from The onset in a typical case is with intense commonly-because of its rich collateral circula- vertigo, the patient's head and eyes turning to the tion-the is infarcted and this con- side of the lesion. He may stagger to the same side tributes to the . is usually and may fall. Nausea and vomiting are almost in- gross and there may be skew deviation of the eyes; variable and the latter may be intractable. Loss of these features are largely attributable to the consciousness though not to be expected has been vestibular disturbance. recorded occasionally, as in two of Merritt and The typical sensory changes found are impair- Finland's cases (I93o). is constant and ment of and temperature sensations in the may even preclude the swallowing of saliva so that distribution of the ipsilateral fifth nerve and similar a hawking cough develops. Regurgitation of impairment over the contralateral body half from fluids through the nose sometimes occurs although the second cervical segment downwards. Touch, the palatal palsy is strictly unilateral. is the of passive movement and vibration sense commonly affected and in different patients all are unaffected. The facial changes are due to degrees from hoarseness to aphonia may occur. ischaemia of the descending tract of the fifth nerve Less frequently, complaint is made of ipsilateral which, together with the spinal nucleus of the tinnitus or deafness and diplopia is sometimes fifth nerve, underlies the tuberculum cinereum. troublesome. Hiccough is not infrequent and may (The upper part of the spinal nucleus of the fifth persist for days. nerve is also affected but in the average case the Generalized or suboccipital pain at the lesion of the tract takes precedence.) The contra- time of onset of the ictus is frequent, but more lateral loss of pain and temperature sensations in interesting is the occurrence of facial pain on the the trunk and limbs is due to interruption of the same side as the lesion. Rarely is pain in the spinothalamic tract which at this level lies internal throat in the distribution of the glossopharyngeal to the descending tract and nucleus of the fifth nerve experienced. Complaint is often made of nerve. The opposite side of the face is rarely numbness, coldness or of pins and needles over the affected because the quintothalamic tract whichProtected by copyright. ipsilateral face and the contralateral body half. arises from the spinal nucleus of the fifth nerve An ipsilateral Horner's syndrome is present in pursues a separate path in the medulla oblongata at least 8o per cent. of cases but is frequently close to the and does not join the incomplete, anhidrosis occurring less commonly spinothalamic tract until it reaches the pons than ptosis and miosis. It is due to interruption of (Smyth, 1939). Trophic changes, including gan- the sympathetic connector fibres running from the grene of the side of the nose and adjoining cheek hypothalamus to the cells of the lateral horn of the have been reported, usually associated with the use of the cord. of a nasal catheter (Savitsky and Elpern, 1948). Some weakness of the ipsilateral masticatory and Many interesting variants have been noted with facial muscles may be seen. There may also be regard to the nature and area of the sensory loss. loss of on the same side over the anterior two- Sometimes the ipsilateral face is not involved and thirds of the tongue. Involvement of the ipsi- in others only the territory of the first or first and

lateral sixth nerve is fairly common giving rise to second divisions of the fifth nerve is affected. Inhttp://pmj.bmj.com/ diplopia, but is often so slight that it is difficult to the latter the upper parts of the descending tract demonstrate clinically. Severe degrees of in- and spinal nucleus of the fifth nerve escape volvement of the sixth and seventh damage; this provides supporting evidence for the probably indicate either that the posterior inferior 'upside down' arrangement of this nucleus. cerebellar artery supplies an unusually wide Rarely does ipsilateral impairment of tactile territory or that short circumferential branches of sensation accompany the loss of pain and tempera- the basilar artery have been affected coincidentally. ture sensations. Infarction of the ipsilateral nucleus ambiguus Occasionally the loss of facial sensation is on September 29, 2021 by guest. and of its emerging nerve fibres is responsible for bilateral, the crossed quintothalamic tract being the dysphagia, dysarthia and palatal weakness affected as well as the ipsilateral descending root of which have already been mentioned. The ipsi- the fifth nerve. Cases have been noted (Sheehan lateral pharyngeal weakness betrays itself by a and Smyth, I937) in which such contralateral im- ' curtaining' effect of the posterior pharyngeal pairment of facial sensation has been restricted to wall on attempted swallowing and like the ipsi- the area supplied by the ophthalamic division of lateral palatal weakness is usually severe. The the fifth nerve. This finding suggests that the of the ipsilateral vocal cord may be less quintothalamic tract is laminated, the fibres de- marked. The tongue is never affected. rived from the upper face (i.e., from the lowest Ipsilateral cerebellar is present- in the part of the spinal nucleus) lying on the outside. great majority of patients. It results mainly from Sometimes, owing to the similar lamination of damage to the inferior . Less the spinothalamic tract, the contralateral sensory lAfarch 1953 KILOH: The Syndromes of the Arteries of the Brain'and Spinal Cord 121 Postgrad Med J: first published as 10.1136/pgmj.29.329.119 on 1 March 1953. Downloaded from loss spares the areas supplied by the cervical and .contributory arteries is absent, then thrombosis even the thoracic segments. The sacral, lumbar, gives rise to a quadriplegia with sensory loss thoracic and cervical fibres lie in this order from (Louis-Bar, I947). The resulting picture re- without inwards and if the area of infarction does sembles that of basilar artery occlusion but will be not extend sufficiently far medially, the cervical- distinguished by the absence of ' pseudobulbar' and perhaps the thoracic-fibres will escape signs. damage. (See also Davison, I937, I944; O'Brien and The prognosis following occlusion of the pos- Bender, I945). terior inferior cerebellar artery is surprisingly good. Thrombosis of the inframedullary portion of the The dysphagia, and vestibular symp- anterior was first described toms commonly disappear and the ataxia shows a spinal artery by marked improvement. The Horner's syndrome Preobrajensky (1907). and the sensory loss usually persist but occasion Thrombosis may occur anywhere in the course little disability. of the vessel but is most frequent in the cervical (See also Anderson et al., I93i; Goodhart and region. As it runs downwards the anterior spinal Davison, artery gives off paired anterior sulcal branches 1936; Spillane, I937). which penetrate the substance of the cord and The Anterior Spinal Artery supply the entire grey matter-with the exception Each anterior spinal artery arises near the ter- of the tips of the posterior horns-and the greater mination of the vertebral artery and runs obliquely part of the lateral and anterior funiculi. The downwards and medially to the anterior aspect of supply of these from the posterior spinal arteries is the medulla oblongata, uniting with its fellow frugal. The latter vessels supply mainly the opposite the decussation of the pyramids. The posterior columns and the tips of the posterior combined artery runs downwards in the antero- horns of the grey matter. The anterior sulcal median fissure reinforced at-intervals by twigs from arteries are strictly unilateral in their distributionProtected by copyright. the vertebral, posterior intercostal and lumbar (Herren and Alexander, 1939). arteries. Sometimes the two vessels join at once Pain is common at the onset and is experienced but in other cases they remain independent for either in girdle distribution at the level of the several centimetres. Occasionally one is absent. lesion or radiating down the legs. Incontinence- Twigs from each artery enter the bulb in line or less commonly retention-of urine and faeces with the paramedian branches of the basilar artery occurs and is sometimes accompanied by priapism. and supply the anterior and medial portions of the If the artery is occluded in the cervical region medulla oblongata, including the pyramidal tract there is weakness of all four limbs, initially with and the medial lemniscus. Stopford (I916, 1917) flaccidity. In the upper limbs the weakness is showed that these vessels also supply the hypo- largely 'lower motor neurone' in character and glossal triangle. is due to segmental destruction of anterior horn Spiller (I908) was the first to describe occlusion cells. Flaccidity will therefore persist and in time of the anterior spinal artery above the level of the wasting will appear. In the lower limbs the weak- decussation of the pyramids. The changes which ness is. 'upper motor neurone' in type and http://pmj.bmj.com/ result constitute the syndrome of the anterior spasticity usually supervenes. The weakness is spinal artery of the medulla (paramedian inferior commonly asymmetrical. Absence of some or all bulbar syndrome). of the deep reflexes in the upper limbs is associated Double incontinence is frequent at the onset but with the lower motor neurone lesion. The deep loss of consciousness is unusual. Contralateral reflexes in the lower limbs are often absent in the paraesthesiae may be experienced. The most flaccid stage but become exaggerated if the patient survives. Occlusion in the lumbar region of the obvious feature is a contralateral hemiplegia on September 29, 2021 by guest. affecting the limbs equally but sparing the face. cord results in a flaccid weakness of the lower Some contralateral impairment of the sense of limbs with wasting and loss of deep reflexes. passive movement and of vibration sense with Sensory loss of a dissociated type is present but is usual and is occasionally associated is variable in extent. Commonly it affects all with hyperpathia. Nystagmus is often seen. An segments below the level of the lesion but is often ipsilateral 12th nerve paralysis when present is not absolute and may be less marked on one side. highly characteristic. In its absence, confusion Sometimes it is possible to define a zone ofabsolute with a lesion of the is likely but loss ofpain and temperature sensations in the lower the escape of the face and the presence of nystag- cervical and upper thoracic regions due to destruc- mus will aid distinction. tion of the crossing fibres in the neighbourhood of Ifthe two anterior spinal arteries form a common the central canal, while below this level the sensory trunk at a higher level than usual or if one of the loss is incomplete as the spinothalamic tracts re- 122 POSTGRADUATE MEDICAL JOURNAL March 1953 Postgrad Med J: first published as 10.1136/pgmj.29.329.119 on 1 March 1953. Downloaded from ·;,..;..·- ,.,1..-c.* ·. 3.'.· i

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FIG. 4.-The arterial supply of the brain stem and h Posterior inferior cerebellar artery. Protected by copyright. cerebellum (semi-diagramatic). i Posterior communicating artery. a Posterior cerebral artery. j . b Superior cerebellar artery. k Trigeminal nerve. c Basilar artery. 1 Oculomotor nerve. d Short circumferential branches of pons. m Pons. e Anterior spinal artery. n Lateral artery of medulla oblongata. f Vertebral artery. (Foix and Hillemand, 1925b.) g Middle cerebellar artery. ceive some blood from the posterior spinal The Basilar Artery arteries. The basilar artery is formed at the lower border The occurrence of a bilateral Horner's syn- of the pons by the junction of the vertebral drome might be anticipated whenever the lesion is arteries. It occupies the basilar groove and ends above the level of the first thoracic segment. into the two cerebral by dividing posterior http://pmj.bmj.com/ Curiously enough this appears to have been re- arteries. Its other branches are classified by Foix corded onc:e only--by Pariser and Lasagna (1949). and Hillemand (1926) into: It may well be more common than this, for its (a) Paramedian group (q.v.). presence nmay be difficult to establish, especially in (b) Short circumferential branches (q.v.). ill and perhaps dying patients. (c) Long circumferential branches: (i) Anterior The asymmetry of the condition is sometimes inferior cerebellar artery (q.v.). (ii) Superior so marked as to merit the title of a Brown-Sequard cerebellar artery (q.v.). syndrome (lacking, of course, evidence of ipsi- The clinical picture resulting from occlusion of on September 29, 2021 by guest. lateral posterior column involvement). This may the basilar artery varies widely, as might be ex- occur duriing the stage of recovery and when pected, according to the precise site and extent of present, suggests that the thrombosis has affected the thrombus. It depends too on the size of the mainly one. of the anterior sulcal branches. posterior communicating arteries. If these are In some cases a considerable degree of im- unobstructed and of such a size as to provide an provement may take place. More commonly the adequate collateral circulation, only the territory paralysis remains severe, bed sores andc urinary of those branches blocked by the thrombus will develop and the patient suffers the usual be affected. fate of any severe chronic spinal affection. At the onset headache may occur and is usually (See also Adams and Merrit, '944; Steegman, occipital in distribution. ' Dizziness' and, less 1952; Sherman, 1948; Zeitlein and Lichtenstein, commonly, true vertigo are frequent complaints. 1936). Impairment of consciousness varying from slight March 195 3 KILOH: The Syndromes of the Arteries of the Brain and Spinal Cod [23 Postgrad Med J: first published as 10.1136/pgmj.29.329.119 on 1 March 1953. Downloaded from

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.e Protected by copyright. FIG. 5.--The arterial supply of the brain stem and cerebellum-lateral aspect (semi-diagramatic). Key as for Fig. 4. (Foix and Hillemand, I925b.) clouding to deep coma is usual. Estimation of the Dysarthria, amounting at times to anarthria, degree of impairment of consciousness may be occurs in most cases and is due to bilateral in- difficult if the double hemiplegia is so profound as terruption of the corticobulbar tracts. Other to render impossible any response on the part of 'pseudobulbar ' phenomena are equally prominent the patient. One of Biemond's cases (I95I) with when consciousness is retained sufficiently to allow a complete anarthria and quadriplegia could move their demonstration; dysphagia, a spastic tongue only his eyes to indicate his awareness of the ex- which the patient is unable to protrude, bilateral ternal world. The explanation of the loss of con- loss of voluntary facial movements and patho- sciousness which occurs so commonly is not logical laughing and crying are evident. A double http://pmj.bmj.com/ altogether clear, for in most of these cases post- hemiplegia is present in every case but varies mortem studies have failed to demonstrate any greatly in severity. It is frequently asymmetrical lesion outside the and pons. Bremer and on one side may be indicated by little more (x935), from animal experiments, concluded that than an extensor plantar response. The deep re- consciousness ceases when the is de- flexes are usually exaggerated but may be prived of afferent stimuli, as would occur in severe diminished or absent in the acute stage. It might midbrain or upper pontine lesions. This view was be expected that decerebrate rigidity would be recently reiterated by Purdon Martin (i949). On common but this is not so, though it was a on September 29, 2021 by guest. the other hand the work of Magoun's school prominent feature in Scott and Lennon's case (Lindsley, et al., 1950) suggests that damage to the (I940). In Kubik and Adams' (I946) series of 25 ascending reticular activating substance is primarily cases one only had tonic fits (which may be re- responsible for the alteration in the state of con- garded as transient decerebrate states). These sciousness and Jefferson (1952) has emphasized authors suggest that the rarity of the condition this possibility in regard to brain stem lesions in might be due to the existence of a state of' shock' man. equivalent to ' spinal shock.' Urinary and faecal incontinence is almost in- The supranuclear connections of the eye muscle variable even though consciousness be retained. nuclei are occasionally involved giving rise to Numbness or tingling down one or other side of defects of lateral or superior conjugate move- the body is common and is most marked in the ments. Internuclear ophthalmoplegias occur lips, hands and feet. rarely. 124 - POSTGRADUATE MEDICAL JOURNAL March I953 Postgrad Med J: first published as 10.1136/pgmj.29.329.119 on 1 March 1953. Downloaded from Theoretically a cerebellar dyssynergia should be instead of directly from the basilar artery itself. present in every case and indeed can sometimes be The structures supplied include the corticobulbar demonstrated though usually on one side only; and corticospinal tracts, the , some commonly it is masked by the paralysis or by fibres of the middle cerebellar peduncles and impairment of consciousness. Nystagmus is sometimes the medial part of the medial lemniscus. common. Occasional cases show involvement of The usual result of occlusion of one of these the third, fifth, sixth or seventh nerves but such vessels is a simple crossed hemiplegia, the severity signs are seen less often than might be expected. of which varies widely in different patients. As a The pupils show some abnormality in nearly rule both limbs are affected equally. The hemi- every case. As a rule they are small and fixed to plegia is very difficult to distinguish from one of light but occasionally one or both may be dilated capsular origin. In the latter a history of weakness and unresponsive. The pupillary changes depend commencing in one limb and later extending to the on involvement of the sympathetic pathways in the other may be obtained, whilst if the dominant body brain stem, of the pupillary fibres in the third half is affected, yet is absent, the lesion is nerves and possibly of the pretecto-nuclear tracts. likely to be in the brain stem. Contralateral im- Sometimes the thrombus extends into one or both of. the posterior leading to infarction of the and the midbrain. If the thrombus reaches beyond the junctions of the posterior communicating arteries--or if these are very small-the area of infarction will include the occipital cortex giving rise to a unilateral or bilateral homonymous hemianopia. It is possible J- 'I that the rarity of such findings is due to the fact i;;F'·' i· E L Protected by copyright. that infarction of this severity is almost always fatal. Tachypnoea, tachycardia and hyperpyrexia are common accompaniments of basilar artery oc- are clusion, though they usually terminal events. ;i i i!Lrj2 b ;1 t It is not unlikely that some of the less severe examples of basilar artery occlusion are regarded It } ·7 A,'i¢ as cases of pseudobulbar palsy due to bilateral 'I* capsular lesions. The prognosis in basilar artery occlusion is generally considered to be grave, but the fact that ..|i.l :F wif"r.'- . of Kubik and Adams' 25 cases seven were still alive after periods varying from two to 14 months, http://pmj.bmj.com/ suggests that the outlook is not quite so desperate as was once thought (see also Moniz, i933; Pines and Gilensky, I932). The Paramedian and Short Circumferential FIG. 6.-Distribution of branches of basilar artery to Branches of the Basilar Artery the brain stem. The basilar artery has been re- In general the following description is based on moved. (Diagramatic.) the work of Foix and Hillemand (1926) which a Posterior perforated substance. on September 29, 2021 by guest. to be the most accurate b Pons. appears assessment of c Trigeminal nerve. this difficult region. d. Pyramid. e Olive. (A) Paramedian Branches f Oculomotor nerve. There are four to six of g Posterior cerebral artery. these entering the pons h Superior cerebellar artery. a few millimetres on either side of the mid-line. i Basilar artery. Each divides into numerous branches (sometimes j Paramedian branches. called the median arteries of k Lateral artery of medulla oblongata. Diiret) running I Short circumferential branches. perpendicularly into the substance of the pons. m Accessory lateral artery' of the medulla In the uppermost part only do they penetrate into oblongata. the tegmentum. Sometimes these vessels arise n Middle cerebellar artery. from the short or long circumferential branches (Foix and Hillemand, I9g5b.) March KILOH: The Syndromes the Arteries the Brain and Cord 1953 of of Spinal I25 Postgrad Med J: first published as 10.1136/pgmj.29.329.119 on 1 March 1953. Downloaded from pairment of postural sensibility and of vibration ing syndromes are discussed as clear-cut entities, sense is stressed by some authors but is only an they also occur in varying combinations: occasional finding and is rarely severe. Cerebellar (i) Millard-Giibler's syndrome. In addition to signs, which might be anticipated in view of the the long tract involvement of which a contra- involvement of the middle cerebellar peduncle, lateral hemiplegia is constant, there is an ipsilateral can rarely be demonstrated. sixth and seventh nerve paralysis. The latter may It has been claimed that ipsilateral paralysis of be incomplete. the fifth, sixth and seventh nerves may result from (2) Raymond's syndrome. This is similar to occlusion of the paramedian vessels but this is the syndrome of Millard-Giibler but the seventh denied by Foix and Hillemand who say that such nerve is not affected. features indicate involvement of the short circum- (3) Foville's syndrome. The essential feature ferential branches. On anatomical grounds it is the presence of paralysis of lateral conjugate appears likely that they are correct. ocular movements to the side of the lesion. This is sometimes stated to be due to damage to the (B) The Short Circumferential Branches parabducens nucleus, but the existence of this (i) The lateral artery of the medulla oblongata. body has never been confirmed and it is more This is the lowest lateral branch of the basilar likely to result from a lesion of the corticonuclear artery. When present it supplies a wedge-shaped fibres entering the sixth nerve nuclei. Evidence of area of the lateral aspect of the upper medulla long tract involvement is present and there may oblongata immediately rostral to that supplied by also be an ipsilateral facial palsy. Foix and the posterior inferior cerebellar artery though not Hillemand remark that when due to thrombosis, including the restiform body (Alexander and Suh, the hemiplegia seen in these syndromes is never 1937). Foix, Hillemand and Schalit (i925) main- severe. When it is marked it suggests that the tain that occlusion of this vessel gives rise to a syn- causal lesion is a haemorrhage or a neoplasm. drome indistinguishable from that following (4) Posterior internuclear ophthalmoplegia. ThisProtected by copyright. thrombosis of the posterior inferior cerebellar is associated with damage to the medial longi- artery and that most of the cases diagnosed as the tudinal bundle in the neighbourhood of the sixth latter are, in fact, examples of occlusion of the nerve nuclei. On looking to the side of the lesion, lateral medullary artery. In view of the very large the ipsilateral eye either fails to deviate outwards number of cases in which involvement of the or having done so, slowly wanders back towards posterior inferior cerebellar artery has been proved the neutral position. On looking to the opposite by post-mortem examination, this view would side, the diverging eye may show a similar defect appear to be exaggerated. though in lesser degree. In addition, when (ii) To the Pons. There are four or five of these looking to either side the converging eye may de-, and they pass laterally for about one centimetre velop coarse lateral jerking movements (ataxic before entering the pons. A branch of one of nystagmus). Superficially there is a resemblance them which penetrates the pons with the fifth to a unilateral or bilateral sixth nerve paralysis but nerve is sometimes known as the trigeminal artery there is no convergent strabismus and the in- http://pmj.bmj.com/ of Duret. These vessels supply the lateral three- tegrity of the sixth nerves can be demonstrated by fifths of the pons including the lateral portion of inducing a vestibular nystagmus. the corticospinal tract, the main mass of the medial (5) Bulbopontine syndrome of Duret's tri- lemniscus, the trigeminal, abducens and facial geminal artery. This syndrome was described by nuclei and the middle cerebellar peduncle. With Gereb (I949) and his case appears to be the only the exception of its uppermost part, these vessels one recorded. There was ipsilateral sensory loss supply the entire tegmentum. restricted to the lower two divisions of the fifth When one or more of these vessels is occluded nerve, most evident in the tongue, with loss of on September 29, 2021 by guest. the result depends very much on whether or not taste on the same side and considerable vestibular the area of infarction includes the tegmentum. disturbance. (a) When it does not, the usual finding is an (6) Palato - pharyngo - laryngeal myoclonus. isolated ipsilateral cerebellar dyssynergia. In Rhythmic myoclonic movements of the palate, some cases this is associated with contralateral pharynx and larynx at a rate of 50 to I8o per min. sensory loss either affecting all modalities or'less sometimes result from lesions of the pontine commonly pain and temperature sensations alone. tegmentum. The lingual, facial and ocular muscles A contralateral hemiplegia-slight in degree-may may also participate in the disturbance. Rarely also be present. the diaphragm too is affected. When due to (b) When the tegmentum is affected, various unilateral vascular disease the myoclonus is also cranial nerves, their nuclei and certain adjacent strictly unilateral but is on the opposite side. It structures may be involved. Although the result- results from destruction of the central tegmental POSTGRADUATE MEDICAL I26 JOURNAL March I953 Postgrad Med J: first published as 10.1136/pgmj.29.329.119 on 1 March 1953. Downloaded from tract (thalamo-olivary bundle) (Foix and Hille- proportional to that of the posterior inferior mand, I926). The ipsilateral inferior olive shows cerebellar artery. a trans-synaptic degeneration and pseudohyper- Dizziness, tinnitus, nausea and vomiting are trophy which is in part due to gliosis (Davison, common at the onset of occlusion of this vessel Riley and Brock, I936). A lesion of the dentate but consciousness is usually retained. On the nucleus is also said to give rise to the same syn- same side as the lesion are found a cerebellar drome but in this case the myoclonus is ipsilateral dyssynergia with nystagmus, a Homer's syndrome, (Guillain, et al., I933). a lower motor neurone facial weakness and nerve Palato - pharyngo - laryngeal myoclonus may deafness. Impairment of all forms of sensation occur in isolation but is more commonly accom- over the ipsilateral face is usually present though panied by symptoms of vestibular disturbance and tactile sensibility may be less affected than pain and is sometimes combined with a Millard-Gubler or temperature sensations. The sensory loss is due Foville syndrome. to involvement of the incoming fifth nerve or of (7) The occurrence of an isolated hemiplegia or its main sensory nucleus. The only contralateral of a cerebellar syndrome has already been noted. abnormal finding is impairment of pain and tem- An isolated spinothalamic lesion giving rise to a perature sensations in the trunk and limbs. dissociated anaesthesia of the entire body half may Typically this is incomplete because the area of also occur. infarction is sufficiently posterolateral as not to involve the entire spinothalamic tract. The existence of such discrete features raises the A number of cases of occlusion of the anterior interesting question as to whether or not isolated inferior cerebellar artery following attempted re- sixth and seventh nerve palsies (and third nerve moval of acoustic neuromata have been reported by paralyses from equivalent lesions of the midbrain) Atkinson (I949) who believes that the consequent might not have a similar origin. The third and infarction of the tegmental area is responsible for sixth nerve palsies of sudden onset so common in a transient rise of blood pressure and for theProtected by copyright. late adult life are usually attributed to small development of cerebral oedema which so com- aneurysms or, if none can be demonstrated, to monly leads to death in these patients. pressure on the nerve by an atheromatous or All the features just described as typical of anomolous vessel. It seems reasonable to suggest occlusion of the anterior inferior cerebellar artery that some of these cases are, in fact, the result of may occas:ionally follow thrombosis of the posterior brain stem thromboses although no pathological inferior c:erebellar artery. Involvement of the proof of this can be offered. nucleus a nbiguus never results from disease of the (See also Alajouanine et al., I935). former v ssel and the presence or absence of dysarthria and dysphagia will enable a distinction (C) Long Circumferential Branches to be made. (i) The anterior inferior cerebellar artery (middle (See also Goodhart and Davison, 1936). cerebellar artery). The anterior inferior cerebellar (ii) Thi superior cerebellar artery. The superior arises from the basilar at the artery artery junction cerebellar arteries are the most constant of the http://pmj.bmj.com/ of its middle and lower thirds and passes laterally cerebellar vessels. Each arises near the termination and downwards crossing the acoustic nerve. of the bai.lar trunk and runs laterally, parallel to Branches from the main stem: Internal auditory the poster ior cerebral artery but separated from it artery (in the majority of individuals). Small by the third nerve. It turns dorsally round the pontine branches supplying the lateral portion of lateral aspect of the cerebral peduncle to reach the the lower two-thirds of the pons (including the cerebellum. fifth and seventh nerve nuclei and the cochlear Branches: Twigs sometimes arise from the nucleus), the middle cerebellar peduncle and main vessel and supply the dorsal aspect of the on September 29, 2021 by guest. sometimes the uppermost part of the medulla pons and midbrain. The medial and lateral oblongata. terminal branches ramify over the superior aspect Terminal branches: (a) A branch running of the vermis and lateral lobe of the cerebellum and laterally and downwards along the medial and form the main supply of the cerebellar anterior border of the cerebellar hemisphere. (b) and nuclei, including the dentate nucleus. Twigs A branch running directly laterally round the also supply the middle and superior cerebellar upper edge of the over the surface of the peduncles, the upper lateral part of the pontine middle cerebellar peduncle and on to the cere- tegmentum, the lateral aspect of the midbrain and bellar hemisphere. the quadrigeminal plate. - There is considerable variation in the size and As with occlusion of the other cerebellar therefore of the importance of the anterior inferior arteries, dizziness, vertigo, nausea and vomiting cerebellar artery. As a rule its size is inversely are common at the onset. A cerebellar dyssynergia KILOH: The the Arteries the Brain and Cord March 1953 Syndromes of of Spinal I27 Postgrad Med J: first published as 10.1136/pgmj.29.329.119 on 1 March 1953. Downloaded from is usually present on the same side as the lesion but Involvement of cranial nerves or their nuclei is may be absent--probably because of the richness not a feature of superior cerebellar artery occlusion of the anastomoses which this artery makes with and the partial lesions of the ipsilateral sixth and the other cerebellar vessels. An ipsilateral seventh nerves which have occasionally been Horner's syndrome may be seen. The most described, usually indicate coincidental involve- striking feature is the presence of ipsilateral in- ment of the . An ipsilateral fourth voluntary movements which may be associated nerve paralysis has been described by Girard, et with diminished or absent deep reflexes. The al (1950). nature of the movements varies from patient to An occasional featUre, notably in the cases patient and has been described as a coarse described by Mills (90o8) and Russel (I93 ), is by Schuster and Critchley (1933), sinuous move- loss of emotional movements with preservation of ments accentuated by emotion or attempts at voluntary movements over the contralateral face. voluntary movement by Worster-Drought and This is to be explained as the result of a lesion of Allen (1929), a rapid by Guillain, Bertrand the mimic tracts subserving emotional movements and Peron (1928) and as by Adams (I943). which run independently of the . The movements have been ascribed to involve- ment of the superior cerebellar peduncle or of the (See also Davison et al., 1935; Freeman and dentate nucleus. Considerable degeneration of Jaffe, I94I; Sandler, 1935.) the opposite with demyelinization of its entering fibres is present in these cases. Contralateral loss of pain and temperature sensation affects the entire body half including the Acknowledgments face but is absent if only the medial branch of the We acknowledge with thanks permission to artery is occluded. Sometimes it is confined to publish illustrations 4, and 6 from the Revue

5 Protected by copyright. the lower part of the body due to the lamination of Neurolgique and permission to publish illustrations the spinothalamic tract. I and z from Williams and Wilkins Co., Baltimore.

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