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Homolateral Ataxia and Crural Paresis: a Vascular Syndrome1

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Homolateral Ataxia and Crural Paresis: a Vascular Syndrome1 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.28.1.48 on 1 February 1965. Downloaded from J. Neurol. Neurosutrg. Psychiat., 1965, 28, 48 Homolateral ataxia and crural paresis: A vascular syndrome1 C. M. FISHER AND MONROE COLE From the Neurology Service ofthe Massachusetts General Hospital and the Department of Neurology, Harvard Medical School, U.S.A. In the past few years, at the Massachusetts General The general examination was not remarkable except for Hospital, we have observed 14 patients having moderate obesity and mild hypertension (138/104 mm. suffered strokes with an unusual neurological deficit Hg). On neurological examination the patient was alert and intelligent with no speech disorder. Visual acuity was in which the arm and leg on the same side showed a normal and the visual fields were full. The optic fundi combination of severe cerebellar-like ataxia and were not remarkable. The pupils were equal and reacted pyramidal signs. The cases so strongly resembled normally. The extraocular movements were full. Hori- one another that the clinical picture may be regarded zontal nystagmus with the quick component to the left as a cerebrovascular syndrome. was present on left lateral gaze. Facial sensation and In a typical case weakness of the lower limb, movements were normal. Hearing was not impaired on especially the ankle and toes, and a Babinski sign careful testing. There was neither dysarthria nor dys- were associated with a striking dysmetria of the arm phagia and the tongue protruded in the midline. Opto-Protected by copyright. and leg on the same side. The neurological examina- kinetic nystagmus was diminished with targets moving the was The only avail- to left. tion otherwise almost normal. Motor power was reduced to 6/10 on dorsiflexion of the able neuropathological examination was indecisive toes and ankle on the right side. Motion was strong at the because of the great number and complexity of the right knee and hip as it was in the other limbs. lesions which had accumulated by the time the patient The right arm and leg showed a severe intention tremor died. The site of the responsible lesion is therefore at of a cerebellar type. On the finger-nose test wild oscilla- present uncertain and indeed it has been difficult to tory movements caused the patient to strike himself in select an anatomical locus which satisfactorily the face. The patient could not use the right hand for accounts for the neurological signs. Consideration of eating. Abnormal rebound was easily demonstrated. these cases requires discussion of the more general On holding the arms out the right deviated laterally. On there was a most severe and ataxia resulting from supra- the heel-knee test dysmetria topic of appendicular the right thigh tended to fall laterally although weakness tentorial hemispheral lesions, a puzzling clinical could not be demonstrated. finding. Furthermore it needs to be emphasized The tendon reflexes in the arms were average and equal. that in cases of stroke many kinds of incoordina- The right knee jerk was 3/4, the left 1/4. The right ankle tion are often encountered which are difficult or jerk was 2/4, the left 0/4. The right plantar response was impossible to categorize accurately. briskly extensor, the left flexor. Sucking and grasping reflexes were not obtained. http://jnnp.bmj.com/ FIVE TYPICAL CASE HISTORIES Sensation was normal to pin prick, temperature, vibration, position, and touch (graded hairs). Walking CASE 1 The patient, a man aged 44, while walking one was unsteady and the right leg was dragged with toe- afternoon noted that the right leg 'acted queerly'. Ten scraping and circumduction as in ordinary hemiplegia. minutes later while seated he found that on lighting a On the Romberg test the patient toppled backwards cigarette the right arm overshot its target. As he walked and to the right. The patient noted the right hand felt 200 yards to his physician's office, the right leg tended to different from the left-'swollen', 'stiff', 'larger', 'as if fall out laterally as ifthe knee were 'wrong' and threatened the tendons are tight'. to buckle. As he waited, turning the pages of a magazine A diagnosis of cerebral thrombosis was made and anti- on October 2, 2021 by guest. was incoordinate. After a 30-minute examination, as the coagulant therapy was started. The ataxia of the right patient was putting on his shoes, all symptoms cleared upper extremity decreased gradually and at the end of one completely and he was able to walk with full stride. It week the patient could use it for cutting his meat and was then approximately 50 minutes from the onset. Five eating. Nystagmus was still present on gaze to the left. minutes later the entire deficit recurred and the patient The right thigh fell laterally on attempting the heel-knee was admitted to the Massachusetts General Hospital. test; on hip flexion the force of contraction fluctuated toe 'This study was aided by grant no. NB-O05 152 of the National Institute on different examinations. Dorsiflexion of the great of Neurological Diseases and Blindness, U.S. Public Health Service. was still weak and the patient said he could exert a better 48 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.28.1.48 on 1 February 1965. Downloaded from Hoinolateral ataxia and crural paresis: A vascular syndrome 49 force if he turned his head to one side. The tendon reflexes stance. The patient was alert and pleasant; memory was were unchanged and there was still a right Babinski sign. mildly impaired. The fundi were not remarkable. The On the Romberg test the patient swayed but remained visual acuity was good and the visual fields were full. The standing. The gait was lurching and the right toe still pupils could not be tested because of pilocarpine therapy scraped the floor. After five months, recovery was judged for glaucoma. The extraocular movements were full to be complete. There were no further incidents in the except for upward gaze. Nystagmus was not present. next three years. There was no cranial bruit. The arms and legs were strong. Rapid alternating movements were performed well CASE 2 The patient, a man aged 57, got up during the bilaterally. Cerebellar ataxia of the mildest degree was night to go to the bathroom and staggered badly. On found in the right leg but there was none in the left. awakening in the morning he noted dragging of the left Sensation in the arms was intact for pin prick, vibration, leg, tingling of the left arm and leg, and a 'tremor' of the touch, position, and temperature. In the legs vibration left hand. sense was almost absent below the knees and pin prick Examination later in the day disclosed an alert patient sensation was impaired over the dorsum of both feet. in full charge of his faculties. The cranial nerves were not Position and light touch sensation were intact. The tendon remarkable except for slight inequality of the pupils reflexes were slightly brisker on the right, especially in the (right 2 mm., left 2-5 mm.). Speech was clear. There was arm. The right knee jerk was 3/4, the left 2/4. Both ankle no facial weakness. The left arm was slightly weak in all jerks were absent; the plantar response was flexor parts (9/10). The left leg was definitely weak with power bilaterally. On standing with the feet together the patient at the hip of 6/10, knee 4/10, dorsi- and plantar-flexion at promptly fell to the right; closing the eyes made no the ankle 3/10 and at the toes 0/10. There was a most difference. He was unable to walk heel-to-toe. When striking wild cerebellar ataxia of the left arm and leg on sitting on the bed with the feet dangling he slowly toppled all tests of coordination. The tendon reflexes were slightly to the right. The blood pressure, which had been 180/120 increased on the left. The left plantar response was mm. Hg four months before, was 150/94 mm. Hg. All absent, the right was flexor. Sensation was intact. Tone pulses were absent at the ankles. Protected by copyright. was slightly increased in the left upper extremity. The Cerebral thrombosis was diagnosed and anticoagulant rebound phenomenon was prominent in the left arm. therapy begun. The patient improved slowly. On the The blood pressure was 180/105 mm. Hg. The spinal thirteenth day he could walk better but on standing with fluid was normal. There had been no headache. the feet together he still toppled to the right and on walk- Great improvement took place in two weeks and a left ing leaned far to the right. On the eighteenth day on Babinski sign had become evident. Three months later getting out of bed in the morning he fell to the floor there was very slight cerebellar ataxia in the left extremi- because of incoordination of the right leg. The next day ties and a left Babinski sign. There was no further neuro- he was worse and had little control over the right leg, logical trouble in the next two years. veered to the right again, and could hardly walk. On the twentieth day the right leg was weak. Control of the right CASE 3 A man, aged 78, on finishing supper at 6 p.m. arm was impaired and he could not write his name or arose from the table and fell to the right to the floor. feed himself. He could still wind his wristwatch. At times He was able to get to his feet and walked home a few he noted a slight thickness of the tongue in talking and for hundred yards but had to push himself to the left to a while the right arm was numb.
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