I19 Postgrad Med J: first published as 10.1136/pgmj.29.329.119 on 1 March 1953. Downloaded from - N/ THE SYNDROMES OF THE ARTERIES OF THE BRAIN AND, SPINAL CORD 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 Artery (See also Cabot, I937; Pines and Gilensky, Each vertebral artery enters the foramen 1930.) magnum in front of the roots of the hypoglossal nerve, inclines forwards and medially to the The Posterior Inferior Cerebellar Artery anterior aspect of the medulla oblongata and unites The posterior inferior cerebellar artery arises with its fellow at the lower border of the pons 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 anterior spinal artery 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 spinothalamic tract 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 posterior spinal artery. A twig to the has commenced early in the region of the inferior dentate nucleus 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 syndrome. 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 cerebellum is infarcted and this con- side of the lesion. He may stagger to the same side tributes to the dyssynergia. Nystagmus 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). Dysphagia is constant and ment of pain 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. Speech is the sense 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 headache 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 medial lemniscus 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 grey matter 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 taste 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 cranial nerves 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 paralysis 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 ataxia 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 cerebellar peduncle. 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.