(Stroke. 1999;30:1490B-1493.)
© 1999 American Heart Association, Inc.
Letters to the Editor |
Ataxic Hemiparesis: An Old Debate for Lacune Aficionados
Service de Neurologie, CHU J. Minjoz, Besançon, France
Service de Neurologie, CHU Vaudois, Lausanne, Switzerland
To the Editor:
We read the article by Gorman et al1 on ataxic hemiparesis (AH) with great interest. The authors studied a small series of 45 patients with AH and stressed that they had reviewed all previously published cases and series in English. Unfortunately, they overlooked our series of 100 stroke patients with AH published 4 years ago.2 Our study, which also cited findings from the English literature, gives substantial consideration to research described in the French literature.3 4 5 6 7 We agree with the clinical conclusions of Gorman et al that the clinical features of AH for the various locations are virtually identical. Although sensory disturbances are frequently associated with AH in the thalamic or capsular location, it is important to distinguish between the different clinical pictures in thalamic involvement: typical Dejerine-Roussy syndrome, "painful AH," and "ataxic-hypesthesic syndrome."8 9 10 11 Cerebellar ataxia is explained by an interruption of this afferent pathway at the level of the ventral lateral nucleus. Moreover, we would like to stress the fact that the most typical picture of crural paresis and homolateral ataxia can be observed only in infarcts involving the anterior cerebral artery territory. In this case, ataxia is explained by the involvement of the cortico-ponto-cerebellar pathway (Türck's tract).12 A potential source of embolism—arterial or cardiac—is not uncommonly found (present in one quarter of our patients), and in addition, infarct may also be caused by a hemodynamic mechanism in the end-zone vascular territory.13 All these findings suggest that no definite correlation can be established between AH and lacunar infarction. An extensive work-up should be performed to precisely define the etiologic mechanism.
Finally, the clinical picture of AH is basically explained by a lesion involving both the corticospinal and the cerebello-thalamo-cortico-ponto-cerebellar tracts between the cortex and the pons. We totally agree that although it is a heterogeneous entity, AH can generally be attributed to small-vessel disease and is therefore a marker of more generalized cerebral vascular disease, even if it appears to predict a positive outcome. Nevertheless, faced with a given individual presenting with AH, it remains difficult to use this concept for specific management, and the specificity of lacunar syndromes should be closely reappraised.14
References
1.
Gorman MJ, Dafer R, Levine SR. Ataxic
hemiparesis: critical appraisal of a lacunar syndrome.
Stroke. 1998;29:2549–2555.
2.
Moulin T, Bogousslavsky J, Chopard JL, Ghika J,
Crépin-Leblond T, Martin V, Maeder P. Ataxic hemiparesis: a
re-evaluation. J Neurol Neurosurg Psychiatry. 1995;58:422–427.
3. Babinski J, Jumentié J. Syndrome cérébelleux unilatéral. Rev Neurol (Paris). 1911;115–118.
4. Marie P, Foix C. Formes cliniques et diagnostic de l'hémiplégie cérébelleuse syphilitique. Semin Med. 1913;33:145–152.
5. Garcin R. Syndrome cérébello-thalamique par lésion localisée du thalamus avec une dégression sur le "signe de la main creuse" et son intéret séméiologique. Rev Neurol (Paris). 1955;93:143–149.[Medline] [Order article via Infotrieve]
6. Nicolesco I, Cretu V, Demestresco L. Syndrome de l'artère cérébrale antérieure: monoplégie crurale droite avec symptomatologie cérébelleuse prépondérante. Bull Soc Med Hop Bucarest. 1930:276.
7. Vincent C. Syndrome thalamique avec troubles cérébelleux et vaso-asymétrie. Rev Neurol (Paris). 1908;1:553–556.
8. Déjerine J, Roussy G. Le syndrome thalamique. Rev Neurol (Paris). 1906;12:521–532.
9.
Bogousslavsky J, Regli F, Ghika J, Feldmeyer JJ.
Painful ataxic hemiparesis. Arch Neurol. 1984;41:892–893.
10.
Melo TP, Bogousslavsky J. Hemiataxia-hypesthesia:
a thalamic stroke syndrome. J Neurol Neurosurg
Psychiatry.. 1992;55:581–584.
11. Melo TP, Bogousslavsky J, Moulin T, Nader J, Regli F. Thalamic ataxia. J Neurol. 1992;239:331–337.[Medline] [Order article via Infotrieve]
12.
Bogousslavsky J, Martin R, Moulin T. Homolateral ataxia
and crural paresis: a syndrome of anterior cerebral artery territory
infarction. J Neurol Neurosurg Psychiatry. 1992;55:1146–1149.
13.
Bogousslavsky J, Regli F. Centrum ovale infarcts:
subcortical infarction in the superficial territory of the middle
cerebral artery. Neurology. 1992;42:1992–1998.
14.
Bogousslavsky J. The plurality of subcortical
infarction. Stroke. 1992;23:629–631.
Response
Department of Neurology, Wayne State University, Detroit, Michigan
Department of Neurology, Medical College of Ohio, Toledo, Ohio
Key Words: ataxia • lacunar infarctions
We appreciate the comments in the letter written by Drs Moulin and Bogousslavsky. While our series of 45 patients is clearly not a small series for a specific stroke syndrome, we regret and apologize for having omitted their series of AH patients.1 Our methodology a priori involved only the English literature, utilized a Medline search with the terms lacunar stroke and AH, and subsequently checking the references in all of the papers located on the Medline search. Current computer searches appear to be a bit more comprehensive, and we have since located a few other papers we had missed on the initial series of searches. Review of these articles does not seem to substantially alter any of our conclusions as written in the paper.2
We thank them also for their thoughtful comments regarding thalamic localization in AH and similar syndromes, as well as those regarding evaluation of a patient with AH. While we can use statistics from a group study to help guide us when we have to make clinical decisions without data specific to an individual, statistics neither diminish the urgency nor replace the necessity to obtain etiologic information for each individual presenting with a stroke syndrome.
References
1. Moulin T, Bogousslavsky J, Chopard J-L, Ghika J, Crepin-Leblond T, Martin V, Maeder P. Vascular ataxic hemiparesis: a re-evaluation. J Neurol Neurosurg Psychiatry. 1995;58:422–427.
2. Gorman MJ, Dafer R, Levine SR. Ataxic hemiparesis: critical appraisal of a lacunar syndrome. Stroke. 1998;29:2549–2555.
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