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Sensory Loss Due to Lesions of the Parietal Lobe
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In the anterior parietal lobe syndrome (Verger-Dejerine syndrome), there are disturbances mainly of discriminative sensory functions of the opposite arm, leg, and side of the face without impairment of the primary modalities of sensation (unless the lesion is extensive and deep) Loss of position sense and sense of movement, impaired ability to localize touch and pain stimuli (topagnosia), widening of twopoint threshold, and astereognosis are the most prominent ndings, as described earlier in this chapter and on page 400 Another characteristic manifestation of parietal lobe lesions is sensory inattention, extinction, or neglect In response to bilateral simultaneous testing of symmetrical parts, using either tactile or painful stimuli, the patient may acknowledge only the stimulus on the sound side; or, if the face and hand or foot on the affected side is touched or pricked, only the stimulus to the face may be noticed Apparently cranial structures command more attention than other less richly innervated parts A similar phenomenon of extinction occurs when visual stimuli are simultaneously delivered to both right and left peripheral elds Yet each stimulus, when applied separately to each side or to each part of the affected side, is properly perceived and localized In the case of sensory neglect, the patient ignores one side of the body and extrapersonal space contralateral to the parietal lesion, which is usually in the nondominant hemisphere Left parietal lesions may also cause (right) sensory neglect, but less frequently Sensory neglect or extinction, which may also occur occasionally with posterior column and medial lemniscus lesions, may be detected in persons who disclaim any sensory symptoms These phenomena and other features of parietal lobe lesions are considered further in Chap 22 Yet another parietal lobe syndrome (Dejerine-Mouzon) is featured by a severe impairment of the primary modalities of sensation (pain, thermal, tactile, and vibratory sense) over half of the body Motor paralysis is variable; with partial recovery, there may be a clumsiness that resembles cerebellar ataxia Since the sensory disorder simulates that due to a thalamic lesion, it was called pseudothalamic by Foix and coworkers Hyperpathia, much like that of the Dejerine-Roussy syndrome (see above), has also been observed in patients with cortical-subcortical parietal lesions The pseudothalamic syndrome was related by Foix and colleagues to a sylvian infarct; Bogousslavsky and associates have traced it to a parietal infarct due to occlusion of the ascending parietal branch of the middle cerebral artery In each of the aforementioned parietal lobe syndromes, if the dominant hemisphere is involved, there may be an aphasia, a bimanual tactile agnosia, or a Gerstmann syndrome; with nondominant lesions, there may be anosognosia (page 401) Often with parietal lesions, the patient s responses to sensory stimuli are variable A common mistake is to attribute this abnormality to hysteria A lesion con ned to only a part of the parietal cortex (the best examples have been due to glancing bullet or shrapnel wounds of the skull) may result in a circumscribed loss of
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Diagnosis of Somatosensory Syndromes
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Af rmation of the clinical sensory syndromes is often possible by the application of electrophysiologic testing Slowing and reduced amplitude of sensory nerve conduction is found with lesions of nerve, but only if the lesion lies distal to (or within) the sensory ganglion Severe sensory loss in a neuropathic pattern with preserved sensory nerve action potentials therefore indicates a radiculopathy Loss or slowing of H and F responses corroborates the presence of lesions in proximal parts of nerves, plexuses, and roots By the use of somatosensory evoked potentials, it is possible to demonstrate slowing of conduction in the peripheral nerves or roots, in the pathways from spinal cord to a point in the lower medulla, in the medial lemniscus to the thalamus, and in the pathway from the thalamus to the cerebral cortex In the context of regional sensory loss, evoked potentials nd their greatest utility in demonstrating root disease when sensory nerve conduction studies are normal; otherwise, they are used most frequently to support the diagnosis of multiple sclerosis, in which case there may or may not be corresponding sensory features (See Chap 2 for further discussion) In practice, it is seldom necessary to examine all modalities of sensation and perception With single peripheral nerve lesions, touch and pinprick testing are the most informative With spinal cord disease, pinprick and thermal stimuli are most revealing of lateral column lesions; testing the senses of vibration, position, and movement, and particularly the sense of direction of a dermal stimulus, reliably indicates posterior column lesions Touch is the least useful In brainstem lesions, all modes of sensation including touch may be affected, and this applies in general to thalamic lesions Thus, one is guided in the selection of tests by the suspected locale of the disease
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