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Lacunar Syndromes
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As one might surmise, small penetrating branches of the cerebral arteries may become occluded, and the resulting infarcts may be so small or so situated as to cause no symptoms whatsoever As the softened tissue is removed, it leaves a small cavity, or lacune Early in the twentieth century, Pierre Marie con rmed the occurrence of multiple deep small cavities of this type, rst described by Durant-Fardel in 1843 Marie referred to the condition as etat lacunaire He distinguished these lesions from a ne loosening of tissue around thickened vessels that enter the anterior and posterior perforated spaces, a change to which he gave the name etat crible Pathologists have not always agreed on these distinctions, but we
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If the lacuna lies in the territory of a lenticulostriate artery, ie, in the internal capsule or adjacent corona radiata, it causes a pure motor hemiplegia involving the face, arm, hand, leg, and foot A lacuna situated in the ventral pons may cause an identical syndrome Symptoms may be abrupt in onset or evolve over several hours, but in some instances (10 of 34 cases, according to Weisberg) the neurologic de cit evolves stepwise and relatively slowly, over as long a period as 2 to 3 days, thereby simulating a small hemorrhage CT scanning shows the lesions in about two-thirds of cases if several days have passed, and MRI in almost all cases within hours of the stroke Sometimes the motor disorder takes the form of a more limited hemiplegia of the face and arm or arm and leg, or a dysarthria with or without hemiplegia Recovery, which may begin within hours, days, or weeks, is sometimes nearly complete, even in the face of a severe initial stroke However, many patients are left with some degree of clumsiness or slowness of movement of the affected side Similarly, a lacuna of the lateral thalamus or (less often of the parietal white matter) presents as a pure hemisensory defect involving the limbs, face, and trunk extending to the midline, a pure sensory stroke The incidence, course, and outcome are much the same as in a pure hemiplegia
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CEREBROVASCULAR DISEASES
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Medial longitudinal fasciculus 6th N nucleus complex
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Vestibular nucleus Cerebellum Restiform body 7th N nucleus Dorsal cochlear nucleus Descending tract and nucleus of 5th N Spinothalamic tract 8th N Lateral inferior pontine syndrome Medial inferior pontine syndrome 6th N Corticospinal and corticobular tract Pontine nuclei and ponto-cerebellar fibers 7th N Middle cerebellar peduncle Medial lemniscus
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Figure 34-14 Transverse section through the lower pons
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Signs and symptoms 1 Medial inferior pontine syndrome (occlusion of paramedian branch of basilar artery) a On side of lesion (1) Paralysis of conjugate gaze to side of lesion (preservation of convergence) (2) Nystagmus (3) Ataxia of limbs and gait (4) Diplopia on lateral gaze b On side opposite lesion (1) Paralysis of face, arm, and leg (2) Impaired tactile and proprioceptive sense over half of the body 2 Lateral inferior pontine syndrome (occlusion of anterior inferior cerebellar artery) a On side of lesion (1) Horizontal and vertical nystagmus, vertigo, nausea, vomiting, oscillopsia (2) Facial paralysis (3) Paralysis of conjugate gaze to side of lesion (4) Deafness, tinnitus (5) Ataxia (6) Impaired sensation over face b On side opposite lesion (1) Impaired pain and thermal sense over half the body (may include face) 3 Total unilateral inferior pontine syndrome (occlusion of anterior inferior cerebellar artery); lateral and medial syndromes combined
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Pontine center for lateral gaze paramedian pontine reticular formation (PPRF) Vestibular nuclei and connections Middle cerebellar peduncle Abducens nerve or nucleus; PPRF Corticobulbar and corticospinal tract in lower pons Medial lemniscus
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Vestibular nerve or nucleus Seventh nerve or nucleus Pontine center for lateral gaze (PPRF) Auditory nerve or cochlear nuclei Middle cerebellar peduncle and cerebellar hemisphere Main sensory nucleus and descending tract of fth nerve Spinothalamic tract
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