Cheiro-oral syndrome with bilateral oral involvement: a study of pontine lesions by high-resolution magnetic resonance imaging

Cheiro-oral syndrome: a clinical analysis and review of literature

PURPOSE

After a century, cheiro-oral syndrome (COS) was harangued and emphasized for its localizing value and benign course in recent two decades. However, an expanding body of case series challenged when COS may arise from an involvement of ascending sensory pathways between cortex and pons and terminate into poor outcome occasionally.

MATERIALS AND METHODS

To analyze the location, underlying etiologies and prognosis in 76 patients presented with COS collected between 1989 and 2007.

RESULTS

Four types of COS were categorized, namely unilateral (71.1%), typically bilateral (14.5%), atypically bilateral (7.9%) and crossed COS (6.5%). The most common site of COS occurrence was at pons (27.6%), following by thalamus (21.1%) and cortex (15.8%). Stroke with small infarctions or hemorrhage was the leading cause. Paroxysmal paresthesia was predicted for cortical involvement and bilateral paresthesia for pontine involvement, whereas crossed paresthesia for medullary involvement. However, the majority of lesions cannot be localized by clinical symptoms alone, and were demonstrated only by neuroimaging. Deterioration was ensued in 12% of patients, whose lesions were large cortical infarction, medullary infarction, and bilateral subdural hemorrhage.

CONCLUSION

COS arises from varied sites between medulla and cortex, and is usually caused by small stroke lesion. Neurological deterioration occurs in 12% of patients and relates to large vessel occlusion, medullary involvement or cortical stroke. Since the location and deterioration of COS cannot be predicted by clinical symptoms alone, COS should be considered an emergent condition for aggressive investigation until fatal cause is substantially excluded.

Bilateral Paramedian Pontine Base Infarction

In paramedian caudal pontine infarctions, the medial lemniscus is often affected. This typically leads to dissociated sensory symptoms. We present a case in which a patient suffering from a bilateral caudal pontine infarction experienced a marked bilateral sensory disorder of the hands and distal arms.

[Clinical study of 17 patients with cheiro-oral-pedal syndrome]

BACKGROUND

To characterize the clinical features, etiology and prognosis in cheiro-oral-pedal syndrome.

PATIENTS AND METHOD

Descriptive study of 17 patients with cheiro-oral-pedal syndrome included in the Sagrat Cor Hospital of Barcelona Stroke Registry over a 11 year period.

RESULTS

Cheiro-oral-pedal syndrome was present in 6 patients (35%), cheiro-oral syndrome in 10 (59%) and isolated oral syndrome in 1 (6%). Cheiro-oral-pedal syndrome was caused by a lacunar infarct in 88% of patients and by atherotrombotic infarcts in 12%. Cheiro-oral-pedal syndrome accounted for 0.7% of all acute strokes (n = 2.244), 1% of all cerebral infarcts (n = 1.649), 3.5% of all lacunar infarcts (n = 422) and 18.5% of all pure sensory lacunar infarcts (n = 80). Thalamus (n = 13), internal capsule (n = 2), striatocapsular involvement (n = 1) and fronto-parietal involvement (n = 1) were the cerebral topographies. Absence of in hospital mortality and absence or mild neurological deficit at discharge from the hospital were present in all the patients.

CONCLUSIONS

Lacune hypothesis is present in cheiro-oral-pedal syndrome. Cheiro-oral-pedal syndrome was caused by a lacunar infarct in 88% of patients. The thalamic topography is the most frequent and the prognosis in cheiro-oral-pedal syndrome is good.

Pure sensory stroke caused by a cerebral hemorrhage: clinical-radiologic correlations in seven patients

BACKGROUND AND PURPOSE

Pure sensory stroke (PSS) usually is caused by a lacunar infarct; reports of PSS caused by cerebral hemorrhage have been rare. We correlated clinical and neuroradiologic findings in patients with PSS caused by cerebral hemorrhage.

METHODS

We retrospectively studied seven patients with appropriate clinical findings and lesions revealed by X-ray CT and MR imaging (five men, two women; age range, 46-64 years; mean age, 55.9 years).

RESULTS

Hemorrhages involved the thalamus, pons, internal capsule, or cerebral cortex. MR imaging revealed thalamic PSS was located in the ventral posterior lateral (VPL) or ventral posterior medial (VPM) nucleus; a lesion producing a thalamic cheiro-oral syndrome was situated on the border between the VPL and VPM. Pontine PSS involved the medial lemniscus together with the ventral trigeminothalamic tract, sparing the anterior and lateral spinothalamic tracts. Accordingly, pontine PSS, but not thalamic PSS, selectively affected vibration and position sense while leaving pinprick and temperature perception intact, and oral sensory involvement was bilateral when cheiro-oral syndrome had a pontine origin. MR imaging revealed hemorrhage in the postcentral gyrus in the cortical variety of PSS and in the posterior part of the posterior limb (thalamocortical sensory pathway) in PSS of internal capsular origin. The postcentral gyral lesion impaired stereognosis and graphesthesia.

CONCLUSION

Focal hemorrhages can lead to purely sensory stroke syndromes, and the clinical deficits are fairly well linked with the locations of the bleeds.

Bilateral cheiro-oral syndrome

Eight cases of pure bilateral cheiro-oral syndrome (COS) are reported. The location and etiology of lesion were well defined in six cases, including pontine infarct in three, and brainstem hemorrhage, unilateral thalamic infarct and bilateral subdural hematoma in one patient each respectively. Neuroimaging and neurophysiological studies were normal in another two patients. Taken together with the previous five reported cases of bilateral COS, pons is the most frequent site for presentation even in the absence of associated brainstem signs.

Pure or predominant sensory stroke due to brain stem lesion

BACKGROUND AND PURPOSE

Pure or predominant hemisensory symptoms can be seen in patients with brain stem stroke. However, there have been no reports in which sufficient numbers of patients were studied with detailed descriptions on the sensory patterns and imaging findings.

METHODS

We describe 17 patients presenting with pure or predominant hemisensory symptoms due to brain stem stroke in whom CT scan and/or MRI identified appropriate lesions.

RESULTS

Eleven patients had an infarct and 6 had a hemorrhage. Aside from sensory deficit, the majority had dizziness and gait ataxia. Fifteen patients had paramedian dorsal pontine lesions associated with pure or predominant lemniscal sensory involvement, often in the cheiro-oral (n = 4) or leg dominance (n = 4) patterns. The lesions of the former group tended to be located more medially compared with those of other patients, which is in agreement with the sensory topography of the pontine lemniscal sensory tract. Bilateral facial or perioral sensory symptoms were noted in 6 patients. One patient with a dorsolateral pontine lesion had selective spinothalamic modality impairment, while one with a lateral midbrain infarct had sensory deficit of all modalities.

CONCLUSIONS

Pure or predominant brain stem sensory stroke is most often produced by small infarcts or hemorrhages in the paramedian dorsal pontine area and may be differentiated from thalamic pure sensory stroke by the following characteristics: frequent association of dizziness/gait ataxia, predominant lemniscal sensory symptoms, occasional leg dominance or cheiro-oral pattern, and frequent bilateral perioral involvement.

Bilateral perioral sensory symptom after unilateral stroke: does it have a localizing value?

Bilateral perioral sensory dysfunction due to unilateral cerebral lesion is rare, and has been thought to be caused by midline brainstem lesions. Six patients are described herewith, with bilateral perioral sensory symptoms due to unilateral strokes that do not involve the mid-brainstem region. Brain-computed tomographic scan and magnetic resonance imaging demonstrated unilateral cerebral strokes in the thalamus, posterior limb of the internal capsule, basal ganglia, fronto-parietal cortex and the insular-frontal subcortical area. This observation suggests that bilateral perioral sensory symptoms do not have a localizing value. Possible pathogenetic mechanisms for this sign are discussed.

Bilateral cheiro-oral syndrome and traumatic subdural hematoma

Typical bilateral cheiro-oral syndrome was encountered in a 74-year-old man who had bilateral subdural hematoma after a minor head injury. The delayed grave neurologic deficits occurred 1 month later without expansion of the hematoma. Removal of the lesions reversed both cheiro-oral syndrome and his late-onset neurological disabilities.

Restricted acral sensory syndrome following minor stroke. Further observation with special reference to differential severity of symptoms among individual digits

BACKGROUND

Restricted acral sensory syndrome (RASS) after minor stroke most often manifests as a cheiro-oral syndrome. However, recent studies have described more varied patterns of RASS and also have reported that the degree of sensory symptoms may vary among individual digits. Until recently, however, there have been no reports in which sufficient numbers of patients were studied with detailed information on the symptomatic severity among individual digits.

SUMMARY OF REVIEW

In this report, I describe 30 patients presenting with RASS secondary to minor stroke. Computed tomographic scan and/or magnetic resonance imaging identified lesions in the lateral thalamus in 11, midbrain in 2, pontine tegmentum in 8, capsulo-corona radiata in 5, and frontoparietal subcortical-cortical areas in 4 patients. The patterns of RASS were cheiro-oral in 10, cheiro-oral-pedal in 8, cheiro-pedal in 4, restricted to palm and/or fingers in 7, and periotal-pedal in 1. Dominant involvement of upper lip, thumb, and index finger was frequent, especially in patients with thalamic and thalamocortical lesions. In patients with cortical-subcortical lesions, cheiro-oral or restricted finger involvements were observed, while the foot was spared. In patients with pontine lesions, bilateral RASS was occasionally observed, and the pattern of preponderant involvement of the first two digits was not apparent.

CONCLUSIONS

These patterns of RASS generally agree with the previously observed sensory topography of monkeys, and they support anatomic proximity of sensory fibers from acral parts of the body. However, other mechanisms such as differential vulnerability of generation of paresthesia in different body parts or a low-threshold concept based on disproportionately large representing areas for the acral parts of the body in the human sensory system may also be required to explain some of the clinical observations.

Brainstem haematomas: early and late prognosis

The purpose of the present retrospective study is to analyse 14 patients harbouring brainstem haematomas and to discuss the early and late prognosis. The patients were divided into two groups: group A (survivors), 8 patients with follow-up duration ranging between 8 months and 12 years; and group B (nonsurvivors), 6 patients. At the time of onset or hospital admission, the former were under 50 years of age and had no important clinical history. Their degree of consciousness was altered only slightly or moderately and their brainstem haemorrhages were focal or only slightly diffuse. Three patients in this group underwent surgical treatment. The members of group B, who died within days of their admission to the hospital, were over 60 years of age, had a number of clinical antecedents and severe alterations of consciousness, while 83% of them presented diffuse brainstem haemorrhages. None of the patients of this group were treated surgically. It was concluded that: 1) the indications for surgery for these lesions were progressive hydrocephalus, increase in the mass effect with progressive symptomatology and suspected "cryptic vascular malformation" with risk of later rebleeding or brain tumour; 2) surgical treatment was necessary to improve the symptomatology in 3 patients in group A, although there were no significant differences between surgically treated and nonsurgically treated patients in the same group with respect to prognosis; 3) age, clinical history, degree of alteration of consciousness and type of haemorrhage are the major factors affecting the early and late prognosis of brainstem haemorrhages.

Small primary intracerebral hemorrhage. Clinical presentation of 28 cases

BACKGROUND

Although there have been sporadic reports of patients with small intracerebral hemorrhages presenting with discrete clinical features, the clinical and distributional characteristics of these hemorrhages have not been adequately investigated.

CASE DESCRIPTIONS

We studied 28 patients who had primary intracerebral hemorrhage of a longest diameter < or = 1.5 cm as seen in computed tomographic scan and/or magnetic resonance imaging. Small primary intracerebral hemorrhages were found in the basal ganglia in 8 patients (2 with intraventricular hemorrhage), the posterior limb of the internal capsule in 8, the area of the fourth ventricle of the cerebellum in 7 (5 with intraventricular hemorrhage), the pontine tegmentum in 4, and the thalamomesencephalic area in 1. All patients except 3 were hypertensive, suggesting that most of the hemorrhages may have occurred because of rupture of small end arteries secondary to long-standing hypertension. Depending on their location, the hemorrhages clinically manifested as pure motor stroke in 7, pure sensory stroke in 6, vertigo/ataxia in 7, sensorimotor stroke in 4, and ataxic hemiparesis in 2 patients. One patient with thalamomesencephalic hemorrhage showed vertical gaze disturbance, and 1 with basal ganglionic hemorrhage presented with symptoms of acute hydrocephalus secondary to a relatively large amount of intraventricular hemorrhage. The prognosis of small intracerebral hemorrhage was generally excellent except for when patients were very old or when there was a significant amount of intraventricular bleeding.

CONCLUSIONS

Small primary intracerebral hemorrhage has its predilection sites: basal ganglia, posterior limb of the internal capsule, area of the fourth ventricle of the cerebellum, and pontine tegmentum. Most of the hemorrhages are probably caused by rupturing of the small end arteries in the setting of chronic hypertension. They produce discrete clinical syndromes often mimicking classic lacunar syndrome, of which pure sensory stroke is relatively common.

Stroke and restricted sensory syndromes

There have been sporadic case reports of a restricted sensory syndrome caused by stroke, most often as a cheiro-oral syndrome. We describe 14 patients with stroke who showed various restricted sensory syndromes and correlated their symptoms with the radiological findings. Twelve had small infarcts and two had haemorrhages; six had lesions in the posterolateral thalamus, five in the pontine tegmentum, one in the lenticulocapsular area, one in the frontoparietal subcortex, and one in the frontal white matter. Sensory abnormalities were in the perioral area, hands, fingers, feet and toes, in various combinations. Two patients with pontine stroke had bilateral sensory abnormalities associated with paramedian lesions. Thus, strokes in the sensory pathways can cause various restricted sensory syndromes of which 'cheiro-oral syndrome' is only one variant. Magnetic resonance imaging is of interest in the clinicoradiological correlation, and helps elucidate the somatotopic pattern of the human sensory pathways.

Pure sensory stroke. Clinical-radiological correlates of 21 cases

BACKGROUND

Although pure sensory stroke is a relatively common lacunar syndrome, the responsible lesions are often unidentified because of their small size. I reported 21 cases of pure sensory stroke in which the lesions could be identified by head computed tomography and/or magnetic resonance imaging and correlated the clinical findings with the radiological lesions.

SUMMARY OF REPORT

Eleven patients had thalamic strokes. Lacunes confined to the posterolateral part of the thalamus were found in nine cases, and hemorrhages of relatively large size were found in two. Five patients showed a loss of all sensory modalities, but six with very small lacunes showed minor or restricted sensory changes. Seven patients with lacunes or hemorrhages in the lenticulocapsular region or corona radiata showed abnormalities of spinothalamic tract sensation. Two patients with a small lacune and a hemorrhage in the pontine tegmentum showed a selective sensory deficit of the medial lemniscal type. One patient with a small cortical infarct showed a cortical sensory loss that was preceded by cortical sensory transient ischemic attacks.

CONCLUSIONS

Pure sensory stroke can occur with lesions in various areas of the somatosensory system. Hemisensory deficits of all modalities usually are associated with a relatively large lacune or hemorrhage in the lateral thalamus, whereas tract-specific or restricted sensory changes suggest very small strokes in the sensory pathway from the pons to the parietal cortex.

Cheiro-oral syndrome due to lesions in the corona radiata

BACKGROUND AND PURPOSE

We describe three patients with cheiro-oral syndrome caused by a small lesion in the corona radiata confirmed by high-resolution magnetic resonance imaging.

CASE DESCRIPTIONS

Case 1: A 56-year-old hypertensive man who developed hypesthesia and paresthesia in the left perioral area and hand was found to have a small hematoma just lateral to the right internal capsule. Case 2: A 67-year-old man noticed hypesthesia around the left mouth angle and thumb and index finger. Magnetic resonance imaging revealed a lesion in the right corona radiata. Case 3: A 45-year-old hypertensive man developed numbness in his perioral region and left hand that later spread to his shoulder. Magnetic resonance imaging revealed a recent small infarct in the lower lateral aspect of the right corona radiata.

CONCLUSIONS

A small lesion in the corona radiata can cause cheiro-oral syndrome, whose pathogenetic mechanism in such patients may be explained by the somatotopical location or by the differing vulnerability of the neuropils in the corona radiata.

Evidence of somatotopic organization of the sensory thalamus based on infarction in the nucleus ventralis posterior

BACKGROUND

This is to describe a restricted sensory syndrome of unique distribution due to thalamic infarct.

CASE DESCRIPTION

We report a case of pure sensory disturbance involving the left intraoral and perioral regions and the tips of the thumb and forefinger of the left hand. Magnetic resonance imaging revealed a small infarct in the contralateral thalamus, presumably affecting the nucleus ventralis posterior.

CONCLUSIONS

This patient provides an excellent correlation between clinical findings and thalamic representation of body surface as established during stereotactic procedures.

Basilar branch pontine infarction with prominent sensory signs

We identified 10 patients with acute pontine infarction and specific sensory findings. Two patients had pure sensory symptoms, two had sensory complaints of the hand and mouth, and the other six had hemisensory loss referable to medial lemniscal or spinothalamic tract dysfunction but localized to one limb, to an arm and leg, or to the face, characteristic of stroke localized to the cerebral hemisphere. All patients had magnetic resonance imaging showing infarction of the medial or lateral pontine tegmentum and a patent basilar artery. No definite source for cardiogenic thromboembolism was found. Infarcts in the midline extending from the base of the pons posteriorly into the tegmentum suggested basilar branch occlusion, while infarcts involving only part of the tegmentum probably resulted from small penetrator branch occlusion. Vertigo, light-headedness, or cranial nerve dysfunction suggested a pontine location of neurological dysfunction in these patients, but the nature of the sensory findings did not always predict the lateral, medial, inferior, or superior extent of tegmental infarction.