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Sung MF, Lim JH. Ataxic hemiparesis: a narrative review for clinical practice in rehabilitation. Top Stroke Rehabil 2024; 31:537-545. [PMID: 37965878 DOI: 10.1080/10749357.2023.2281722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 11/04/2023] [Indexed: 11/16/2023]
Abstract
BACKGROUND Ataxic hemiparesis (AH) is a well-recognized clinical lacunar stroke syndrome, characterized by paresis with ataxia on the same side of the body. It affects patients with stroke involving the basal ganglia, pons, internal capsule, corona radiata, and thalamus. In the past, lacunar syndrome denotes good functional recovery with low mortality and morbidity rate. However, recent evidence suggests AH has an association with more debilitating outcomes in the long term. OBJECTIVE To provide a comprehensive narrative review of published literatures on the topics related with AH and update clinical practice including rehabilitation. METHODS Literature review was performed by using the keywords "Subcortical Ataxia," "Lacunar Stroke," "Diaschisis", and "Ataxic Hemiparesis" on PubMed and Google Scholar Engines from 1978 to 2022. All papers published in English were reviewed and manual search of references from retrieved literature was performed for other relevant articles. RESULTS A comprehensive review was carried out on the following topics: neuroanatomical localization, pathogenesis, clinical features and clinical assessment scales, pharmacological and non-pharmacological modalities for ataxia treatment, prognosis, and outcome. CONCLUSION AH imposes significant challenges on stroke survivors when it comes to remediation of balance and coordination. It is associated with increased risk of mortality, stroke recurrence, and dementia. Though application of the concept of neuroplasticity and the utilization of repetitive transcranial magnetic stimulation have shown early promising results, further research is needed to establish the practice guidelines for rehabilitation of patients with AH.
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Affiliation(s)
- Mei-Fen Sung
- Division of Rehabilitation Medicine, University Medicine Cluster, National University Hospital, Singapore
| | - Jeong Hoon Lim
- Division of Rehabilitation Medicine, University Medicine Cluster, National University Hospital, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Aoyama T, Kanazawa A, Kohno Y, Watanabe S, Tomita K, Kimura T, Endo Y, Kaneko F. Feasibility Case Study for Treating a Patient with Sensory Ataxia Following a Stroke with Kinesthetic Illusion Induced by Visual Stimulation. Prog Rehabil Med 2020; 5:20200025. [PMID: 33134593 PMCID: PMC7591318 DOI: 10.2490/prm.20200025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 10/13/2020] [Indexed: 12/16/2022] Open
Abstract
Background: Sensory ataxia is a disorder of movement coordination caused by sensory
deficits, especially in kinesthetic perception. Visual stimulus-induced kinesthetic
illusion (KINVIS) is a method used to provide vivid kinesthetic perception without
peripheral sensory input by using a video showing pre-recorded limb movements while the
actual limb remains stationary. We examined the effects of KINVIS intervention in a
patient with sensory ataxia. Case: The patient was a 59-year-old man with a severe
proprioceptive deficit caused by left thalamic hemorrhage. During KINVIS intervention, a
computer screen displayed a pre-recorded mirror image video of the patient’s unaffected
hand performing flexion–extension movements as if it were attached to the patient’s
affected forearm. Kinematics during the flexion–extension movements of the paretic hand
were recorded before and after 20-min interventions. Transcranial magnetic stimulation was
applied to the affected and non-affected hemispheres. The amplitude of the motor-evoked
potential (MEP) at rest was recorded for the muscles of both hands. After the
intervention, the total trajectory length and the rectangular area bounding the trajectory
of the index fingertip decreased. The MEP amplitude of the paretic hand increased, whereas
the MEP amplitude of the non-paretic hand was unchanged. Discussion: The changes in
kinematics after the intervention suggested that KINVIS therapy may be a useful new
intervention for sensory ataxia, a condition for which few effective treatments are
currently available. Studies in larger numbers of patients are needed to clarify the
mechanisms underlying this therapeutic effect.
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Affiliation(s)
- Toshiyuki Aoyama
- Department of Physical Therapy, Ibaraki Prefectural University of Health Sciences, Ami, Japan
| | - Atsushi Kanazawa
- Department of Physical Therapy, Ibaraki Prefectural University of Health Sciences Hospital, Ami, Japan
| | - Yutaka Kohno
- Centre for Medical Sciences, Ibaraki Prefectural University of Health Sciences, Ami, Japan
| | - Shinya Watanabe
- Department of Occupational Therapy, Ibaraki Prefectural University of Health Sciences Hospital, Ami, Japan
| | - Kazuhide Tomita
- Department of Physical Therapy, Ibaraki Prefectural University of Health Sciences, Ami, Japan
| | - Takehide Kimura
- Department of Physical Therapy, Faculty of Health Sciences, Tsukuba International University, Tsuchiura, Japan
| | - Yusuke Endo
- Department of Physical Therapy, Health Science University, Fujikawaguchiko, Japan
| | - Fuminari Kaneko
- Department of Rehabilitation Medicine, Keio University School of Medicine, Tokyo, Japan
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Effect of Sensory Loss on Improvements of Upper-Limb Paralysis Through Robot-Assisted Training: A Preliminary Case Series Study. APPLIED SCIENCES-BASEL 2019. [DOI: 10.3390/app9183925] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Sensory disorder is a factor preventing recovery from motor paralysis after stroke. Although several robot-assisted exercises for the hemiplegic upper limb of stroke patients have been proposed, few studies have examined improvement in function in stroke patients with sensory disorder using robot-assisted training. In this study, the efficacies of robot training for the hemiplegic upper limb of three stroke patients with complete sensory loss were compared with those of 19 patients without complete sensory loss. Robot training to assist reach motion was performed in 10 sessions over a 2-week period for 5 days per week at 1 h per day. Before and after the training, the total Fugl–Meyer Assessment score excluding coordination and tendon reflex (FMA-total) and the FMA shoulder and elbow score excluding tendon reflex (FMA-S/E) were evaluated. Reach and path errors (RE and PE) during the reach motion were also evaluated by the arm-training robot. In most cases, both the FMA-total and the FMA-S/E scores improved. Cases with complete sensory loss showed worse RE and PE scores. Our results suggest that motor paralysis is improved by robot training. However, improvement may be varied according to the presence or absence of somatic sensory feedback.
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Gupta N, Pandey S. Post-Thalamic Stroke Movement Disorders: A Systematic Review. Eur Neurol 2018; 79:303-314. [PMID: 29870983 DOI: 10.1159/000490070] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 05/14/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND After a stroke, movement disorders are rare manifestations mainly affecting the deep structures of the brain like the basal ganglia (44%) and thalamus (37%), although there have been case studies of movement disorders in strokes affecting the cerebral cortex also. SUMMARY This review aims to delineate the various movement disorders seen in association with thalamic strokes and tries to identify the location of the nuclei affected in each of the described movement disorders. Cases were identified through a search of PubMed database using different search terms related to post-thalamic stroke movement disorders and a secondary search of references of identified articles. We reviewed 2,520 research articles and only 86 papers met the inclusion criteria. Cases were included if they met criteria for post-thalamic stroke movement disorders. Case-cohort studies were also reviewed and will be discussed further. Key Messages: The most common post-stroke abnormal movement disorder reported in our review was dystonia followed by hemiataxia. There was a higher association between ischaemic stroke and movement disorder. Acute onset movement disorders were more common than delayed. The posterolateral thalamus was most commonly involved in post-thalamic stroke movement disorders.
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Osumi M, Sumitani M, Otake Y, Morioka S. A "matched" sensory reference can guide goal-directed movements of the affected hand in central post-stroke sensory ataxia. Exp Brain Res 2018; 236:1263-1272. [PMID: 29480355 DOI: 10.1007/s00221-018-5214-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Accepted: 02/20/2018] [Indexed: 12/24/2022]
Abstract
Patients with central post-stroke sensory ataxia (CPSA) suffer from not only somatosensory dysfunction but also the ataxic movement disorder of the affected limb. These sensory and motor impairments possibly interfere each other, but such interference is still unclear. We evaluated smoothness of grasp movements in CPSA patients using a kinematic analysis, and verified the effect of somatosensory reference from the intact hand on grasp movements. Eight CPSA patients were enrolled. We recorded their reach-and-pinch movements of both affected and intact hands toward the tip of the 3-cm-diameter vertical bar, using a three-dimensional measurement system. When executing these movements of one hand, the patients simultaneously pinched the same diameter bar as the goal tip (matched-reference condition: Matched-Ref) or the 5-cm-diameter thicker bar (mismatched-reference condition: Mismatched-Ref) by the other hand. The normalized jerk index (i.e., movement smoothness) of the affected hand was disturbed compared with the intact hand. The kinematic data of the finger opening and closing phases were also disturbed. These disturbances were partially improved with Matched-Ref but not Mismatched-Ref of the intact hand. We successfully evaluated the features of CPSA, indicating that the somatosensory reference method could be useful for rehabilitation in sensory ataxia.
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Affiliation(s)
- Michihiro Osumi
- Graduate School of Health Science, Kio University, 4-2-2 Umaminaka, Kouryou-cho, Kitakatsuragi-gun, Nara, 635-0832, Japan.
- Neurorehabilitation Research Center, Kio University, 4-2-2 Umaminaka, Kouryou-cho, Kitakatsuragi-gun, Nara, 635-0832, Japan.
| | - Masahiko Sumitani
- Department of Pain and Palliative Medicine, The University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8656, Japan
| | - Yuko Otake
- Department of Pain and Palliative Medicine, The University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8656, Japan
| | - Shu Morioka
- Graduate School of Health Science, Kio University, 4-2-2 Umaminaka, Kouryou-cho, Kitakatsuragi-gun, Nara, 635-0832, Japan
- Neurorehabilitation Research Center, Kio University, 4-2-2 Umaminaka, Kouryou-cho, Kitakatsuragi-gun, Nara, 635-0832, Japan
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Urushidani N, Okamoto T, Kinoshita S, Yamane S, Tamashiro H, Kakuda W, Abo M. Combination Treatment of Low-Frequency Repetitive Transcranial Magnetic Stimulation and Intensive Occupational Therapy for Ataxic Hemiparesis due to Thalamic Hemorrhage. Case Rep Neurol 2017; 9:179-187. [PMID: 28966585 PMCID: PMC5618400 DOI: 10.1159/000478975] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 06/21/2017] [Indexed: 11/19/2022] Open
Abstract
Background Both low-frequency repetitive transcranial magnetic stimulation (LF-rTMS) and intensive occupational therapy (OT) are clinically beneficial for post-stroke patients with upper-limb hemiparesis. However, the usefulness of LF-rTMS and intensive OT for ataxic hemiparesis (AH) is unknown. Methods The study subjects included 7 patients with AH. All patients had ataxia and mild hemiparesis without a sensory disturbance that was due to thalamic hemorrhage. Each patient was scheduled to receive 20-min rTMS at 1 Hz at the contralesional cerebral hemisphere followed by 120-min intensive OT, daily for 21 sessions. The primary outcome was the motor function of the affected upper limb that was evaluated by using the Fugl-Meyer Assessment (FMA). In addition, the International Cooperative Ataxia Rating Scale (ICARS) score was determined to assess the severity of ataxia. Results All patients completed the protocol without any adverse effects. The FMA score significantly increased after treatment. Notably, the ICARS score also significantly decreased. Conclusions Our proposed combination treatment is a safe and feasible neurorehabilitative intervention for patients with AH due to thalamic hemorrhage. Our results demonstrate the possibility that rTMS in combination with intensive OT could improve motor function and alleviated ataxia in patients with AH.
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Affiliation(s)
| | - Takatsugu Okamoto
- Nishi-Hiroshima Rehabilitation Hospital, Hiroshima, Japan.,Department of Rehabilitation Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Shoji Kinoshita
- Nishi-Hiroshima Rehabilitation Hospital, Hiroshima, Japan.,Department of Rehabilitation Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Shingo Yamane
- Institute of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | | | - Wataru Kakuda
- Department of Rehabilitation Medicine, International University of Health and Welfare, Mita Hospital, Tokyo, Japan
| | - Masahiro Abo
- Department of Rehabilitation Medicine, The Jikei University School of Medicine, Tokyo, Japan
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Agrawal A, Mittal A, Kohali GB, Sampley S, Singh S. Extensive traumatic thalamic contusions in a child. Asian J Neurosurg 2017; 12:151-152. [PMID: 28413564 PMCID: PMC5379796 DOI: 10.4103/1793-5482.145107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Amit Agrawal
- Department of Neurosurgery, MM Institute of Medical Sciences and Research, Mullana (Ambala), Harayana, India
| | - Amit Mittal
- Department of Radiology, MM Institute of Medical Sciences and Research, Mullana (Ambala), Harayana, India
| | - G B Kohali
- Department of Anesthesiology, MM Institute of Medical Sciences and Research, Mullana (Ambala), Harayana, India
| | - Sunil Sampley
- Department of Surgery, MM Institute of Medical Sciences and Research, Mullana (Ambala), Harayana, India
| | - Satendra Singh
- Department of Surgery, MM Institute of Medical Sciences and Research, Mullana (Ambala), Harayana, India
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Kase CS, Shoamanesh A, Greenberg SM, Caplan LR. Intracerebral Hemorrhage. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00028-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
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Kase CS, Greenberg SM, Mohr J, Caplan LR. Intracerebral Hemorrhage. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10029-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Small ischaemic lesions strategically placed could give rise to specific clinical manifestations depending on the location and size of the lesion. We present the case of five patients with imbalance and falls with no other neurological findings. The computed tomographic scan showed a lacunar infarct in the right or left thalamus. The tendency to fall may complicate rehabilitation. The possible physiological mechanisms are discussed.
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Affiliation(s)
- Nages Nagaratnam
- Department of Medicine (Aged Care and Rehabilitation Services), Blacktown-Mt Druitt Health, Blacktown, NSW, Australia.
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Bastian AJ, Thach WT. Cerebellar outflow lesions: a comparison of movement deficits resulting from lesions at the levels of the cerebellum and thalamus. Ann Neurol 1995; 38:881-92. [PMID: 8526460 DOI: 10.1002/ana.410380608] [Citation(s) in RCA: 115] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Previous work has shown that lesions in the lateral cerebellum involving the dentate nucleus impair both reaching and pinching movements in humans and monkeys. This study addressed the question of whether disruption of the cerebellar-thalamo-cortical pathway at the level of the thalamus would produce behavioral deficits similar to those seen after dentate damage. We compared the performance of both reaching and pinching movements in patients with lateral cerebellar lesions and in patients with discrete lesions of the ventrolateral thalamus. The patients with thalamic lesions had minimal or no sensory loss and no corticospinal signs, suggesting that the abnormal movements were due to disruption of the cerebellar projection to the thalamus. We found that lesions of the ventrolateral thalamus resulted in impaired pinching movements, but remarkably normal reaching movements with the exception of a slight tremor. This is in contrast to the profound pinching and reaching impairments of patients with lateral cerebellar lesions involving the dentate nucleus. Implications about the functional organization of cerebellar output are discussed.
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Affiliation(s)
- A J Bastian
- Program in Physical Therapy, Washington University School of Medicine, St. Louis, MO 63110, USA
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Wessel K, Vieregge P, Kessler C, Kömpf D. Thalamic stroke: correlation of clinical symptoms, somatosensory evoked potentials, and CT findings. Acta Neurol Scand 1994; 90:167-73. [PMID: 7847056 DOI: 10.1111/j.1600-0404.1994.tb02700.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
We studied 18 patients with a single ischemic thalamic lesion, who had somatosensory disturbances and/or central pain in the opposite hemibody, by correlating their clinical symptoms, somatosensory evoked potentials (SEPs), and computed tomography (CT) findings. Patients were divided into three groups: (1) those with somatosensory deficits, central pain, and abnormal SEPs, which comprised two thirds of the patients (classic thalamic pain syndrome), (2) those with somatosensory deficits, no central pain, and abnormal SEPs (analgetic thalamic syndrome), and (3) those with almost normal sense perception, central pain, and normal SEPs (pure algetic thalamic syndrome). CT evidence of a paramedian or anterolateral thalamic lesion might be an indicator for the development of central pain, because these types of infarctions occurred only in patients with the classic thalamic syndrome or the pure algetic thalamic syndrome. The differentiation of the thalamic syndrome into three subtypes is of prognostic value, because patients with a loss of cortical SEPs and a posterolateral ischemic thalamic lesion on the CT scan probably will not exhibit central pain.
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Affiliation(s)
- K Wessel
- Department of Neurology, Medical University of Lübeck, Germany
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Gutrecht JA, Zamani AA, Pandya DN. Lacunar thalamic stroke with pure cerebellar and proprioceptive deficits. J Neurol Neurosurg Psychiatry 1992; 55:854-6. [PMID: 1402983 PMCID: PMC1015118 DOI: 10.1136/jnnp.55.9.854] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Case reports of two patients with cerebellar ataxia and proprioceptive sensory loss are presented. MRI of the brain revealed lesions of the ventroposterior part of the thalamus. These patients illustrate clinically the anatomical independence of cerebellar and sensory pathways in the thalamus. We suggest that the ataxic deficit is caused by interruption of cerebellar outflow pathways in the thalamus and not secondary to sensory deafferentation.
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Affiliation(s)
- J A Gutrecht
- Department of Neurology, Lahey Clinic Medical Center, Burlington, Massachusetts 01805
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Abstract
Seventeen patients with hemiataxia as a manifestation of thalamic infarction were studied. Hemiataxia had the main clinical characteristics of a "cerebellar type" of ataxia, though it never occurred in isolation, being associated with ipsilateral sensory disturbance (hemiataxia-hypaesthesia) in 7 patients, with ipsilateral sensory disturbance and hemiparesis (hypaesthetic ataxic hemiparesis) in 8 patients, and with hemiparesis (ataxic hemiparesis) in 2 patients. Recovery was good, and in all patients the sensory and motor disturbances improved or cleared before the hemiataxia. All patients had an infarct involving the lateral part of the thalamus (thalamogeniculate territory in 16, tuberothalamic territory in 1), also affecting the posterior limb of the internal capsule (PLIC) in 7 patients. Hemiataxia seemed linked to involvement of the caudal part of the ventral lateral nucleus of the thalamus or the immediately adjacent medial part of the PLIC. These structures are near the corticospinal pathways and the ventral posterior nucleus of the thalamus, explaining why hemiataxia is associated with hemiparesis or hypaesthesia in this type of infarct.
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Affiliation(s)
- T P Melo
- Department of Neurology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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Abstract
Six patients had isolated hemiataxia and ipsilateral sensory loss, as a manifestation of thalamic infarction in the thalamogeniculate territory. Acute hemiataxia-hypesthesia was not found in 1075 other patients from the Lausanne Stroke Registry who were admitted during the same period. Stroke onset was progressive in five patients and immediately complete in one. Five patients had an objective sensory loss. In two patients this affected light touch, pain and temperature sense, and in another three light touch, pain temperature, position and vibration sense. One patient had a purely subjective sensory disturbance. The sensory deficit cleared or was clearing although the ataxia persisted in all patients. On lesion mapping on CT or MRI, all patients had involvement of the lateral part of the thalamus (ventral posterior nucleus and ventral lateral nucleus). The presumed causes of stroke were cardioembolism in one patient, posterior cerebral artery occlusion in one patient and meningovascular syphilis in one patient, hypertensive small vessel disease in two patients, and undetermined in one patient. Hemiataxia-hypesthesia is a new stroke syndrome involving the perforating branches to the lateral thalamus, but in which small vessel disease may not be the leading cause.
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Affiliation(s)
- T P Melo
- Department of Neurology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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