1. DWI

2. ADC

3. Cheiro-pedal syndrome
Joshua Lukas MS4
Journal Club – IUSM Neurology Student Interest Group
9 January 2017

4. Etymology Cheiro = (Greek) hand; pertaining to the hand or hands
Pedal = foot (duh)

5. What is it?
Incomplete pure sensory disorder confined strictly to simultaneous hand/finger and ipsilateral foot/toe
Location of lesions:
corona radiata
medulla oblongata
cervical spinal cord
peripheral nerves

6. Why is this happening?
Close proximity of the cheiral and pedal sensory fibers in the pons, thalamus, internal capsule
The caudal thalamocortical projections (VPN)

8. Restricted acral sensory syndromes
A constellation of incomplete sensory disorders confined to the distal parts of the limbs and/or face.
Single site or multiple, distantly separated sites
Cheiro-oral syndrome
Cheiro-oral-pedal syndrome
Cheiro-pedal syndrome
Restricted nonacral sensory syndromes exist too

10. Multiple etiologies Ischemic stroke High altitude expedition*
Fabry’s disease*
Medullary cavernous hemangioma
Cervical stenotic myelopathy

16. ? ? ?

18. Takeaway
A central lesion can produce somatosensory impairment without definite contiguous distribution

19. Lacunar Infarcts

20. Ischemic strokes - etiologies
Large artery stenosis 2/2 atherosclerosis
Small vessel/penetrating artery disease (lacunes)
Cardio-embolic
Nonatherosclerotic vasculopathies
Hypercoagulable disorders

21. Lacunar Infarcts
Lacune: small ischemic infarctions in the deep regions of the brain or brainstem
Range in diameter from 0.5 to 15 mm
Occlusion of single perforating vessel (AChA, MCA, PCA, basilar artery)

22. Mechanism
Lipohyalanosis of penetrating arteries related to chronic arterial hypertension
Chronic hypertension  hypertrophy of media & deposition of fibrinoid material into vessel wall  vessel occlusion
Diabetes is a risk factor

23. Locations Putamin Basis pontis Thalamus
Posterior limb of the internal capsule
Caudate nucleus
Also: anterior limb of internal capsule, subcortical cerebral white matter, cerebellar white matter, and corpus calosum

25. 5 well-recognized lacunar syndromes
Pure motor hemiparesis or pure motor stroke
Pure sensory stroke
Ataxic hemiparesis
Dysarthria – clumsy hand syndrome
Sensorimotor stroke

26. Pure motor hemiparesis/pure motor stroke
Internal capsule, corona radiata, or basis pontis lacune
Unilateral motor hemiparesis or hemiplegia - face, arm, leg (less)
Frequently there will be several preceding/crescendo TIAs (capsular warning syndrome)
Mild dysarthria at stroke onset in some cases
Most common of classic lacunar syndromes
Ischemic cortical lesions also cause pure motor hemiparesis
Pure motor monoparesis is rarely a lacunar infarct

28. Pure sensory stroke Ventroposterolateral nucleus of the thalamus
Also internal capsule/corona radiata, subthalamus, midbrain, parietal cortex, and paramedian dorsal pons
Numbness, parasthesias, unilateral hemisensory deficit involving the face, arm, trunk, and leg
Subjective symptoms more common than objective findings
Often distal symptoms with a pattern of cheiro-oral, cheiro-pedal, or cheiro-oral-pedal syndromes
Rarely sensory symptoms will be proximal

30. Ataxic hemiparesis
Contralateral posterior limb of the internal capsule/basis pontis
Also contralateral thalamocapsular region, red nucleus, corona radiata, lentiform nucleus, SCA territory, superficial ACA (paracentral structures)
Mild-moderate hemiparesis – usually lower extremities
Ipsilateral cerebellar-type incoordination of arm and leg out of proportion to the weakness

32. Dysarthria – clumsy hand syndrome
Lacune between upper third and lower two thirds of basis pontis
Also anterior limb/genu of internal capsule, putamen, corona radiate, basal ganglia, thalamus, and cerebral peduncle
Supranuclear facial weakness, tongue deviation, dysarthria, dysphagia, loss of fine hand motor control, and extensor plantar response.

34. Sensorimotor stroke
Lacune in the posteroventral thalamus and adjacent posterior limb of the internal capsule or lateral pons
Hemibody (face, arm, leg) sensorimotor deficits
Selective involvement of face/arm but sparing the leg suggests a nonlacunar stroke

36. Summary Pure motor hemiparesis or pure motor stroke
Unilateral motor hemiparesis or hemiplegia - face, arm, leg (less)
Pure sensory stroke
Numbness, parasthesias, unilateral hemisensory deficit involving the face, arm, trunk, and leg
Ataxic hemiparesis
Mild-moderate hemiparesis – usually lower extremities
Dysarthria – clumsy hand syndrome
Supranuclear facial weakness, tongue deviation, dysarthria, dysphagia, loss of fine hand motor control, and extensor plantar response.
Sensorimotor stroke
Hemibody (face, arm, leg) sensorimotor deficits

37. References
Brazis, Paul W., Joseph C. Masdeu, and José Biller. Localization in clinical neurology. Philadelphia: Lippincott Williams & Wilkins, Print.
Chen, Wei-Hsi, Hung-Sheng Lin, Chi Chui, Shou-Shun Wu, Chun- Chung Lui, and Hsin-Ling Yin. "Clinical analysis of cheiro-pedal syndrome." Journal of Clinical Neuroscience 19.7 (2012): Web.
Schmahmann, J. D. "The human basis pontis: motor syndromes and topographic organization." Brain 127.6 (2004): Web.