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Clinical Case

CLINICAL CASE | Dissociated Somatic Sensory Loss

A 69-year-old man suddenly developed vertigo and difficulty walking. He went to the emergency room and, upon examination, was found to have several additional sensory and motor deficits. Here we will only consider his somatic sensory deficits. We will revisit this patient in the case in Chapter 15, when we consider his other neurological deficits.

Neurological examination revealed a striking dissociated pattern of mechanosensory and pain/thermal sensory loss. Facial pain and thermal sensation were largely absent on the left side of his face. Remarkably, pain and thermal sensations on the arm, trunk, and leg were absent on the right side. Figure 6–1A (gray tint) shows the approximate distribution of pain and thermal sensory loss. Mechanosensation was spared bilaterally on the face, limbs, and trunk. Jaw and limb proprioception were also spared.

The patient had an MRI of the head. It was normal except for the medulla (Figure 6–1B), which showed a wedge-shaped lesion, dorsolaterally, on the left side. A myelin-stained section corresponding to this level of the medulla is shown.

You should be able to answer the following questions based on your reading of this chapter, earlier readings, inspection of the images, and consideration of the neurological signs.

1. What artery supplied the infarcted region in the medulla?

2. Explain why pain is lost ipsilaterally on the face.

3. Explain why pain is lost contralaterally on the limbs and trunk.

4. Why is mechanosensation from the limbs and trunk spared?

5. Describe the circuit for mechanosensation from the face.

Conclusion: The patient had a stroke involving posterior inferior cerebellar artery (PICA). This is a long circumferential artery that branches off the vertebral artery. It supplies the dorsolateral medulla and parts of the cerebellum. The territory supplied by PICA does not receive a collateral supply from other arteries. As a consequence, the occluded territory is infarcted.

Key neurological signs and corresponding damaged brain structures Ipsilateral loss of facial pain and thermal senses

PICA supplies the dorsolateral medulla. The infarcted region on the MRI in Figure 6–1B was produced by PICA occlusion, which damaged the spinal trigeminal tract and nucleus at the level of the mid-medulla. The locations of these structures are shown in Figure 6–1B, inset. Tract damage results in loss of most axons from the level of occlusion, caudally. Because damage occurred caudal to the decussation, the nociceptive and thermal innervation of the ipsilateral face was eliminated.

Contralateral loss of pain and thermal senses

There was also loss of pain and temperature sensation on the contralateral limbs and trunk. This is because PICA occlusion damaged the ascending anterolateral pathway, which decussated in the spinal cord (Figure 6–1B, inset; Figure 6–12B).

Sparing of mechanical sensations and limb and jaw proprioception

PICA occlusion spared the medial lemniscus, which carries ascending mechanosensory and limb proprioception information (Figure 6–1B, inset). It also spared trigeminal mechanosensations (touch, vibration sense, ...

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