Ghika J, Ghika-Schmid F, Bogousslasvky J
Service de Neurologie, CHUV, Lausanne, Switzerland.
Clin Neurol Neurosurg. 1998 Dec;100(4):271-82. doi: 10.1016/s0303-8467(98)00054-7.
We prospectively studied motor symptoms in 32 patients with CT- or MRI-proven acute pure parietal stroke. A transient, mild, 'pseudoparesis' of the hand (90%), was noted, improved by visual attention and prompting, associated with non-awareness of muscle power (53%), transient soft pyramidal signs (50%), unilateral akinesia (100%) and motor hemineglect (37%) in non-dominant lesions. Lower motoneurone-type atrophy was not observed in this acute phase. We called 'poikilotonia' the striking unpredictable variations in muscle tone, ranging from extreme hypertonia to hypotonia, found in all patients. When maintaining postures, patients showed large oscillations (100%), laterodeviation or levitation of the arm (60%), especially in the case of large or posterior lesions, or, occasionally (3%), motor persistence or even hemicatalepsy (3%). Limb kinetic and manipulatory apraxia, with inadequate organization and anticipation of motor sequences and synergies, motor arrests, perplexity, unrecognizable gestures and loss of bimanual coordination, was a constant finding (100%). Other apraxias (62%) and difficulty in copying intransitive gestures of the hand (84%) were associated with posterior lesions involving the supramarginal gyrus. When reaching towards objects, all patients showed abnormal anticipatory hand shaping, but visuomotor ataxia (3%) was only seen with bilateral posterior stroke. Sensory (70%) or pseudocerebellar (4%) ataxia, was seen in both anterior and posterior lesions. Avoidance behaviors (34%) were not uncommon, but had no localizing value. Of the dyskinesias, hand dystonia (84%) was frequent, but athetosis (16%), asterixis (15%), postural tremor (15%), myoclonus (9%) and stereotypia (9%), were uncommon. The abnormal eye movements were unilateral hypo-akinesia of exploratory saccades (43%), abnormal ipsilateral pursuit and contralateral optokinetic nystagmus in the case of posterior lesions, and oculomotor apraxia with bilateral posterior lesions. In conclusion, parietal motor syndrome can be recognized during bedside examination, and probably reflects the loss of multiple sensory feedback to motor programs, especially those directed to the extrapersonal space.
我们对32例经CT或MRI证实为急性单纯性顶叶卒中的患者的运动症状进行了前瞻性研究。发现手部出现短暂、轻度的“假性轻瘫”（90%），通过视觉注意和提示可改善，伴有对肌肉力量无感知（53%）、短暂的软锥体束征（50%）、单侧运动不能（100%）和非优势侧病变中的运动偏侧忽视（37%）。在急性期未观察到下运动神经元型萎缩。我们将所有患者中发现的肌肉张力从极度高张力到低张力的显著不可预测变化称为“肌张力异常”。在维持姿势时，患者表现出大幅度摆动（100%）、手臂的侧偏或抬起（60%），尤其是在病变较大或位于后部时，或偶尔出现（3%）运动持续或甚至半身僵住（3%）。肢体运动和操作失用，表现为运动序列和协同动作的组织和预期不足、运动停顿、困惑、无法识别的手势以及双手协调性丧失，是一个持续存在的表现（100%）。其他失用（62%）和复制手部非传递性手势困难（84%）与涉及缘上回的后部病变有关。在伸手拿取物体时,所有患者均表现出异常的预期手部塑形，但视觉运动性共济失调（3%）仅在双侧后部卒中时出现。感觉性共济失调（70%）或假性小脑性共济失调（4%）在前部和后部病变中均可见到。回避行为（34%）并不少见，但无定位价值。在运动障碍中，手部肌张力障碍（84%）较为常见，但手足徐动症（16%）、扑翼样震颤（15%）、姿势性震颤（15%）、肌阵挛（9%）和刻板动作（9%）并不常见。异常眼动包括探索性扫视的单侧运动减退（43%）、后部病变时同侧追踪和对侧视动性眼球震颤异常，以及双侧后部病变时的动眼神经失用。总之，顶叶运动综合征可在床边检查时识别，可能反映了对运动程序，尤其是指向个人空间外的运动程序的多种感觉反馈丧失。
