Asterixis as a Presentation of Cerebellar Ischemic Stroke

Abstract

Asterixis is not yet considered a common neurological sign of cerebellum infarction, and the pathogenic mechanism for asterixis remains elusive. We report a 58-year-old male with moderate hypertension who presented to our emergency department for acute headache in both cervical and occipital regions of the left side. About 2 hours later the patient developed ipsilateral asterixis in the upper left limb; 3 days later the asterixis disappeared. Magnetic resonance imaging of the brain disclosed cerebellar infarctions at the left superior cerebellar artery. In conclusion, we observed that a transitory asterixis associated with ipsilateral headache can be an initial clinical manifestation of ipsilateral cerebellar infarctions in the superior cerebellar artery area.

Movement Disorders Following Cerebrovascular Lesions in Cerebellar Circuits

“…Asterixis, which is a negative myoclonus, is an involuntary movement of the hand characterized by brief flapping of the outstretched limb due to intermittent failure to maintain sustained muscle contraction [ 44 , 45 ]. It is commonly bilateral, and in these cases, it is observed in metabolic encephalopathy.…”

“…Therefore, lesions in the cerebellar circuits were responsible for post-stroke asterixis in 23 of 30 cases of post-stroke asterixis [ 44 ]. Asterixis usually occurred in the acute phase of stroke [ 4 , 45 ].…”

“…Asterixis can be caused by the abnormal control of arm posture maintenance owing to dysfunctional regulation of the brainstem-spinal pathways from the cerebello-brainstem-thalamo-cortical system [ 44 ]. Tonic control of the limbs is associated with various brainstem-spinal tracts which are regulated by supratentoral structures [ 45 ]. The ventral lateral thalamic nucleus is the area where the cerebello-rubral or vestibulo-cerebellar fibers merge, and it is also connected to the prefrontal area [ 45 ].…”

“…Tonic control of the limbs is associated with various brainstem-spinal tracts which are regulated by supratentoral structures [ 45 ]. The ventral lateral thalamic nucleus is the area where the cerebello-rubral or vestibulo-cerebellar fibers merge, and it is also connected to the prefrontal area [ 45 ]. Therefore, the development of asterixis in patients with lesions of the cerebellum or thalamus can be interpreted as the failure of supraspinal control over brainstem-spinal pathways.…”

Asterixis

“…[ 4 ] A good correlation was found between the presence of unilateral asterixis and structural intracranial disease. [ 4 ] Unilateral asterixis has been reported in cases of cerebrovascular insult at multiple locations including the cerebellum,[ 11 ] posterior thalamic-subthalamic paramedian region,[ 12 ] midbrain,[ 13 ] and pons. [ 14 ]…”