«Dysarthria–clumsy hand syndrome» as lacunar stroke manifestation

A detailed analysis of the neurological disorders of «dysarthria–clumsy hand» syndrome (DCHS) is important for its earlier diagnosis.

The purpose of this study was to evaluate the incidence of DCHS and the range of its clinical signs, as well as the degree of hand/arm dysfunctions and its dynamics in patients with the acute lacunar stroke (LS).

Material and methods. 139 patients with acute LS were examined. Quantitative assessment of neurological deficits, such as paresis, cerebellar ataxia, and apraxia was performed using the relevant scales. The upper limb function was assessed by Action Research Arm Test and 9-Hole Peg Test. Barthel Index was used for disability evaluation.

Results. DCHS was diagnosed in 17% of LS patients (group1) and other clinical variants of LS was detected in 83% of patients (group 2). The cause of «clumsiness» in the hand/arm in DCHS was ataxia (83%), mild paresis (71%) and kinesthetic apraxia (29%), which were present independently or in combination. Hand/arm dysfunction and disability, while performing daily activities, were less severe in group 1 patients compared to group 2. The complete restoration of hand/arm function was observed in 63% of the patients with DCHS in 2 weeks after the onset of LS.

Conclusions. Mild paresis, cerebellar ataxia and apraxia are the main causes of «clumsiness» of the hand/arm in patients with DCHS. In general, DCHS has good functional outcomes.

1. Fisher C.M. A lacunar stroke. The dysarthria-clumsy hand syndrome. Neurology. 1967;17(6):614–617. https://doi.org/10.1212/wnl.17.6.614

2. Fisher C.M. Lacunar strokes and infarcts: a review. Neurology. 1982;32(8):871–876. https://doi.org/10.1212/wnl.32.8.871

3. Arboix A., Bell Y., García-Eroles L., Massons J., Comes E., Balcells M. et al. Clinical study of 35 patients with dysarthriaclumsy hand syndrome. J. Neurol. Neurosurg. Psychiatry. 2004;75(2):231‒234. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1738934/

4. Arboix A., Martí-Vilalta J.L. Lacunar stroke. Expert Rev. Neurother. 2009;9(2):179–196. https://doi.org/10.1586/14737175.9.2.179

5. Venkataraman P., Tadi P., Lui F. Lacunar Syndromes. StatPearls. StatPearls Publishing 5 July 2020. [Electronic resource. URL: https://www.ncbi.nlm.nih.gov/books/NBK534206/

6. Cuadrado-Godia E., Dwivedi P., Sharma S., Santiago A.O., Gonzalez J.R., Balcells M. et al. Cerebral Small Vessel Disease: A Review Focusing on Pathophysiology, Biomarkers, and Machine Learning Strategies. J. Stroke. 2018;20(3):302–320. https://doi.org/10.5853/jos.2017.02922

7. Glass J.D., Levey A.I., Rothstein J.D. The dysarthria-clumsy hand syndrome: A distinct clinical entity related to pontine infarction. Ann. Neurol. 1990;27(5):487–494. https://doi.org/10.1002/ana.410270506

8. Vakhnina N.V., Tsoy A.E., Voskresenskaya O.N., Damulin I.V. Chorea as a result of lacunar infarction. Nevrologicheskiy zhurnal. 2015;20(4):46–50 (In Russian). https://cyberleninka.ru/article/n/horeya-vsledstvie-lakunarnogo-infarkta

9. Hoonhorst M.H., Nijland R.H., van den Berg J.S., Emmelot C.H., Kollen B.J., Kwakkel G. How Do Fugl-Meyer Arm Motor Scores Relate to Dexterity According to the Action Research Arm Test at 6 Months Poststroke? Arch. Phys. Med. Rehabil. 2015;96(10):1845–1849. https://doi.org/10.1016/j.apmr.2015.06.009

10. Grice K.O., Vogel K.A., Le V., Mitchell A., Muniz S., Vollmer M.A. Adult norms for a commercially available Nine Hole Peg Test for finger dexterity. Am. J. Occup. Ther. 2003;57(5):570–573. https://doi.org/10.5014/ajot.57.5.570

11. Feys P., Lamers I., Francis G., Benedict R., Phillips G., LaRocca N. et al. Multiple Sclerosis Outcome Assessments Consortium. The Nine-Hole Peg Test as a manual dexterity performance measure for multiple sclerosis. Mult. Scler. 2017;23(5):711–720. https://doi.org/10.1177/1352458517690824

12. Ekstrand E., Lexell J., Brogardh C. Test-retest reliability and convergent validity of three manual dexterity measures in persons with chronic stroke. PM&R. 2016;8(10):935–943. https://doi.org/10.1016/j.pmrj.2016.02.014

13. Fisher M. Putaminal hemorrhage presenting as dysarthria-clumsy hand syndrome. Case reports. Bull. Clin. Neurosci. 1984;49:1–3. https://pubmed.ncbi.nlm.nih.gov/6546036/

14. Timmann D., Diener H.C. Cerebellar ataxia. (eds) Bogousslavsky J., Caplan L.: Stroke Syndrome. Cambridge University Press. 2001:48–59.

15. Grandas F., Villanueva J.A., Mateo D., Gimenez-Roldán S. The dysarthria-clumsy hand syndrome: Ataxic or bradykinetic hand? Ann. Neurol. 1991;30(3):430–431. https://doi.org/10.1002/ana.410300321

16. Fisher C.M. Ataxic hemiparesis. A pathologic study. Arch. Neurol. 1978;35(3):126–8. https://doi.org/10.1001/archneur.1978.00500270008002

17. Semenova T.N., Grigoryeva V.N., Novosadova O.A. Upper limb impairment and its recovery in patients with acute lacunar stroke. Saratov Journal of Medical Scientific Research. (Saratovskij nauchnomedicinskij zhurnal). 2020;16(1):380–383 (In Russian). http://ssmj.ru/taxonomy/term/20366

18. Park J.E. Apraxia: review and update. Journal of clinical neurology. 2017;13(4):317–324. https://doi.org/10.3988/jcn.2017.13.4.317