CED750.indd Case Reports 140 References 1 Fisher CM: Pure sensory stroke and allied conditions. Stroke 1982; 13: 434–447. 2 Kim JS, Bae YH: Pure or predominant sensory stroke due to brainstem lesion. Stroke 1997; 28: 1761–1764. 3 Bogousslavsky J, Maeder P, Regli F, Meuli R: Pure midbrain infarction: clinical syndromes, MRI, and etiologic patterns. Neurology 1994; 44: 2032–2040. 4 Kumral E, Bayulkem G, Akyol A, Yunten N, Sirin H, Sagduyu A: Mesen- cephalic and associated posterior circulation infarcts. Stroke 2002; 33: 2224–2231. 5 Kim JS, Kim J: Pure midbrain infarction. Clinical, radiologic and patho- physiologic fi ndings. Neurology 2005; 64: 1227–1232. 6 Ono S, Inoue K: Cheiro-oral syndrome following midbrain haemorrhage. J Neurol 1985; 232: 304–306. 7 Azouvi P, Tougeron A, Hussonois C, Schouman-Claeys E, Bussel B, Held JP: Pure sensory stroke due to midbrain haemorrhage limited to the spi- nothalamic pathway. J Neurol Neurosurg Psychiatry 1989; 52: 1427– 1428. Konstantinos Spengos, MD Vas. Sofi as 82 GR–11528 Athens (Greece) Tel. +30 6946 466216, Fax +30 210 6742604 E-Mail spengos@hol.gr Discussion To our knowledge, no case of isolated dorsal midbrain infarc- tion has been reported previously. The investigators of the Laus- anne [3] and the Ege Stroke Registry [4] described 22 and 9 patients with infarct limited to the mesencephalon respectively. More re- cently, the clinical, radiological and pathophysiological fi ndings of 40 patients with pure midbrain infarction were reported [5] . How- ever, the authors did not observe any subject with lesion restricted to the dorsal midbrain. This territory is supplied by different arter- ies arising from the collicular artery, which gives rise to a network of small arteries also supplied by branches of the posterior cerebral artery. Sometimes the superior cerebellar artery also participates in the supply of the inferior colliculus. Furthermore, the same authors indicated that according to their experience, infarcts in this area were invariably associated with the concomitant involvement of the cerebellum [5] . In our case, the clinical features were characterised by sensory defi cits caused by the involvement of the dorsolaterally located lem- niscal and spinothalamic sensory fi bres ( fi g. 2 ). Although the infarct affected the superior colliculus and the periaqueductal grey matter unilaterally as demonstrated on MRI, these lesions did not corre- spond to any clinically overt neurological defi cit. Pure sensory stroke is most frequently associated with thalamic lacunes [1] , or occasionally with lesions located in the lateral pontine tegmentum, involving the medial lemniscus and the lateral spinothalamic tracts in the rostral pons [2] . Two cases of lateral tegmental midbrain haemorrhages limited to the spinothalamic pathways have been described as extremely rare causes of pure sensory stroke [6, 7] . In addition, Kim and Kim [5] identifi ed 2 patients with ischaemic le- sions restricted to the lateral midbrain presenting with isolated sen- sory symptoms. Small vessel disease was the pathogenic mechanism of infarction in 1 case, while atherothrombotic large vessel disease was categorized as the pathogenic aetiology in the other. In the ab- sence of any evidence of stenosis or occlusion of the large vessels and of any emboligenic heart disease, we considered small vessel disease as the most plausible cause of stroke in our patient. In conclusion, the present report highlights the diversity of the topography of the underlying ischaemic lesions in patients present- ing with pure sensory stroke. Therefore, although its incidence is extremely low, isolated posterior midbrain infarction should be considered as an infrequent cause of pure sensory stroke. Fig. 2. Axial schematic diagram of midbrain depicting the ana- tomical structures and the different locations (A, anteromedial, B, anterolateral, C, lateral, D, dorsal) of midbrain infarctions. Beauty Parlor Stroke Syndrome J.G. Heckmann a , P. Heron a , B. Kasper a , A. Dörfl er b , C. Maihöfner a Departments of a Neurology and b Neuroradiology, Stroke Unit, University of Erlangen-Nuremberg, Erlangen , Germany A 63-year-old woman visited her beauty parlor to have her hair cut. During shampooing with her head hanging backwards into a hair washbasin she developed sudden dizziness, nausea and started vomiting. The alarmed paramedics assumed a gastrointestinal dis- order, and she was initially admitted to the department of gastro- enterology. As symptoms persisted for 2 days, neurological advice was sought. The neurological examination revealed nystagmus at forced lateral view bilaterally, slight left-sided ataxia of both limbs and she was prone to fall to the left side in the Romberg test. The vascular risk factors were suffi ciently treated diabetes type II and arterial hypertension. In our routine stroke workup which is based on the EUSI guidelines [1] , no further pathological fi ndings were detected, in particular no signs of cardioembolism. MRI of the brain showed an ischemic infarction in the territory of the left pos- terior inferior cerebellar artery ( fi g. 1 a). MR angiography ( fi g. 1 b) showed a smaller lumen of the left vertebral artery compared to the right but without signs of arterial dissection or major arterioscle- rosis. In our patient we diagnosed beauty parlor stroke syndrome, a term proposed by Weintraub in 1993 [2] . Pathophysiologically, acute arterial dissection is considered to be a major cause [3, 4] . In these cases, patients often reported about pain in the neck and a Cerebrovasc Dis 2006;21:140–141 DOI: 10.1159/000090449 Case Reports 141 predisposing intimal-medial weakness has been assumed [5] . Oth- er predisposing vascular factors discussed for this stroke entity are atherosclerosis, impaired collateral blood fl ow and presence of con- genital vascular hypoplasia. However, also speed, applied force and duration of the hair washing defi nitely contribute [5, 6] . In our case dissection could confi dently be excluded by MR angiography and conventional MR sequences. An arterio-arterial embolism, occur- ring by shearing of an athersclerotic plaque of the vertebral arteries during hyperextension, seems unlikely due to missing signs of pro- nounced arteriosclerosis in MR angiography and additional neuro- sonological examinations. Cardiac embolism was unlikely due to normal ECG and transesophageal echocardiography. Therefore, we assume a disturbed end organ perfusion mecha- nism affecting the territory of the left posterior inferior cerebellar artery as the pathophysiological cause, for which the slight left-sided vertebral artery hypoplasia may have been predisposing. The inter- ruption of the blood fl ow is thought to be caused by mechanical compression of the vertebral artery between the occiput and the ver- tebral arc of the atlas during the prolonged hyperextension ( fi g. 2 ). This concept is supported by cerebral blood fl ow studies in symptomatic individuals which demonstrated abnormal fi ndings during hyperextension and rotation of the neck and head and un- suspected hypoplastic vertebral artery in 13% [7] . Thus, it can be speculated that hypoplasia may play a predisposing role, in par- ticular if the vertebral artery with the larger calibre is compromised by the tilting of the neck during barbering. Taken together, hyperextension combined with hanging the head backwards in a hair washbasin can be seen as a risk factor for posterior circulation ischemia. It probably occurs more often than assumed [8] and a number of patients may report about previous dizziness episodes under the same conditions when asked specifi - cally [9] . It can be prevented by changing the shampoo routine from the hanging head position to a fl exed or neutral position [5] . Age can be regarded as a potentially predisposing factor, as our patient and nearly all the patients whose cases were reported in the litera- ture are 50 years and older [2, 8] . 1 The European Stroke Initiative Executive Committee and the EUSI Writ- ing Committee: European stroke initiative recommendations for stroke management – Update 2003. Cerebrovasc Dis 2003; 16: 311–337. 2 Weintraub MI: Beauty parlor stroke syndrome: report of fi ve cases. JAMA 1993; 269: 2085–2086. 3 Nwokolo N, Batemen DE: Stroke after visit to the hairdresser. Lancet 1997; 350: 866. 4 Agarwal R, Shukla R, Chandra A, Pant MC: Posterior circulation stroke following manipulation of neck by a barber. J Assoc Physicians India 2004; 52: 79–81. 5 Weintraub MI: Stroke after visit to the hairdresser. Lancet 1997; 350: 1777–1778. 6 Jeret JS, Bluth M: Stroke following chiropractic manipulation: report of 3 cases and review of the literature. Cerebrovasc Dis 2002; 13: 210–213. 7 Weintraub MI, Khoury A: Critical neck positions as an independent risk factor for posterior circulation stroke: a magnetic resonance angiographic analysis. J Neuroimaging 1995; 5: 16–22. 8 Shimura H, Yuzawa K, Nozue M: Stroke after visit to the hairdresser. Lancet 1997; 350: 1778. 9 Foye PM, Najar MP, Camme A, et al: Pain, dizziness, and central nervous system blood fl ow in cervical extension: vascular correlations to beauty parlor stroke syndrome and salon sink radiculopathy. Am J Phys Med Rehabil 2002; 81: 395–399. References Dr. Josef G. Heckmann Department of Neurology, University of Erlangen-Nuremberg Schwabachanlage 6, DE–91054 Erlangen (Germany) Tel. +49 9131 8533001, Fax +49 9131 8534436 E-Mail josef.heckmann@neuro.imed.uni-erlangen.de Fig. 1. a Diffusion-weighted MRI demonstrating an ischemic in- farction in the territory of the left posterior inferior cerebellar ar- tery. b MR angiography showed normal posterior circulation ves- sels except for a slight hypoplasia of the left vertebral artery. Fig. 2. Schematic drawing of the proposed pathomechanism. Through hyperextension of the neck and head, the vertebral artery (arrow) is compressed between the occiput and the vertebral arc of the atlas in susceptible individuals.