Acute Brainstem Infarction Research Articles

Brain Diffusion in Brainstem Infarctions and Lesion Segmentation using Fluidattenuation Inversion Recovery: A Diagnostic Accuracy Study

Introduction: Diffusion can efficiently detect infratentorial and brainstem infarctions. Fluid-attenuation Inversion Recovery (FLAIR) is a widely used Magnetic Resonance Imaging (MRI) technique for the segmentation of brain lesions and strokes. Aim: To investigate the sensitivity of the Lesion Prediction Algorithm (LPA) within the Lesion Segmentation Tool (LST) in the automated segmentation of acute and subacute brainstem infarctions. Materials and Methods: This study was a retrospective diagnostic accuracy study where 24 patients with brainstem infarctions were referred from the Emergency Department to the Department of Radiodiagnosis at Kasr Alainy Hospital, Cairo University, Egypt. The study was conducted from September 2016 to June 2023. It included 24 patients (14 males and 10 females) with acute and subacute brainstem infarctions. MRI of the brain and diffusion were performed on all patients. Automated segmentation of brainstem infarctions using FLAIR was conducted in all cases. Manual and segmented volumes of brainstem infarctions were calculated. Sensitivity and accuracy of the LPA within the LST in automated segmentation of acute and subacute brainstem infarctions were evaluated. Pearson correlation was used to correlate volumes of White Matter Lesion (WML) burden in patients with brainstem infarctions and patients’ age. Results: The mean age of the participants was 51.75±11.95 years. The sensitivity of the LPA in automated segmentation of acute and subacute brainstem infarctions was 63.6% and 76.9%, respectively. An insignificant correlation (r=0.08; p-value=0.68) between the volumes of WML burden in patients with brainstem infarctions and patients’ age was noted. Conclusion: The sensitivity of the automated method in the segmentation of subacute brainstem infarctions was higher than that in acute brainstem infarctions.

A new scheme of global feature management improved the performance and stability of radiomics model: a study based on CT images of acute brainstem infarction.

The performance and stability of radiomics model caused by dimension reduction remain being confronted with major challenges. In this study, we aimed to propose a new scheme of global feature management independent of dimension reduction to improve it. The non-contrast computed tomography (NCCT) images of acute brainstem infarction (ABI) from two medical centers were used as test and validation sets. A new scheme was constructed based on global feature management, and the traditional scheme dependent on dimension reduction was used as control. The radiomic features of NCCT images were extracted in Matlab R2013a. The performance of prediction model was evaluated by the generalized linear model (GLM) and multivariate logistic regression. And, the stability of radiomics model was evaluated with the difference of area under curve (AUC) between the test and validation sets. Compared with the traditional scheme, the new scheme presented a similar detection performance (AUC: 0.875 vs. 0.883), yet a better performance in predicting prognosis (AUC: 0.864, OR = 0.917, p = 0.021 vs. AUC:0.806, OR = 0.972, p = 0.007). All these results were well verified in an independent validation set. Moreover, the new scheme showed stronger stability in both the detection model (ΔAUC: 0.013 vs. 0.039) and prediction model (ΔAUC = 0.004 vs. 0.044). Although there might be several limitations, this study proved that the scheme of global feature management independent of dimension reduction could be a powerful supplement to the radiomics methodology. • The new scheme (Swavelet) presented similar detection performances for ABI with the traditional scheme. • A better predictive performance for END was found in the new scheme (Swavelet) compared with the traditional scheme. • Stronger model stability was found in both the detection and prediction models based on the new scheme.

Predicting functional outcome in patients with acute brainstem infarction using deep neuroimaging features.

Acute brainstem infarctions can lead to serious functional impairments. We aimed to predict functional outcomes in patients with acute brainstem infarction using deep neuroimaging features extracted by convolutional neural networks (CNNs). This nationwide multicenter stroke registry study included 1482 patients with acute brainstem infarction. We applied CNNs to automatically extract deep neuroimaging features from diffusion-weighted imaging. Deep learning models based on clinical features, laboratory features, conventional imaging features (infarct volume, number of infarctions), and deep neuroimaging features were trained to predict functional outcomes at 3months poststroke. Unfavorable outcome was defined as modified Rankin Scale score of 3 or higher at 3months. The models were evaluated by comparing the area under the receiver operating characteristic curve (AUC). A model based solely on 14 deep neuroimaging features from CNNs achieved an extremely high AUC of 0.975 (95% confidence interval [CI] = 0.934-0.997) and significantly outperformed the model combining clinical, laboratory, and conventional imaging features (0.772, 95% CI = 0.691-0.847, p<0.001) in prediction of functional outcomes. The deep neuroimaging model also demonstrated significant improvement over traditional prognostic scores. In an interpretability analysis, the deep neuroimaging features displayed a significant correlation with age, National Institutes of Health Stroke Scale score, infarct volume, and inflammation factors. Deep learning models can successfully extract objective neuroimaging features from the routine radiological data in an automatic manner and aid in predicting the functional outcomes in patients with brainstem infarction at 3months with very high accuracy.

Crossed brainstem syndrome revealing bleeding brainstem cavernous malformation: an illustrative case

BackgroundSince the nineteenth century, a great variety of crossed brainstem syndromes (CBS) have been described in the medical literature. A CBS typically combines ipsilateral cranial nerves deficits to contralateral long tracts involvement such as hemiparesis or hemianesthesia. Classical CBS seem in fact not to be so clear-cut entities with up to 20% of patients showing different or unnamed combinations of crossed symptoms. In terms of etiologies, acute brainstem infarction predominates but CBS secondary to hemorrhage, neoplasm, abscess, and demyelination have been described. The aim of this study was to assess the proportion of CBS caused by a bleeding episode arising from a brainstem cavernous malformation (BCM) reported in the literature.Case presentationWe present the case of a typical Foville syndrome in a 65-year-old man that was caused by a pontine BCM with extralesional bleeding. Following the first bleeding episode, a conservative management was decided but the patient had eventually to be operated on soon after the second bleeding event.DiscussionA literature review was conducted focusing on the five most common CBS (Benedikt, Weber, Foville, Millard-Gubler, Wallenberg) on Medline database from inception to 2020. According to the literature, hemorrhagic BCM account for approximately 7 % of CBS. Microsurgical excision may be indicated after the second bleeding episode but needs to be carefully weighted up against the risks of the surgical procedure and openly discussed with the patient.ConclusionsIn the setting of a CBS, neuroimaging work-up may not infrequently reveal a BCM requiring complex multidisciplinary team management including neurosurgical advice.

Improved Detectability of Brain Stem Ischemia by Combining Axial and Coronal Diffusion-Weighted Imaging.

To evaluate the benefit of a coronal diffusion-weighted imaging (DWI) in addition to standard axial DWI for the detection of brain stem infarctions. A retrospective analysis of patients with symptoms consistent with acute and subacute brain stem infarction who received magnetic resonance imaging, including axial and coronal DWI. Diffusion restrictions were identified by 2 independent raters blinded for the final clinical diagnosis in 3 separate reading steps: axial DWI, coronal DWI, and combined axial and coronal DWI. Lesion location and certainty level were both documented for each reading step. In cases of reader disagreement, an additional consensus reading was performed. Two hundred thirty-nine patients were included. Of these, 124 patients (51.9%) were clinically diagnosed with brain stem infarction. Sensitivity, specificity, positive, and negative predictive values were best for combined DWI assessment (90.3%, 99.1%, 99.1%, and 90.5%) compared with axial (85.5%, 94.9%, 94.6%, and 85.8%) and coronal DWI alone (87.9%, 96.5%, 96.5%, and 88.1%). Diffusion restriction on combined DWI was diagnosed in 112/124 patients compared with 106/124 on axial DWI and 109/124 on coronal DWI. Interobserver agreement for the detection of brain stem lesions was the highest in the combined rating step (Cohen κ coefficient=0.94). Coronal DWI sequences might improve the detection rate of brain stem infarction compared with standard axial DWI. The combined coronal and axial DWI provides the best detection rate while minimally increasing scan times.

Is Dimensionality Reduction Indispensable for Radiomics Analysis? Construction a New Radiomics Analysis Scheme Independent of Dimension Reduction

Background: Dimension reduction has always been considered indispensable to analysis. However, its non-substitutability may still cause major challenges. In this study, we tried to propose a new radiomics analysis scheme independent of dimension reduction, and evaluated its clinical application value by comparing it with the general analysis scheme dependent on dimension reduction. Methods: The non-contrast computed tomography (NCCT) images of 274 acute brainstem infarction (ABI) were analyzed using radiomic features algorithm in Matlab R2013a, and two types of radiomic indicators were established (with global feature management and dimension reduction). Multivariate logistic regression was used to evaluate the abilities of ABI detection. Multiple linear regression was used to investigate the correlations amongst clinical characteristics. And, the abilities to predict the prognosis of ABI were evaluated by the generalized linear model (GLM) and multivariate logistic regression. Findings: Both types of schemes could effectively detect ABI, and showed significant correlations amongst clinical characteristics, as well as predicted the prognosis of ABI. And, although the ABI detecting ability of the new sheme was slightly weaker than that of the general analysis scheme (AUC: 0.893 vs. 0.835), it presented a stronger performance in predicting prognosis (AUC: 0.864, OR = 0.917, p = 0.021 vs. AUC:0.806, OR = 0.972, p = 0.007). Interpretation: This study proved that the scheme of global feature management could be a powerful supplement to the radiomics methodology. Also, this study provided an unprecedented suggestion to effectively improve decision-support in ABI using radiomics. Funding Statement: This work was supported by National Natural Science Foundation of China (81871343, 81525014), Jiangsu Provincial Key Research and Development Plan (BE2018693), and Natural Science Foundation of Jiangsu Province (BK20181226). Declaration of Interests: The authors declare that they have no competing interests. Ethics Approval Statement: This study was approved by the institutional review board of Jiangsu University (JSDXPROSPERO-20180898), and written informed consent was obtained from all patients, or their legal guardians.

Usefulness and Clinical Significance of Thin-slice Gapless Coronal Diffusion-weighted Imaging for Acute Brainstem Infarction Diagnosis

The lesions caused by brainstem infarction are usually small. Therefore, it is often difficult to diagnose them using axial diffusion-weighted imaging (axial DWI). The purpose of this study was to evaluate the usefulness of thin-slice gapless coronal DWI in acute brainstem infarction diagnosis by difference of elapsed time from the onset of cerebral infarction. Axial DWI and coronal DWI were performed in 90 patients (mean age: 70.0±12.5 years) with acute brainstem infarction. Patients were classified into four groups according to the elapsed time after the onset of brainstem infarction: <3 h (group A), 3-10 h (group B), 10-30 h (group C), and ≥30 h (group D). We compared axial DWI and coronal DWI in terms of visual evaluation score, apparent diffusion coefficient (ADC) value, and contrast in the four groups. The visual evaluation scores were significantly higher using coronal DWI in groups A, B, and C than in group D. The ADC values in groups C and D were significantly higher in coronal DWI. The contrast in groups C and D was significantly higher in coronal DWI. Coronal DWI is especially useful for acute brainstem infarction diagnosis within 30 hours of its onset.

Diagnostic benefit of high b-value computed diffusion-weighted imaging in acute brainstem infarction

Background and purposeDiffusion-weighted imaging (DWI) is a cornerstone in diagnostic of ischemic stroke. The aim of this study was to investigate the usefulness of high-b-value computed DWI (c-DWI) in comparison to standard DWI in patients with acute brainstem infarction. Materials and methods56 patients with acute brainstem infarction were retrospectively analysed by two readers. DWI was obtained with the b-values 0, 500 and 1000 s/mm² on either a 1.5 or 3 T magnetic resonance imaging (MRI) scanner. c-DWI was calculated with a monoexponential model with high b-values 2000, 3000, 4000 and 5000 s/mm². All c-DWI series with high-b-values were compared to the standard DWI sequence at b-value of 1000 s/mm² in terms of image artifacts, lesion extent and contrast. ResultsThere was no statistically significant difference between 1.5 and 3 T MRI regarding the measured ischemic lesion size. There were no statistically significant differences between the ischemic lesion sizes on DWI at b-values of 1000 s/mm² and on c-DWI at higher b-values. Overall, the contrast between the lesion and the surrounding normal areas improved with increasing b-value on the isotropic DWIs: maximum at b = 5000, followed by that at b 2000 and b 1000 s/mm², in order. The best relation between artifacts and lesion contrast was identified for b 2000 s/mm². ConclusionHigh b-value DWI derived from c-DWI has a higher visibility for ischemic brainstem lesions compared to standard DWI without additional time cost. The b-2000 image is recommended to use in clinical routine, higher b-value images lead to more imaging artifacts, which might result in misdiagnosis.

Sagittal diffusion-weighted imaging in preventing the false-negative diagnosis of acute brainstem infarction: Confirmation of the benefit by anatomical characterization of false-negative lesions.

Background:In some cases of acute brainstem infarction (BI), standard axial diffusion-weighted imaging (DWI) does not show a lesion, leading to false-negative (FN) diagnoses. It is important to recognize acute BI accurately and promptly to initiate therapy as soon as possible.Methods:Of the 171 patients with acute cerebral infarctions in our institution who were examined, 16 were diagnosed with true-positive BI (TP-BI) and six with FN-BI. We evaluated the effectiveness of sagittal DWI in accurately diagnosing acute BI and sought to find the cause of its effectiveness by the anatomical characterization of FN-BIs.Results:Considering the direction of the brainstem perforating arteries, we supposed that sagittal DWI might more effectively detect BIs than axial DWI. We found that sagittal DWI detected all FN-BIs more clearly than axial DWI. The mean time between the onset of symptoms and initial DWI was significantly longer in the TP group (17.6 ± 5.5 h) than in the FN group (5.0 ± 1.2 h; P < 0.0001). The lesion volumes were much smaller in FN-BIs (259 ± 82 mm3) than in TP-BIs (2779 ± 767 mm3; P = 0.0007). FN-BIs had a significant inverse correlation with the ventrodorsal length of infarcts (FN 3.5 ± 1.1 mm, TP 11.4 ± 3.6 mm; P < 0.0004) and no correlation with other size parameters such as rostrocaudal thickness and lateral width.Conclusion:Anatomical characterization clearly confirmed that the addition of sagittal DWI to the initial axial DWI in suspected cases of BI ensures its accurate diagnosis and improves the patient’s prognosis.

Portable Thermographic Screening for Detection of Acute Wallenberg's Syndrome.

Wallenberg's syndrome (WS) is a type of brainstem infarction. WS patients often show Horner's syndrome, dissociated sensory disturbance, truncal ataxia, and hoarseness. However, they rarely show tactile sensory disturbance and paralysis of the extremities. Additionally, acute brainstem infarction is often not apparent in magnetic resonance images. These symptomatic and imaging characteristics sometimes lead to misdiagnosis of WS as a non-stroke disease, including auditory vertigo. Although careful neurological examination is necessary to prevent misdiagnosis of WS, this type of examination may be difficult for non-neurologists to whom affected patients initially present. Lateral differences in body surface temperature (BST) constitute a recognized and widespread symptom of WS. We previously reported that most acute WS patients exhibit lateral differences in BST at multiple locations and that these lateral differences in BST could easily be detected by thermographic measurement. Here, we present the method for use of portable thermography to detect acute WS, using a simple, rapid, noninvasive, and cost-effective approach. To assess lateral differences in BST among patients with suspected WS, BST was measured as soon as possible in the examination room or in the patient's bedroom. Measurements were performed bilaterally at four locations where images could easily be acquired (face, palm of the hand, abdomen, and dorsum of the foot) using a portable thermal camera. When lateral differences in BST are observed macroscopically, especially in multiple locations on the same side, a diagnosis of WS should be suspected. Macroscopic assessment of BST laterality can be made within 2 min of the acquisition of thermographic images. This method may be useful in preventing misdiagnosis of acute WS as a non-stroke disease, especially when such patients initially present to non-neurologists.

Value of Combination of Standard Axial and Thin-Section Coronal Diffusion-weighted Imaging in Diagnosis of Acute Brainstem Infarction.

AIM:To determine the value of the combination of thin-section 3 mm coronal and standard axial DWI and their impact in facilitating the diagnosis of acute brainstem infarction.METHODS:A cross-sectional study conducted from the 1st of April 2017 to the end of February 2018 on 100 consecutive patients (66% were male, and 34% were female) with isolated acute ischemic infarction in the brainstem. The abnormal MRI findings concerning the ischemic lesions were interpreted on standard axial 5 mm and thin-section coronal 3mm DWI.RESULTS:The mean age of the studied group was 69.2 ± 4.3 for male and 72.3 ± 2.5 years. The standard axial DWI can diagnose 20%, 6.7% and 6.7% of the infarctions in midbrain, pons and medulla oblongata respectively, while both axial and thin coronal sections together can diagnose 80% of midbrain infarctions, 93.3% of pons infarctions and 93.3% of medulla oblongata infarctions. Furthermore, the thin section coronal 3 mm section can diagnose very smaller ischemic lesion volume in comparison to the standard axial 5mm section (3.4 ± 0.45 / cm3 versus 4.6 ± 0.23 / cm3, P < 0.001)CONCLUSION:The addition of thin-section coronal DWI can facilitate the detection of brainstem ischemic lesions. We suggest its inclusion in the stroke MRI protocol.

Improved detectability of acute and subacute brainstem infarctions by combining standard axial and thin-sliced sagittal DWI.

Background and purposeMost false negative findings in DWI of ischemic stroke are in patients with minor deficits clinically localized to the brainstem. Our goal was to evaluate the benefit of a thin-sliced sagittal DWI in addition to conventional axial DWI at 1.5T for the detection of brainstem infarctions.MethodsData of patients with symptoms consistent with acute and subacute brainstem infarction and an MRI examination including standard axial DWI and thin-sliced sagittal DWI were retrospectively analyzed. Patients with the later diagnosis of a TIA, an inflammation or a tumor of the brainstem were excluded from analysis. Diffusion restrictions were identified by two independent raters blinded for the final clinical diagnosis in three separate reading steps: First, only axial DWI, secondly only sagittal DWI, and lastly both DWIs together. Presence and size of DWI-lesions were documented for each plane. Differences between the observers were settled in consensus in a separate joint reading.ResultsOf 73 included patients, 46 patients were clinically diagnosed with brainstem infarction. Inter-observer agreement was excellent for the detection of brainstem lesions in axial and sagittal DWI (kappa = 0.94 and 0.97). In 28/46 patients (60.9%) lesions were detected in the axial plane alone, whereas in 6 more patients (73.9%) lesions were detected in the review of both sequences together. All lesions undetectable in the axial plane were smaller than 5 mm in cranio-caudal direction.ConclusionsThin-sliced sagittal DWI in addition to axial DWI improves the detection rate of brainstem infarction with little additional expenditure of time.

Laterality of body surface temperature in patients of acute brainstem infarction with Horner's syndrome

Background: It is reported that patients of Wallenberg’s syndrome (WS) with Horner’s syndrome (HS) show bilateral discrepancy of body surface temperature (BST) because of the disturbance of sympathetic nerve tract. Thermography can easily detect BST in a visual manner.

Diffusion-weighted imaging with reverse phase-encoding polarity: the added value to the conventional diffusion-weighted imaging in differentiating acute infarctions from hyperintense brainstem artifacts.

The aim of our study was to assess the value of diffusion-weighted imaging with reverse phase-encoding polarity (R-DWI) in addition to conventional DWI using forward phase-encoding polarity (F-DWI) in differentiating acute brainstem infarctions from hyperintense artefacts. Seventy-six patients with 38 hyperintense brainstem artefacts and 38 acute brainstem infarctions that had undergone F-DWI and R-DWI were retrospectively selected based on the clinicoradiological diagnosis. Four radiologists independently rated their confidence in diagnosing acute infarctions and ruling out brainstem artefacts in a blind manner, and then compared the diagnostic performance and confidence between F-DWI alone and F-DWI with R-DWI. The areas under the curve determined for F-DWI with R-DWI in diagnosing infarctions were significantly higher than F-DWI alone for all readers (resident 1, 0.908 vs 0.776; resident 2, 0.908 vs 0.789; neuroradiologist, 0.961 vs 0.868; emergency radiologist, 0.934 vs 0.855, all p < 0.05). All readers were more confident using F-DWI with R-DWI than F-DWI alone (all p < 0.05) for diagnosing acute brainstem infarction, and three readers (readers except the neuroradiologist) were more confident using F-DWI with R-DWI for ruling out brainstem artefacts (p ≤ 0.001). The addition of R-DWI to F-DWI is a valuable method for differentiating acute brainstem infarctions from hyperintense artefacts. • Hyperintense brainstem artefacts can be confused with acute infarctions on DWI. • Additional R-DWI to F-DWI reduces inter-reader variability in diagnosing brainstem infarctions. • Additional R-DWI improves performance and confidence for discriminating infarctions from artefacts.

Peripheral, central and functional vertigo syndromes

Depending on the temporal course, three forms of vertigo syndrome can be differentiated: 1) vertigo attacks, e.g. benign paroxysmal positional vertigo (BPPV), Menière's disease and vestibular migraine, 2) acute spontaneous vertigo lasting for days, e.g. acute unilateral vestibulopathy, brainstem or cerebellar infarction and 3) symptoms lasting for months or years, e.g. bilateral vestibulopathy and functional vertigo. The specific therapy of the various syndromes is based on three principles: 1) physical treatment with liberatory maneuvers for BPPV and balance training for vestibular deficits, 2) pharmacotherapy, e.g. for acute unilateral vestibulopathy (corticosteroids) and Menière's disease (transtympanic administration of gentamicin or steroids and high-dose betahistine therapy); placebo-controlled pharmacotherapy studies are currently being carried out for acute unilateral vestibulopathy, vestibular paroxysmia, prophylaxis of BPPV, vestibular migraine, episodic ataxia type 2 and cerebellar ataxia; 3) psychotherapy for functional dizziness.

Relationship Between the Hypersensitive c-Reactive Protein (hs-CRP) Level and the Prognosis of Acute Brainstem Infarction

The objective of this study is to explore the relationship between the hypersensitive c-reactive protein (hs-CRP) level and the prognosis of acute brainstem infarction. Serum levels of hs-CRP were measured in 68 patients with acute brainstem infarction 72 h after disease onset. The hs-CRP levels in the U.S. National Institutes of Health Stroke Scale (NIHSS) score group and in the modified RANKIN scale (mRS) score group were compared. The independent risk factors of brainstem infarction were analyzed using Logistic binary regression. The hs-CRP level was significantly higher in the group with NIHSS >5 compared with the one with NIHSS ≤ 5 (P = 0.004). In the group with mRS > 2, the age, smoking history, and blood glucose level were significantly higher than those in the group with mRS ≤ 2 (P < 0.05), whereas the hs-CRP level was significantly higher (P = 0.001). Age and hs-CRP level were the independent prognostic factors of the brainstem infarction. The serum hs-CRP level is closely related with the severity and prognosis of brainstem infarction, and is an independent risk factor of acute brainstem infarction.

Pattern of Voiding Dysfunction after Acute Brainstem Infarction

Background: The purpose of this study is to compare the patterns of voiding dysfunction according to the locations of brainstem lesions. Methods: Between November 2008 and December 2011, a total of 30 patients participated in this study. All 30 subjects, consisting of 16 men and 14 women, aged between 41 and 82 years (mean age, 63.0 ± 11.0 years) underwent a urodynamic study within 7 days after the onset of a stroke. Results: Twenty-one (70%) patients had a pontine lesion and 9 (30%) had a medullary lesion. Fourteen of these patients (46.7%) had bladder storage disorder, 7 patients (23.3%) had bladder emptying disorder, and 9 patients (30%) had a normal report. Five of the patients who had a medullary lesion (55.6%) had bladder emptying disorder, whereas only 2 patients who had a pontine lesion (9.5%) had bladder emptying disorder. Thirteen patients who had a pontine lesion (61.9%) showed bladder storage disorder. Discussion: The descending pathway from the midbrain tegmentum is inhibitory, and the pathway from the pontine tegmentum is stimulatory. Because of their location pontine lesions could disrupt the descending fibers of the midbrain tegmentum and medullary lesions could disrupt the descending fibers of the pontine tegmentum.

P336 – 1667 Acute brain stem infarction with atypical Wallenberg syndrome in a boy revealing Lyme neuroborreliosis

P336 – 1667 Acute brain stem infarction with atypical Wallenberg syndrome in a boy revealing Lyme neuroborreliosis

Ischemic Volumes and Early Neurologic Deterioration in Acute Brainstem Infarctions with Hemoglobin A1c

Aim: To investigate the association of hemoglobin A_1c (HbA_1c) with acute diffusion-weighted imaging lesion volumes (DIV) and early neurologic deterioration (END) in brainstem infarctions (BSIs). Methods: 152 patients with acute BSIs were included in this study. The relationship between HbA_1c and DIV quartiles was examined. Data considered potentially associated with HbA_1c and END after admission and patients' symptomatic changes prior to admission were collected. Results: There was a significant correlation between HbA_1c (%) and DIV (Spearman ρ = 0.201, p = 0.013). The median HbA_1c (%) values for successive DIV quartiles (lowest to highest quartile) were as follows: 5.90, 6.35, 6.25, and 7.50 (p = 0.033). The incidence of diabetes mellitus had a significant association with DIV quartiles (p = 0.042). HbA_1c was significantly associated with symptomatic progression prior to admission (p = 0.015). 29 patients developed END after admission. Age, HbA_1c, systolic blood pressure, and fibrinogen were significantly associated with END. On logistic regression analysis, HbA_1c and fibrinogen proved to be independent variables. Conclusions: HbA_1c may be a possible predictor for ischemic severity, early deterioration of acute BSIs, and short-term prognosis. Long-term good glycemic control is very important in BSIs. Further studies are warranted to confirm these results.

Dural Arteriovenous Fistula at the Craniocervical Junction Mimicking Acute Brainstem and Spinal Cord Infarction

Dural Arteriovenous Fistula at the Craniocervical Junction Mimicking Acute Brainstem and Spinal Cord Infarction