Brainstem Infarction Research Articles

Abstract TP80: Imaging Characteristics of Methamphetamine-Associated Ischemic Strokes

Objective: To examine the clinical and neuroimaging characteristics in patients with acute ischemic stroke and concurrent methamphetamine (meth) use. Introduction: Meth is a highly addictive stimulant with harmful effects that lead to cardiovascular disease and stroke. Despite a strong association between meth use and increased cerebrovascular risk, detailed descriptions of clinical and neuroradiologic characteristics in larger cohorts are lacking. Methods: Single-center retrospective analysis of consecutive adults admitted for acute ischemic stroke and meth-positive toxicology between 2016 and 2019. Stroke imaging characteristics, including suspected etiologic mechanism as defined by Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria, were documented. Results: Ninety patients were admitted with radiologically confirmed acute ischemic stroke and meth exposure. The average age was 55 years (range, 36-77 years) and 69% were male. Although 47% were Caucasian, nearly half were from an underrepresented minority ethnic/racial group (24% Black, 8% Hispanic/Latino, 9% Asian/Pacific Islander). A multiplicity of strokes was seen in the majority of cases (57%), and 31% affected the bilateral hemispheres. Although 91% of all cases had subcortical involvement, only 34% were purely subcortical of which one-half had brainstem infarctions. The middle cerebral artery distribution was affected most commonly (71%) while multiple vascular territories were involved in 30% of cases. The most frequently encountered stroke subtypes were small vessel occlusion (27%) and a cardioembolic source (26%) as defined by the TOAST criteria. A substantial proportion of patients (31%) were discharged to a rehabilitation or nursing facility, dispositions with high predictive value for unfavorable post-stroke outcomes. Moreover, 15% of patients died during their hospitalization. Conclusion: Meth-associated acute ischemic stroke is a multicultural problem with variable widespread effects throughout the cerebrum. Although small vessel vasculopathy is suspected in most, a significant proportion is due to proximal embolic sources. Long-term care is often required in survivors, and nearly 1 in 6 died during their hospitalization.

Abstract TP293: Prognostication in Neurological Emergencies

Background: Neurologic prognosis is often estimated acutely based on clinical experience, scoring systems and patient co-morbidities. We investigated the consistency of prognostication among trainees, junior and senior neurologists. Methods: Five cases (2 large hemispheric infarcts; 1 brainstem infarct, 1 lobar hemorrhage, 1 hypoxic-ischemic encephalopathy) were chosen for a simulation exercise. All cases involved patients presenting to our hospital’s ED where poor outcome predictions were documented within 24 hours, yet care was not withdrawn. Relevant clinical data were presented through a web-based platform to respondents who remained blinded to actual outcome. The trainee/faculty was requested to rank-order, from most to least likely, predicted 90-day modified Rankin Scale (mRS) scores and possible management options (intensive comfort measures now; defer prognostication for 48-72 hours; treat aggressively). The average highest ranks were compared to actual patient outcomes. Responses were compared between pre-defined groups: trainees vs. faculty; junior vs. senior faculty; non-vascular vs. vascular (‘expert’) faculty. Results: We received 106-113 responses per case. The mean predicted 90-day mRS matched the actual outcome in only 3 of 5 cases (60%). Individual responses were more variable, with predicted mRS matching actual mRS only 20% across the 5 cases. With dichotomous cutoffs of mRS 0-3 vs. 4-6, predicted outcomes were accurate in 4 of 5 cases. In the one case that the group predicted inaccurately, the respondents prognosticated a severely disabled state (mRS 5) while the actual 90-day was mRS 2. Only 2/106 respondents (1.8%) predicted mRS 0-2 and 67/106 (63%) predicted mRS 5-6. Across all cases there were no significant differences between sub-groups. Conclusion: In acute neurological conditions, estimates of clinical prognosis can be highly variable. We acknowledge possible selection bias in case selection and the limitations of a simulation exercise. Further analysis is ongoing to determine consistency of responses against validated outcome prediction scoring systems. Our results have led to new department guidelines regarding the timing of acute prognostication.

Vertebrobaziler hipoplazi bulunan olguda unilateral vertebral arter diseksiyonuna bağlı beyin sapı enfarktının radyolojik bulguları

Vertebrobaziler sistemin konjenital hipoplazisi oldukça nadir görülen fakat özellikle genç erişkin hasta grubunda posterior sistem iskemi ya da enfarktına neden olabilecek önemli bir klinik durumdur. Genellikle semptomatik olduğunda tespit edilen bu hastalığın tanısında beyin bilgisayarlı tomografi (BT), manyetik rezonans görüntüleme (MRG) ve diffüzyon görüntüleme yöntemlerinden faydalanılır. Biz bu olguyu nadir görülen ve klinik olarak önemli sonuçları olan bu hastalığın radyolojik bulgularının bilinmesinin tanıya katkı sağlayacağı düşüncesiyle sunmaktayız.

A meta-analysis of case studies and clinical characteristics of hypertrophic olivary degeneration secondary to brainstem infarction.

Transsynaptic degeneration in the cerebellum and brainstem may give rise to a rare neurological condition with various clinical manifestations, namely hypertrophic olivary degeneration. The classical manifestations of hypertrophic olivary degeneration comprise myoclonus, palatal tremor, ataxia, and ocular symptoms. Any lesions interrupting the dentate-rubro-olivary pathway, referred to as the anatomic Guillain-Mollaret triangle, contribute to the broad aetiologies of hypertrophic olivary degeneration. The clinical diagnosis depends primarily on the associated symptoms and the characteristic magnetic resonance imaging findings. Concerning treatment and prognosis, there are no widely accepted guidelines. Here, we identified 11 cases of hypertrophic olivary degeneration secondary to brainstem infarction from 1964 to the present. Combined with two of our cases, the clinical and imaging findings of 13 patients with hypertrophic olivary degeneration secondary to brainstem infarction were studied. A meta-analysis of case studies gives the correlation coefficient between infraction location and time to develop hypertrophic olivary degeneration as 0.217 (P = 0.393, P > 0.05). At the significance level of P < 0.05, there was no significant correlation between information location and time to develop hyperophic olivary degeneration. The χ2 between infraction location and magnetic resonance imaging findings of hypertrophic olivary degeneration was 8.750 (P = 0.364, P > 0.05). At the significance level of P < 0.05, there was no significant correlation between infraction location and magnetic resonance imaging findings of hypertrophic olivary degeneration. Conclusion based on the analysis of available data suggests that when newly developed or progressive worsening motor symptoms are presented in patients with previous brainstem infarction, a diagnosis of hypertrophic olivary degeneration should be investigated.

Locked-In Syndrome after Traumatic Basilar Artery Entrapment within a Clivus Fracture: A Case Report and Review of the Literature.

We report the case of a 58-year-old male with a rare vascular complication after traumatic head injury: entrapment of the basilar artery into a fracture of the clivus, ultimately leading to a locked-in syndrome due to brainstem infarction. Review of the literature revealed 19 earlier published cases of basilar artery entrapment within traumatic longitudinal clival fractures. In the majority of these patients there is an unfavorable neurological outcome.

Cerebellar and brainstem infarction secondary to basilar artery dolichoectasia

Cerebellar and brainstem infarction secondary to basilar artery dolichoectasia

Diplopia and Vertical Gaze Palsy with Punctate Brain Stem Infarct

Diplopia and Vertical Gaze Palsy with Punctate Brain Stem Infarct

Seesaw nystagmus with internuclear ophthalmoplegia from bilateral dorsomedial pons and left thalamus infarction: a case report

BackgroundWe describe for the first time the clinical features and mechanisms of a bilateral dorsomedial pons and left thalamus infarction with seesaw nystagmus and internuclear ophthalmoplegia.Case presentationA 62-year-old Chinese man was hospitalized for sudden-onset dizziness, diplopia, and gait disturbance. A neurological examination revealed seesaw nystagmus and internuclear ophthalmoplegia. Magnetic resonance imaging disclosed an acute infarction confined to the bilateral dorsomedial pons and left thalamus. Subsequently, 2 weeks of antithrombotic therapy led to an improvement in his symptoms.ConclusionsThis case illustrates that the acute onset of seesaw nystagmus and internuclear ophthalmoplegia accompanied by risk factors for cerebrovascular diseases are highly suggestive of brainstem infarction.

Mortality of ischemic stroke patients admitted to the intensive care unit in Sultan Qaboos University Hospital

Background: Haemorrhagic and ischemic stroke is the second most common cause of death worldwide, with more than 10 million cases each year1. Hypertension, diabetes mellitus, smoking, hyperlipidemia, and aging are the most common risk factors of this cerebrovascular disease2. Mortality and disability increase with the complications experienced during the early phase of stroke, such as infection, seizures, and thromboembolism3. The intensive care unit (ICU) is the most appropriate treatment environment for stroke patient care in developing countries4. Aims: The aims of this study were to determine the ICU and in-hospital mortality of ischemic stroke patients admitted to the ICU within 24 hours of hospitalization, and the factors that determine and affect the outcomes of ischemic stroke to predict patients requiring early ICU admission. Methods: This is a retrospective study looking at the data of patients admitted to the intensive care unit in Sultan Qaboos University Hospital (SQUH) with an ischemic stroke diagnosis within 24 hours of hospitalization from 1st January 2013 to 31th December 2017. Results: There were 37 patients admitted to the ICU immediately from the emergency department because of ischemic stroke during the study period. There were 14 patients who died in the ICU, 2 died in-hospital after discharge from ICU, and the others were discharged from hospital (Table 1). There were 21 male patients and 16 females, with a mean age of 61.05 years. Most patients had comorbidities and risk factors that lead to poor outcome, the most common being diabetes mellitus (70.3%) and hypertension (67.6%). However, there was no association between blood pressure and glycemic control on admission with outcome (chi-square test, p = (0.667), (0.505) respectively). CT, MRI, and CT angiography are the most common diagnostic imaging tools used for ischemic stroke. We classified CT brain findings on admission according to the location of infarction. Middle cerebral artery infarction was present in 40.5% of the patients, 18.9% had other cerebral infarction, 10.8% had brain stem infarction, and the same proportion of patients had lacunar infarction, and the rest showed no abnormality. The two main reasons for admission to ICU were coma (73.0%) and neurological monitoring post-thrombolysis (24.3%). The rest were admitted because of respiratory failure. In ICU, 48.6% received intravenous thrombolysis and the majority of patients were discharged. Others were out of the therapeutic window and had a high chance of haemorrhagic transformation. Patients developed complications after ICU admission as shown in Figure 1. There was a significant association between ICU mortality and ICU complications, (chi-square test, p < 0.05). Conclusion: The mortality of ischemic stroke patients admitted to ICU within 24 hours of hospitalization in the study period was 43.2% with higher prevalence among older and male patients. The majority of these patients had comorbidities and risk factors that lead to a poor outcome. The main two reasons for admission to ICU were impaired consciousness and neurological monitoring post-thrombolysis. The outcome can be improved by preventing such complications and therefore reducing ICU mortality. More studies are recommended to find more factors that can predict the outcome of ischemic stroke.

Neurofibromatosis type 2 and related disorders.

Neurofibromatosis type 2 (NF2) is a schwannoma predisposition syndrome, alongside schwannomatosis related to germline LZTR1 and SMARCB1 pathogenic variants. This review highlights their overlapping phenotypes, new insight into NF2 phenotype and treatment outcomes. Mosaic NF2 is more prevalent than previously thought. Use of next-generation sequencing and tumour testing is needed to differentiate mosaic NF2 and schwannomatosis. Developing NF2 phenotypic insights include vasculopathy with brainstem infarction and vessel stenosis; focal cortical dysplasia in severe phenotypes; swallowing/speech difficulties and continued debate into malignancy in NF2. Proposed are: use of visual evoked potentials to monitor optic nerve sheath meningioma; potential routine magnetic resonance angiogram in adolescence and a genetic score to cohort patients with similar pathogenic_variants, for natural history/treatment outcome studies. Cohort studies found survival analysis to hearing loss and unilateral visual loss in severe mutation groups was 32 and 38 years; active management gave better outcomes than surveillance in spinal ependymoma; gamma knife, bevacizumab and hearing preservation surgery maintained or improved short-term hearing in selected patients, and gamma knife had a good long-term tumour control in mild patients with small tumours. Further long-term outcome studies are needed comparing similar severity patients to allow informed decision making.

Catheter balloon dilation combined with acupuncture for cricopharyngeal achalasia after brain stem infarction: a randomized controlled trial

To screen the optimal acupuncture regimen for cricopharyngeal achalasia (CPA) after brain stem infarction and compare the therapeutic effect between the combined therapy of catheter balloon dilation and acupuncture and the simple application of catheter balloon dilation. The patients suffering from neuropathic dysphagia in CPA after brain stem infarction were selected as the subjects. After confirmed in the diagnosis with video fluoroscopic swallowing study (VFSS), they were randomized into 6 groups, 15 cases in each one, named group A (routine treatment), group B (catheter balloon dilation), group C1 (treated with acupuncture in local area), group C2 (treated with acupuncture based on zangfu differentiation), group C3 (treated with acupuncture at the local area and the acupoints based on zangfu differentiation) and group D (catheter balloon dilation combined with the optimal acupuncture). Two phases were included in the study. In the first phase of study, the therapeutic effect was compared among the three acupuncture groups, named C1, C2 and C3 group, so as to screen the optimal acupuncture regimen. In the group C1, the main acupoints included Fengchi (GB 20), Wangu (GB 12), Yifeng (TE 17) and three-tongue points (Extra). In the group C2, the main acupoints were Neiguan (PC 6), Tongli (HT 5), Zusanli (ST 36) and Sanyinjiao (SP 6) as well as the supplementary acupoints in accordance with the syndrome differentiation. In the group C1 and group C2, after deqi, the electroacupuncture was used, with continuous dense wave, 5 to 8 Hz in frequency. The needles were retained for 30 min. Acupuncture was given once a day, 5 treatments a week. Before treatment, in 6 weeks of treatment or after removal of gastric tube, the rehabilitation was evaluated. In the group C3, the acupoints, manipulation and treating course were same as the group C1 and group C2. In the 2nd phase of study, theresults of rehabilitation treatment were compared among the group A, group B and group D. The treatment was given once a day, 5 times a week. Before treatment, after gastric tube removal or in 6 weeks of treatment, the evaluation was conducted. The feeding-swallowing function grade and VFSS were adopted in the evaluation among the above 6 groups. ① In the VFSS comparison at 1st phase of study after treatment, the food transporting ability at oral dysphagia, the results in the group C3 and group C1 were better obviously than the group C2 (both P<0.05). For the improvement in aspiration, the result in the group C3 was better obviously than the group C2 (P<0.05). In comparison of the three acupuncture groups with the group A, the difference was not significant statisticallys in the extubation rate among the four groups (P>0.05). The severity of dysphagia in the group C3 was milder than the group C2 and group A (both P<0.05). ② In the VFSS comparison at the 2nd phase of study, for the food transporting ability, the results in the group D and the group B were obviously better than the group A (both P<0.05). Regarding the function at the pharyngeal dysphagia and aspiration, the results in the group D were better than the group B and group A, those in the group B were better than the group A (all P<0.05). The difference in the extubation rate among the group A, group B and group D after treatment was significant statistically (P<0.01), of which, the extubation rate in the group D was the highest and the rate in the group A was the lowest. The dysphagia degree in the group D was milder than the group B and group A and that in the group B was milder than the group A (all P<0.05). In the study of the different acupuncture methods, the acupuncture at the local acupoints and the acupoints selected based on zangfu differentiation is the optimal acupuncture regimen for cricopharyngeal achalasia after brain stem infarction. The catheter balloon dilation combined with acupuncture present the synergistc effect on cricopharyngeal achalasia after brain stem infarction, obviously relieve dysphagia and reduce aspiration.

HINTS IN THE ER- case report

Vertigo is a false sense of motion of either the environment or self and is diagnosed in approximately half of the patients with dizziness. Acute spontaneous onset of vertigo is called acute vestibular neuritis (AVN). It is caused by peripheral lesion and requires symptomatic treatment. The symptoms of AVN can mimic a central pathology like cerebellar or brainstem infarction with no concomitant red-flag manifestation. Magnetic Resonance Neuroimaging with Diffusion-weighted imaging (MRI-DWI) as well as Computed Tomography (CT) scan delivers false negatives results what significantly delays stroke treatment. HINTS is an acronym for the battery of three bedside tests of ocular motor physiology. The method is more sensitive in diagnosing posterior circulation infarct than MRI-DWI with specificity -96 %. We present a case of a patient with vertigo who underwent two cranial CT scans and neurological examination. HINTS was worrisome. The brainstem infarct diagnosis was confirmed by MRI-DWI.

Endoscopic surgical treatment of Cushing's disease: A single-center experience of cauterization of peritumoral tissues.

Endoscopic transsphenoidal surgery is a form of treatment for Cushing's disease that is initially preferred compared with other types of treatment. Peritumoral tissue is inactivated by cauterization if a clear border of the lesion cannot be identified. In order to compare the surgical outcomes and post-operative complications between patients who underwent inactivation (cauterization of peritumoral tissues is referred to as inactivation) and those who did not, the medical records of patients treated between January 2010 and June 2016 were retrospectively reviewed. Furthermore, the results of conventional examinations performed in order to diagnose and locate the tumors, including neuroimaging, high-dose dexamethasone suppression tests and/or bilateral inferior petrosal sinus sampling, were collected. A total of 79 consecutive patients with Cushing's disease were included in the present analysis. Inactivation of peritumoral tissue had been applied in 35 (44.3%) of the cases. A gross total resection was achieved in 73 (92.4%) of the cases, while partial resection had been performed in the remaining six (7.6%). Early post-operative endocrinological remission was attained in 71 (89.8%) of the patients. A total of seven cases suffered from hypopituitarism, while cerebrospinal fluid rhinorrhea and brain stem infarction were recorded in four cases and one case, respectively. During the follow-up, the duration of which ranged between 11 and 62 months, recurrence was documented in five patients, as determined by endocrinal examinations. All of the cases that were initially treated unsuccessfully and those with recurrence achieved endocrinological remission following radiotherapy. Enhanced pituitary magnetic resonance imaging revealed no further enlargement of tumors during follow-up. The extent of endocrinological remission, recurrence and post-operative complications did not significantly differ between patients who underwent inactivation and those who did not. In conclusion, inactivation of peritumoral tissue by cauterization achieved satisfactory results in patients with intricate lesions, however it is comparable to conventional procedures.

Prediction of The Functional Outcome in A Group of Egyptian Patients with Posterior Circulation Stroke

Background: Stroke is the third most common cause of disability and second most common cause of death worldwide. Brainstem is involved in almost all the important functions of the central nervous system, and brainstem infarction is relatively dangerous with high mortality. Early prediction of the severity and degree of disability and identification of high-risk patients are critical for the treatment of patients with brain stem infarction and might contribute to reduce death rates and comorbidities after stroke. Objective: To assess the usefulness of Posterior circulation Alberta Stroke Program Early CT Score (pc-ASPECTS) for predicting functional outcome in posterior circulation stroke patients. Subjects and Methods: A cohort study on 61 patients with first-ever acute ischemic stroke who were admitted within 24 h from onset. Results: We observed a statistically significant correlation between poor outcome and high NIHSS score on initial assessment, as well as low pc-ASPECTS score, in contrast to other factors involved in the study such as, age, sex, hypertension, atrial fibrillation, diabetes mellitus, high lipid profile, smoking, time from onset to presentation, ESR, initial blood glucose measurement, HbA1C, leukoaraiosis, silent infarction or type of stroke. Conclusion: both the pc-ASPECTS and NIHSS help clinicians predict functional outcomes. The pc-ASPECTS is more reliable than the NIHSS in minor stroke prediction. Moreover, the combination of the pc-ASPECTS and NIHSS has an additive effect in predicting the functional outcomes of patients with posterior circulation stroke.

Prediction of The Functional Outcome in A Group of Egyptian Patients with Posterior Circulation Stroke

Background: Stroke is the third most common cause of disability and second most common cause of death worldwide. Brainstem is involved in almost all the important functions of the central nervous system, and brainstem infarction is relatively dangerous with high mortality. Early prediction of the severity and degree of disability and identification of high-risk patients are critical for the treatment of patients with brain stem infarction and might contribute to reduce death rates and comorbidities after stroke. Objective: To assess the usefulness of Posterior circulation Alberta Stroke Program Early CT Score (pc-ASPECTS) for predicting functional outcome in posterior circulation stroke patients. Subjects and Methods: A cohort study on 61 patients with first-ever acute ischemic stroke who were admitted within 24 h from onset. Results: We observed a statistically significant correlation between poor outcome and high NIHSS score on initial assessment, as well as low pc-ASPECTS score, in contrast to other factors involved in the study such as, age, sex, hypertension, atrial fibrillation, diabetes mellitus, high lipid profile, smoking, time from onset to presentation, ESR, initial blood glucose measurement, HbA1C, leukoaraiosis, silent infarction or type of stroke. Conclusion: both the pc-ASPECTS and NIHSS help clinicians predict functional outcomes. The pc-ASPECTS is more reliable than the NIHSS in minor stroke prediction. Moreover, the combination of the pc-ASPECTS and NIHSS has an additive effect in predicting the functional outcomes of patients with posterior circulation stroke.

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.

57-Year-Old Man With Vertigo

57-Year-Old Man With Vertigo

A Case Report of an Internuclear Ophthalmoplegia Patient caused by Pontine Infarction Treated by Korean Medicine Treatment Including &lt;italic&gt;Yukmijihwang-tang&lt;/italic&gt;

Internuclear Ophthalmoplegia (INO) is characterized by lesion side eye’s adduction limitation in lateral horizontal gaze and nystagmus in the abducting eye due to lesions in the Medial Longitudinal Fasciculus (MLF). Brainstem infarction is one of the causes of INO, but related issues have seldom been reported in the Korean medical literature. The present case was a pontine infarction patient with INO who complained of diplopia and eye movement disorder. The patient was treated with Korean medicine treatment, including herbal medicine, acupuncture, cupping, and moxibustion for 30 days. Her changes in clinical symptoms were measured with a Numeric Rating Scale (NRS) and a length of External Ocular Movement (EOM), in which the patient’s right eyeball moved to the left from the midline in the left gaze. After treatment, her clinical symptoms were improved. Diplopia decreased from NRS 10 to NRS 2, and eye movement disorder was improved such that EOM increased from 1mm to 5 mm. Therefore, integrative Korean medicine treatment may be effective in the treatment of INO patients caused by pontine infarction. Keywords: diplopia, ocular motility disorders, internuclear ophthalmoplegia, pontine infarction, Yukmijihwang-tang-gami (Liuwei-Dihuang-tang), case report