Holmes Tremor Secondary to a Brainstem Haemorrhage With Partial Symptomatic Improvement Following Levetiracetam Use

Although morbidity and fatalities related to nonpenetrating kinetic impact projectiles (KIPs), including rubber bullets and sponge rounds, have been reported, fatal traumatic brain injury resulting from these projectiles remains uncommon. A 38-year-old incarcerated male sustained a nonpenetrating sponge round impact to the frontotemporal region of the head during an altercation. The impact resulted in severe traumatic brain injury with traumatic axonal injury, ultimately resulting in death. Autopsy findings included subdural and subarachnoid hemorrhage, coup and contrecoup cortical contusions, and cerebral edema. Midline brainstem (Duret) hemorrhages were identified, consistent with increased intracranial pressure and axial displacement. Histologic examination demonstrated both traumatic and ischemic axonal injury. No skull fractures were identified. This case documents fatal neurotrauma resulting from a nonpenetrating kinetic impact projectile and emphasizes the role of neuropathological examination in determining injury severity. Given the increasing use of KIPs in correctional and crowd-control settings, this report adds a documented example of fatal traumatic brain injury with traumatic axonal injury following nonpenetrating projectile impact. Recognition of the potential for severe head injury from nonpenetrating projectiles has implications for forensic investigation and the evaluation of kinetic impact munition use.

Intraoperative Subdural and Postoperative Brainstem Hemorrhage in Glioma Surgery: A Case Report

Spontaneous intracerebral hemorrhage (ICH) is characterized by acute onset and high rates of disability and mortality. Although surgical intervention is theoretically capable of decreasing intracranial pressure efficiently and mitigating secondary brain injury, its clinical benefit has long lacked high-level evidence. This article systematically reviews the evolution of ICH surgical treatment-from empirical attempts in the 17th century, through the establishment of early evidence-based guidelines in the CT era of the 20th century, to the conceptual innovation driven by minimally invasive technology in the 21st century. Currently, critical unresolved issues include optimal timing of surgery, selection of surgical approach, intelligent surgical technologies, selection for deep hemorrhage patients, and the surgery in brainstem hemorrhage. Future progress requires multicenter, high-quality clinical research to advance standardized, visualized, precise, intelligent, and homogeneous surgical interventions, thereby providing high-quality evidence from Chinese populations for the diagnosis and treatment of spontaneous ICH worldwide.

A new and modified northern occlusion myocardial infarction pattern.

Brainstem Hemorrhage Stereotactic Aspiration in Mali: About the First Two Cases in West Africa

Introduction: Spontaneous brainstem haemorrhage (SBH) is a rare but life-threatening subtype of intracerebral haemorrhage (ICH) that carries high mortality and morbidity rates. Given the brainstem's critical role in vital functions, rapid diagnosis and appropriate management are essential for improving outcomes. Objective: This systemic review aims to comprehensively analyse the definition, diagnostic modalities, and management options for spontaneous brainstem haemorrhage using evidence from studies published over the past 25 years. Methods: A systematic search of PubMed, Scopus, and Cochrane Library databases was conducted for studies published between 1999 and 2024. Inclusion criteria encompassed studies focusing on spontaneous brainstem haemorrhage, its diagnosis, and management strategies. Data were extracted, analysed, and synthesized into tables summarizing diagnostic modalities and treatment outcomes. A meta-analysis was performed where applicable. Results: Advances in neuroimaging, particularly computed tomography (CT) and magnetic resonance imaging (MRI), have significantly improved the early diagnosis of SBH. Management primarily focuses on controlling blood pressure, optimizing neurocritical care, and addressing anticoagulation. While surgical options are limited due to the brainstem's sensitive anatomy, emerging minimally invasive procedures show promise. Mortality rates remain high, ranging from 30% to 70%, with functional recovery being poor in a significant proportion of patients. Conclusion: Spontaneous brainstem haemorrhage remains a challenging neurological emergency with high mortality and poor functional outcomes. While medical management remains the cornerstone, ongoing advancements in neuroimaging and minimally invasive techniques offer hope for improved outcomes. Further research is needed to develop standardized treatment protocols and assess the efficacy of emerging therapies

Disorders of consciousness (DoC) encompass a range of states characterized by prolonged altered awareness due to heterogeneous brain damage and are associated with highly diverse prognoses. However, the neural mechanisms underlying such diverse recoveries in DoC remain unclear. To address this issue, we analyzed direct recordings from the central thalamus (CeTh), a key hub in arousal regulation, in a series of 23 DoC patients receiving deep brain stimulation treatment (CeTh-DBS). We identified a core set of electrophysiological features of the CeTh, particularly those of the theta rhythm. These features could account for individual recovery outcomes across highly varied etiologies (trauma, brainstem hemorrhage, and anoxia), and across clinical baselines and patient ages. CeTh activities also identified two subgroups of patients with recovery potential, including those with poor initial clinical manifestations but who eventually exhibited functional recovery. A biophysical model further revealed the neurodynamics of the theta rhythm in the CeTh across different brain states correlating with varying consciousness levels. These findings uncover a shared CeTh mechanism underlying diverse recoveries in DoC.

Introduction Sudden bilateral hearing loss is not commonly encountered by neurologists. Many first‐line providers commonly label hearing loss as peripheral in origin, leading to misdiagnosis and delayed treatment. Case Presentation A 49‐year‐old female presented with sudden bilateral hearing loss and headache. Neurologic examination revealed a left gaze palsy and mild right sided drift. CT scan of the brain revealed a mid‐dorsal pontine intraparenchymal hemorrhage. Further testing with MRI brain and brainstem auditory evoked potentials confirmed a central etiology of hearing loss. Prompt diagnosis and treatment resulted in only mild, nondisabling deficits at 3‐month clinic follow‐up. Discussion Sudden bilateral hearing loss is a rare clinical entity. It can be conductive (e.g., Meniere's disease), sensorineural (e.g., brainstem ischemia), or mixed. Sudden‐onset sensorineural hearing loss (SSNHL) has an estimated incidence of 5 to 20 per 100,000 with the vast majority being unilateral, bilateral is a very rare condition compromising 0.44‐3.4%. Vascular etiologies like basilar artery occlusion and brainstem hemorrhage need to be ruled out first because both have high morbidity and mortality if not treated promptly. Sudden bilateral hearing loss and tinnitus may be the only brainstem ischemia symptoms for up to 10 days in patients with basilar artery occlusion. Conclusion Sudden‐onset bilateral hearing loss should be considered a neurologic emergency until proven otherwise. We discuss the etiologies of sudden‐onset sensorineural hearing loss and carefully localize the lesion to the brainstem in this rare presentation of a pontine syndrome. We highlight common principles of brainstem auditory evoked potential testing and expected findings in patients with stroke and demyelinating lesions. image

Robot-Assisted surgery for primary brainstem Hemorrhage: A systematic review and Meta-Analysis

BackgroundPrimary brainstem hemorrhage (PBSH) is a life-threatening neurological condition associated with high mortality and disability rates. Stereotactic hematoma aspiration surgery has been explored as a treatment option, and postoperative brainstem function monitoring is considered important for patient management.ObjectiveThis study aimed to evaluate the integration of minimally invasive stereotactic aspiration surgery with quantitative electroencephalography (qEEG) and transcranial Doppler (TCD) monitoring to assess brain function and improve predictive models for clinical outcomes in PBSH patients.MethodsWe conducted a retrospective analysis of 34 PBSH patients admitted between December 2022 and October 2023. After applying exclusion criteria, 25 eligible patients underwent stereotactic aspiration surgery within 24–48 hours of symptom onset. Both qEEG and TCD monitoring were performed preoperatively and within 24 hours postoperatively. Changes in qEEG parameters and TCD-derived hemodynamic indices were analyzed to assess surgical safety and efficacy.ResultsStereotactic surgery was associated with higher rates of favorable outcomes at 90 days compared with the non-surgical group (68.75% vs. 11.11%, p = 0.01). Postoperative TCD parameters improved significantly, indicating better hemodynamic stability, though no correlation with mRS scores was found. qEEG analysis showed significant correlations between RBP δ% and mRS scores (ρ = 0.480, p = 0.015), and RBP α% (ρ = −0.456, p = 0.022). aEEG also correlated strongly with 90-day mRS scores (ρ = 0.544, p = 0.004). The combined model of hematoma volume, RBP α%, and aEEG showed the highest predictive accuracy (AUC = 0.865).ConclusionThis study suggests the prognostic value of qEEG and explores the utility of combining neurophysiological monitoring with stereotactic aspiration surgery. The integration of these tools may assist in prognostic assessment for PBSH patients; however, validation in larger prospective studies is required before clinical adoption.

Primary brainstem hemorrhage (PBSH) is a life-threatening neurological condition associated with high mortality and disability rates. Stereotactic hematoma aspiration surgery has been explored as a treatment option, and postoperative brainstem function monitoring is considered important for patient management. This study aimed to evaluate the integration of minimally invasive stereotactic aspiration surgery with quantitative electroencephalography (qEEG) and transcranial Doppler (TCD) monitoring to assess brain function and improve predictive models for clinical outcomes in PBSH patients. We conducted a retrospective analysis of 34 PBSH patients admitted between December 2022 and October 2023. After applying exclusion criteria, 25 eligible patients underwent stereotactic aspiration surgery within 24-48 hours of symptom onset. Both qEEG and TCD monitoring were performed preoperatively and within 24 hours postoperatively. Changes in qEEG parameters and TCD-derived hemodynamic indices were analyzed to assess surgical safety and efficacy. Stereotactic surgery was associated with higher rates of favorable outcomes at 90 days compared with the non-surgical group (68.75% vs. 11.11%, p = 0.01). Postoperative TCD parameters improved significantly, indicating better hemodynamic stability, though no correlation with mRS scores was found. qEEG analysis showed significant correlations between RBP δ% and mRS scores (ρ = 0.480, p = 0.015), and RBP α% (ρ = -0.456, p = 0.022). aEEG also correlated strongly with 90-day mRS scores (ρ = 0.544, p = 0.004). The combined model of hematoma volume, RBP α%, and aEEG showed the highest predictive accuracy (AUC = 0.865). This study suggests the prognostic value of qEEG and explores the utility of combining neurophysiological monitoring with stereotactic aspiration surgery. The integration of these tools may assist in prognostic assessment for PBSH patients; however, validation in larger prospective studies is required before clinical adoption.

Primary brainstem hemorrhage (PBH) is characterized by sudden onset, rapid progression, and high mortality. The optimal therapeutic strategy for PBH remains controversial. This case report demonstrates the safety and efficacy of robot-assisted stereotactic puncture and drainage for PBH. A 56-year-old female presented with sudden-onset unconsciousness persisting for 48 hours. Noncontrast cranial computed tomography (CT) revealed a pontine hemorrhage. On the basis of hematoma location and clinical status, robot-assisted stereotactic puncture and drainage was performed. Postoperatively, the patient exhibited gradual neurological improvement without new deficits. At the 3-month follow-up, the patient regained consciousness but required substantial assistance for activities of daily living. Current management focuses on intensive rehabilitation with ongoing clinical surveillance. This case suggests that robot-assisted drainage may enhance procedural safety and efficacy in PBH, potentially improving survival and long-term functional outcomes.

In this video, the authors present the microsurgical treatment of a superior petrosal dural arteriovenous fistula (dAVF) associated with a symptomatic hemorrhagic brainstem cavernous malformation in a 38-year-old male. The patient underwent a retrosigmoid craniotomy for cavernoma evacuation and fistula disconnection. Intraoperative indocyanine green angiography revealed cortical venous reflux not evident on catheter angiography, prompting reclassification to a higher-grade fistula. Postoperatively, the patient returned to neurological baseline, and follow-up imaging confirmed complete fistula obliteration, cavernoma resection, and new appearance of a developmental venous anomaly (DVA). This case highlights the dynamic nature of dAVF venous drainage and illustrates the rare co-occurrence of dAVF, DVA, and brainstem cavernoma.The video can be found here: https://stream.cadmore.media/r10.3171/2025.7.FOCVID2553

This study analyzes adverse event (AE) signals associated with ramucirumab using data from the FDA Adverse Event Reporting System (FAERS) to provide evidence supporting the safety of the drug for clinical use. Data were extracted from the FAERS database using Open Vigil 2.1. Signal detection was performed using the Reporting Odds Ratio (ROR), Proportional Reporting Ratio (PRR), and Bayesian Confidence Propagation Neural Network (BCPNN) methods. AEs were categorized and described using the Preferred Terms (PTs) and System Organ Class (SOC) classifications from the Medical Dictionary for Regulatory Activities. A total of 1,701 AE reports related to ramucirumab were retrieved. Most reported cases involved male patients (59.79%), most aged 65-74 years (25.57%), with Asia being the primary region of report origin (59.08%). Based on the screening criteria, 130 PT signals across 18 SOC categories were identified, of which 72 PTs were not listed in the drug label. Frequently reported and strongly signaled AEs included hypertension, ascites, proteinuria, edema, and neutropenia-events already noted in the prescribing information of the drug. However, additional AEs, such as pyogenic granuloma, brainstem hemorrhage, interstitial lung disease, and peritonitis, which were not included in the labeling, also showed strong signals and warrant further exploration. The commonly reported AEs of ramucirumab observed in real-world data are consistent with those listed on the drug label. Nevertheless, new suspicious AEs were identified. Enhanced clinical vigilance, through pretreatment risk assessment and ongoing posttreatment monitoring, is recommended to ensure patient safety.

Patients who have experienced bleeding in the posterior circulation of the brain often develop Hypertrophic Olivary Degeneration (HOD). This condition can lead to new neurological problems several months after the initial hemorrhage, potentially worsening the overall outcome for these patients. However, its pathogenesis and prognosis remain inconclusive. The research included 214 patients diagnosed with brainstem or cerebellar hemorrhage, of which 36 developed secondary HOD.The study aimed to analyze the clinical data of these patients, investigate the risk factors associated with HOD development, and evaluate the prognosis for those affected. (1) No significant differences in common cerebrovascular risk factors, such as hypertension and diabetes, were observed between the HOD and non-HOD groups among patients with lesions involving the Guillain-Mollaret triangle (GMT) (P > 0.05). (2) The site of hemorrhage was significantly correlated with the location of HOD (P < 0.05). (3) A significant association was found between the primary lesion's site and the interval before HOD onset (P < 0.05). (4) Patients in the HOD group showed poorer functional outcomes, reflected by higher mRS scores (Z = -2.859, P = 0.004) and lower ADL scores (Z = -2.859, P = 0.004). Among patients with brainstem or cerebellar hemorrhage, all individuals with HOD had lesions involving the GMT. A significant correlation was identified between the site of hemorrhage and the location of HOD. Cerebellar hemorrhage cases were associated with shorter intervals before HOD onset, and HOD was linked to significantly worse functional outcomes.

IntroductionThe aim of this study was to investigate the impact of the Pan-Immune-Inflammation Value (PIV) on the prognosis of spontaneous intracerebral hemorrhage (ICH) and to develop and validate a nomogram for identifying patients with a poor prognosis following ICH.MethodsWe retrospectively collected the clinical data of 742 patients with ICH admitted to the Affiliated Hospital of Xuzhou Medical University from September 2018 to March 2024. A modified Rankin Scale score > 3 at 90 days after discharge was defined as a poor short-term prognosis. The enrolled patients were randomly assigned to a training cohort and a validation cohort in a 7:3 ratio. In the training cohort, risk factors associated with poor short-term prognosis were identified through univariate and multivariate logistic regression analyses. Based on these risk factors, a nomogram was developed and validated.ResultsOf the 742 ICH patients included in this study, 519 were assigned to the training cohort and 223 to the validation cohort. Multivariate logistic regression analysis identified several risk factors for poor prognosis of ICH: brainstem hemorrhage (OR = 3.17, 95% CI = 1.80–5.59, p < 0.01), reduced activated partial thromboplastin time (APTT) (OR = 0.94, 95% CI = 0.89–0.99, p = 0.047), large bleeding volume (OR = 1.06, 95% CI = 1.04–1.09, p < 0.01), low Glasgow Coma Scale (GCS) score (OR = 0.76, 95% CI = 0.70–0.82, p < 0.01), and high PIV level (OR = 1.01, 95% CI = 1.01–1.01, p < 0.01). A nomogram was constructed based on these factors. The area under the receiver operating characteristic curve was 0.86, indicating good discrimination ability. The Hosmer-Lemeshow goodness-of-fit test for the validation cohort demonstrated that the model had satisfactory calibration. Decision curve analysis revealed that the nomogram had clinical utility across a wide range of threshold probabilities.ConclusionA high PIV level, large bleeding volume, and low GCS score are significant risk factors for poor prognosis in patients with ICH. The nomogram based on these factors demonstrates robust predictive performance.

This study systematically compares various methods for calculating brainstem hematoma volume, and introduces a novel estimation method based on the maximum cross-sectional area. First, we assessed the accuracy of the Tada formula and 3D Slicer software for quantifying brainstem hematomas of different sizes and morphologies. The results revealed significant differences among methods, with the traditional Tada formula frequently overestimating hematoma volumes. We therefore propose an improved algorithm that substantially increases both the accuracy and reliability of hematoma volume assessment. Experimental results demonstrate that this new method provides greater precision and consistency when measuring the volume of irregular hematomas. These findings not only contribute to improved diagnosis and treatment of brainstem hemorrhage but also provide valuable support for future research and practical applications.

Effectiveness of 3D Technology-Assisted Minimally Invasive Surgery for Brainstem Hemorrhage

There is limited high-level evidence guiding the surgical treatment of hypertensive intracerebral hemorrhage, leaving the decision to the clinician's discretion. To understand treatment practices, a questionnaire survey was conducted among members of the Japanese Society on Surgery for Cerebral Stroke. This survey examined stroke care systems at various institutions, stroke numbers, and treatment details of patients with hypertensive intracerebral hemorrhage from January 2021 to December 2023. We examined data from 42 facilities, compared with 10 primary stroke centers cores and 32 non-primary stroke center cores. The total number of physicians involved in stroke care (primary stroke center cores vs. non-primary stroke center cores, median interquartile range; 18 [11-26] vs. 8 [4-14], p = 0.01), stroke specialists (8 [5-12] vs. 4 [2-7], p = 0.03), and supervising stroke surgeons (2 [1-2] vs. 1 [0-2], p = 0.008) was significantly higher in the primary stroke center cores group. Overall, 36,412 patients with stroke were hospitalized: 68% had cerebral infarction, 22% cerebral hemorrhage, 8% subarachnoid hemorrhage, and 2% other strokes. The locations of hypertensive intracerebral hemorrhage varied, with the putamen (31%), thalamus (25%), and lobe (24%) being predominantly affected. Non-invasive treatment was more prevalent in non-primary stroke center cores for most hypertensive intracerebral hemorrhage types, except for putaminal and brainstem hemorrhages. Surgical interventions were more common in primary stroke center cores, with craniotomies, neuroendoscopic surgeries, and ventricular drainage being preferred for cerebellar hemorrhage (28%), caudate nucleus hemorrhage (20%), and intraventricular hemorrhage (41%). This study highlights the treatment variability of hypertensive intracerebral hemorrhage between primary stroke center and non-primary stroke center cores.