Brainstem Infarction Research Articles

Complete functional recovery in a child after endovascular treatment of basilar artery occlusion caused by spontaneous dissection: a case report

Stroke caused by dissection of arteries of the vertebrobasilar system in children is still poorly investigated in terms of etiology, means of treatment, course of disease, and prognosis. The aim of this report was to describe the unusual course of a spontaneous dissection of the basilar artery (BA) in a child treated with endovascular techniques and to point out that the plasticity of the brain stem can fully compensate for structural damage caused by stroke. We report the case of a 15-year-old boy who suffered a wake-up stroke with BA occlusion caused by spontaneous dissection. A blood clot was aspirated from the false lumen and the true lumen re-opened, but the patient deteriorated a few hours later, and repeated angiography revealed that the intimal flap was detached, occluding the BA again. The lumen of BA was then reconstructed by a stent. Despite a large pons infarction, the patient was completely recovered 11 months after the onset. The case was analyzed with angiograms and magnetic resonance imaging, macroscopic and microscopic pathological analysis, computed tomographic angiography, magnetic resonance-based angiography, and diffusion tensor imaging. This case illustrates that applied endovascular techniques and intensive care measures can alter the course of potentially fatal brain stem infarction. Our multimodal analysis gives new insight into the anatomical basis for the plasticity mechanism of the brain stem.

Relationship of brainstem infarction to rupture of nonsaccular vertebrobasilar aneurysms.

Symptomatic nonsaccular vertebrobasilar aneurysms (NSVBAs) are associated with high rates of aneurysm-related death. Anecdotal evidence suggests that brainstem infarction may be a harbinger of aneurysm rupture. The authors aimed to investigate the association between brainstem infarction and subsequent NSVBA rupture. The clinical records and radiographic imaging studies of patients presenting to the authors' institution between 1996 and 2019 for evaluation and management of an NSVBA were retrospectively reviewed to determine the effect of perforating artery infarction on the natural history of NSVBAs. Kaplan-Meier curves for patients with and patients without perforator infarction were constructed, and predictors of aneurysm rupture were identified using a multivariate Cox proportional hazards model. There were 98 patients with 591.3 person-years of follow-up who met the inclusion criteria for analysis. There were 20 patients who experienced perforator infarction during follow-up. Ten patients (10.2%) experienced aneurysm rupture during follow-up and 26 patients (26.5%) died due to aneurysm-related complications, with annual rates of rupture and aneurysm-related death of 1.7% and 4.4%, respectively. Five patients with a perforator infarction later experienced aneurysm rupture, with a median time between infarction and rupture of 3 months (range 0-35 months). On multivariate analysis, the presence of intraaneurysmal thrombus (risk ratio [RR] 4.01, 95% confidence interval [CI] 1.12-14.44, p = 0.033) and perforator infarction (RR 6.37, 95% CI 1.07-37.95, p = 0.042) were independently associated with risk of aneurysm rupture. NSVBAs continue to be extremely challenging clinical entities with a poor prognosis. These results suggest that brainstem infarction due to perforating artery occlusion may be a harbinger of near-term aneurysm rupture.

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.

Case Report: Prominent Brainstem Involvement in Two Patients With Anti-CASPR2 Antibody-Associated Autoimmune Encephalitis

Anti-contactin-associated protein-like 2 (CASPR2) antibody-associated autoimmune encephalitis is commonly characterized by limbic encephalitis with clinical symptoms of mental and behavior disorders, cognitive impairment, deterioration of memory, and epilepsy. The classical lesions reported are located at the medial temporal lobe or hippocampus, whereas prominent brainstem lesions have not been addressed to date. Herein, we reported two patients mimicking progressive brainstem infarction with severe neurological manifestations. On brain magnetic resonance imaging (MRI), prominent brainstem lesions were noted, although multifocal lesions were also shown in the juxtacortical and subcortical white matters, basal ganglia, hippocampus, and cerebellar hemisphere. Unexpectedly and interestingly, both cases had detectable CASPR2 antibodies in sera, and an exclusive IgG1 subclass was documented in the further analysis. They were treated effectively with aggressive immunosuppressive therapies including corticosteroids, intravenous immunoglobulin G, and rituximab, with the first case achieving a rapid remission and the other undergoing a slow but gradual improvement. To the best of our knowledge, this is the first report on prominent brainstem involvement with definite MRI lesions in anti-CASPR2 antibody-associated autoimmune encephalitis, which helps to expand the clinical spectrum of this rare autoimmune disease and update the lesion patterns in the CNS.

Vestibular Migraine With Brainstem Auras: A Review of Pathogenesis, Clinical Varieties, Abortive and Prophylactic Treatment

Vestibular migraine (VM) is the most common etiology of vertigo in the adults. VM accompanied by brainstem symptoms is not uncommon, but underrecognized so far. It is often misdiagnosed as brainstem infarction. Earlier correct diagnosis could help avoid thrombolysis, intravascular intervention, excessive auxiliary examination, panic and fear, repeated hospitalization, waste of medical resources, early and short-term use of steroid hormone, and antioxidant. Family or sporadic hemiplegic migraine (HM) is a kind of encephalopathy instead of simple hypoperfusion; the pathogenesis, which was not well described, might also account for the neurological symptoms in VM patients. The genomic identification of the migraine could facilitate better understanding on molecular pathogenesis of familial HM. Genetic mutations are believed to be associated with more susceptible alterations of cortical spreading depression in the brain. J Neurol Res. 2021;11(5):77-86 doi: https://doi.org/10.14740/jnr651

Vestibular Migraine With Brainstem Auras: A Review of Pathogenesis, Clinical Varieties, Abortive and Prophylactic Treatment

Vestibular migraine (VM) is the most common etiology of vertigo in the adults. VM accompanied by brainstem symptoms is not uncommon, but underrecognized so far. It is often misdiagnosed as brainstem infarction. Earlier correct diagnosis could help avoid thrombolysis, intravascular intervention, excessive auxiliary examination, panic and fear, repeated hospitalization, waste of medical resources, early and short-term use of steroid hormone, and antioxidant. Family or sporadic hemiplegic migraine (HM) is a kind of encephalopathy instead of simple hypoperfusion; the pathogenesis, which was not well described, might also account for the neurological symptoms in VM patients. The genomic identification of the migraine could facilitate better understanding on molecular pathogenesis of familial HM. Genetic mutations are believed to be associated with more susceptible alterations of cortical spreading depression in the brain. J Neurol Res. 2021;11(5):77-86 doi: https://doi.org/10.14740/jnr651

Postoperative Dysphagia Aortica: Comparison with Other Dysphagia.

Dysphagia can be classified as oropharyngeal or esophageal, and functional or structural deficits of the esophagus can cause esophageal dysphagia. Dysphagia aortica (DA) is defined as dysphagia caused by extrinsic compression of the esophagus by the aorta. The aim of this study was to investigate the characteristics of DA by comparing the findings of videofluoroscopic swallowing studies (VFSS) with those of other dysphagia. Sixty-seven patients with postoperative dysphagia aortica (PDA), dysphagia after brainstem infarction (DBI), dysphagia after anterior cervical discectomy and fusion (DACDF), and subjective swallowing difficulty (SSD) without penetration and/or aspiration, who had undergone VFSS incorporating tests using 5ml of thin and thick liquids, were included. The clinical data were collected retrospectively. The penetration-aspiration scale, functional dysphagia scale (FDS), esophageal transit time (ETT), and aortic lesion parameters (maximal diameter and distance between the lesion and the apex of the aortic arch) were assessed. The patients with PDA had higher FDS scores than the patients with SSD and lower scores than the patients with DBI did on thin liquids, while the FDS scores on thick liquids were lower in the patients with PDA than in those with DBI or DACDF. The patients with PDA had longer ETT than the other three groups. No correlation was found between the aortic lesion parameters and the VFSS findings. Although PDA has some oropharyngeal symptoms, the esophageal phase was affected mainly by PDA. After an operation on the aorta, VFSS should be considered before resuming oral feeding.

The spectrum and differential diagnosis of acquired ocular motor nerve palsies: a clinical study of 502 patients

BackgroundOcular motor nerve palsies (OMNP) frequently cause patients to present in an emergency room. In the following study, we report the differential diagnosis of OMNP by use of magnetic resonance imaging (MRI) and CSF examination as a standard.MethodWe performed a data analysis of N = 502 patients who presented with oculomotor, trochlear, and/or abducens nerve palsy in the emergency room of the Department of Neurology, University of Ulm, between January 2006 and December 2019. We report clinical and MRI scan findings in all patients; furthermore, the CSF of 398 patients has been analysed.ResultsAbducens nerve palsies were most common (45%), followed by palsies of the oculomotor (31%) (CNP III) and trochlear nerve (15%). Multiple OMNPs were seen in 9% of our cohort. The most common causes included inflammations (32.7%), space-occupying lesions, such as aneurysms or neoplasms (17.3%), diabetes mellitus (13.3%), and brainstem infarctions (11%). Still 23.4% of the patients could not be assigned to any specific cause after differential diagnostic procedures and were described as idiopathic. One of three patients with an inflammation and 39% of the patients with space-occupying lesions showed additional cranial nerve deficits.ConclusionInflammation and space-occupying processes were the most frequent causes of OMNP, although brainstem infarctions also play a significant role, in particular in CNP III. The presence of additional CNPs increases the probability of an inflammatory or space-occupying cause.

Acute brain stem vertigo without neurological deficits

An infarct at the brain stem or cerebellum is rarely associated with vertigo without any other localizing clinical features. Stroke at the posterior circulation of the brain may cause spontaneous vertigo and imbalance. In some cases, isolated posterior inferior cerebellar artery infraction presents isolated vertigo and nystagmus. The diagnosis of the brain stem vertigo can be done easily when associated with other neurological symptoms along with vertigo, whereas, when the vertigo occurs in isolation, it may be difficult to differentiate it from the other benign disorders affecting the inner ear. A head impulse test may differentiate the acute isolated vertigo with cerebellar stroke from more benign disorders associated with labyrinth. Appropriate evaluation of the patient is better than imaging for diagnosis of the brain stem vertigo. Here, we are presenting a case of isolated acute onset of the vertigo due to brain stem infarct which mimics to the peripheral vestibular pathology.

The utility of “heart sign” on neuroimaging in acute-onset quadriparesis: A series of three cases

The “heart sign” is a well-described radiological sign in bilateral medial medullary infarction, which is a rare stroke syndrome. It has also been rarely reported in infarction of bilateral paramedian pons and caudal paramedian midbrain. Bilateral brainstem infarcts usually present with varying degree of quadriparesis and in the initial stages, it is difficult to distinguish from other conditions such as Guillain–Barre syndrome and brainstem encephalitis. Recognizing the “heart sign” on magnetic resonance imaging in a stroke-like episode may be helpful in differentiating these conditions from bilateral brainstem infarcts.

The Death of a Young Adult due to Wallenberg Syndrome: A Case Report

Wallenberg syndrome which is also known as lateral medullary syndrome (LMS) and posterior inferior cerebellar artery syndrome ((PICA syndrome) is detected relatively rarely among young adults. A 42-year-old apparently healthy male presented with headache, vomiting and vertigo. He was diagnosed to have severe hypertension and type-2 diabetes mellitus. During his first admission his first non-contrast computed tomography (NCCT) scan of the brain had confirmed a cerebellar infarction. With clinical findings, the patient was treated as a possible case of LMS. With the repeat NCCT on the third day, he was diagnosed to have progressive cerebellar infarction and a medullary infarction. In the following day the patient was discharged with reserved dates for vertebral artery duplex and ultrasound scan of abdomen (USS). On the seventh day of the illness he had collapsed and died. Subsequent autopsy revealed a left-sided cerebellar and a brain stem infarction along with generalized cerebral oedema. Important findings deduced by forensic pathologists should be conveyed to the clinicians in order to broaden the treatment options and to prevent premature deaths.

Ondine\u2019s curse, a fatal infarction diagnosed by polysomnography and saved by ventilation: a case report

BackgroundLateral medullary syndrome causing Ondine’s curse is a rare yet fatal brainstem infarction. Any patient presenting with lateral medulla infarction ought to be well observed and a polysomnography must be ordered for him.Case presentationA patient presenting with Ondine’s curse is dealt with through polysomnography as a diagnostic procedure that was followed by tracheostomy with portable ventilator and cardiac pacemaker as a therapeutic maneuver which ultimately preserved his life.ConclusionLateral medullary syndrome infarct could be a life-threatening stroke if not diagnosed and managed properly.

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.

Transcavernous Approach for Microsurgical Clipping of Ruptured Right Superior Cerebellar Artery Aneurysm with Cadaveric Stepwise Video Illustration.

Superior cerebellar artery (SCA) aneurysms are rare. The management options are not well defined. There is increasing role of endovascular treatment for all aneurysms, especially for aneurysms of the posterior circulation. However in some situations (wide base, dysmorphic features) coiling is not feasible. The surgical management of these aneurysms has its own distinct complexity and requires careful planning. The classic pterional or subtemporal approaches had its own limitation in proper visualization of the neurovascular anatomy.In this video, we describe the technical nuances of transcavernous sinus approach for microsurgical clipping SCA and A-comm aneurysms. We present the case of a 67-year-old RHF who presented with ruptured right-sided SCA aneurysm. She complained of Headache, confusion, and double vision. On physical examination, she had no focal deficits and was Hunt and Hess grade 3. A brain computed tomography (CT) scan revealed a subarachnoid hemorrhage Fisher's grade 4. A brain CT angiography (CTA) demonstrated an aneurysm at the origin of right SCA. The patient had failed attempt of endovascular coiling and she underwent microsurgical clipping.Stepwise demonstration of the approach with cadaveric anatomical dissection is illustrated. The technique presented here allows for safe clipping of the aneurysm through the cavernous sinus. The approach allows for good exposure of the aneurysm and the surrounding structures. Care is taken to visualize the perforators to avoid any devastating brain stem infarction during the clipping.The transcavernous sinus is a robust approach with good visualization of the neurovascular structures allowing safe aneurysm clipping in this location. The link to the video can be found at: https://youtu.be/oE-HyDASiKM .

A rare case of lateral pontine syndrome-Marie Foix syndrome

Lateral pontine syndrome or Marie Foix Alajouanine syndrome refers to the brainstem stroke syndrome involving lateral pons due to the infarction in the distribution of the anterior inferior cerebellar artery. It involves the lateral inferior part of the pons, middle cerebellar peduncle, and floccular region. Computed Tomography (CT) is less sensitive in brainstem infarction than Magnetic Resonance Imaging (MRI). With the introduction of MRI, it is possible to precisely locate the brainstem infarcts. We present a case with a typical clinical picture of brainstem stroke with radiological findings consistent with the lateral pontine syndrome. Proper correlation with the clinical picture and radiological findings is important for the diagnosis of brainstem infarctions.

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.

Fast and slow progressors of infarct growth in basilar artery occlusion strokes

BackgroundHeterogeneity in the infarct growth rate among anterior circulation large vessel occlusion (LVO) strokes has triage and treatment implications. Such data are lacking for basilar artery occlusion (BAO) strokes. We...

A novel technique to manage internal carotid artery injury in endoscopic endonasal skull base surgery in the premise of proximal and distal controls.

Intraoperative internal carotid artery injury is one of the most daunting complications in endoscopic skull base surgery. This paper proposed a novel technique to manage ICA injury after proximal and distal controls. The appropriate block sites together with the proximal and distal controls of ICA were demonstrated in six injected cadaveric specimens. The surgical outcomes of five patients with intraoperative ICA injury and managed with this concept were retrospectively reviewed. Five block sites for vascular control could be identified in all six specimens, including (1) distal to the distal dural ring, (2) proximal to the proximal dural ring, (3) anterior genu of the parasellar ICA, (4) the upper third of the paraclival ICA, and (5) just above the foramen lacerum. Both proximal and distal controls of ICA were achieved by using the block sites in combination. Gross tumor resection was achieved in all five cases after the intraoperative ICA injury was successfully managed. Three coping techniques were used, including direct coagulation to seal (three cases), endoscopic suture (one case), and coagulation to sacrifice (one case). Focal brainstem infarction occurred in one case, one patient died of intracranial infection, and the other three cases had no sequelae. No pseudoaneurysm occurred in all patients. Except the sacrificed ICA, the other ICA was intact during follow-up. It is technically feasible to manage ICA injuries after proximal and distal controls during EEA surgeries. The surgical outcomes from our case series supported the use of this novel technique.

The Longitudinal Distribution and Stability of Curved Basilar Artery Plaque: A Study Based on HR-MRI.

Aims: This study aims to evaluate the differences in the characteristics of atherosclerotic plaques in the proximal, curved, and distal segments of the curved basilar artery (BA) through high-resolution magnetic resonance imaging(HR-MRI). Methods: The imaging and clinical data of 146 patients were retrospectively analyzed. On the basis of three-dimensional (3D) time -of -flight magnetic resonance angiography (3D-TOF-MRA), 51 patients with BA curvature were selected for the study. The BA plaque is divided into three groups: proximal, curved, and distal. Plaques were identified and analyzed according to spin echo acquisition imaging via T1-weighted 3D volumetric isotropic Tse acquisition (T1W-3D -VISTA), and compare the differences in clinical related factors and plaque characteristics between groups. Diffusion-weighted imaging (DWI) and/or T2WI identified brainstem infarction. The patients were divided into symptomatic and asymptomatic groups. The correlation between plaque location and symptoms was identified and analyzed. Results: Among 51 patients, a total of 376 plaques were detected. Plaques in the proximal and curved segments are more common than those in the distal segments. Proximal plaques are more likely to have intraplaque hemorrhage ( P =0.002 ＜0.05). There was no significant difference in the distribution of criminal plaques and non-criminal plaques between each group ( P =0.36 ＞0.05). Conclusion: Plaques in the proximal and curved segments of the BA are more common than those in the distal segments. The proximal plaque is more prone to intraplaque hemorrhage.

Ischemic stroke secondary to self-inflicted carotid sinus massage: a case report

BackgroundThe risk of stroke after carotid sinus massage is greater if there is preexisting carotid stenosis or carotid plaques. We present the case of a patient with underlying 40% carotid stenosis, who developed a watershed stroke after a self-neck massage in our stroke unit. We show a well-documented case with magnetic resonance images before and after the neck massage. We report a case of a watershed brain infarct after a self-massage of the carotid sinus, with preexisting carotid artery stenosis. Neck massage continues to be a significant cause of stroke and should therefore not be performed by patients. Clinicians must be aware of the implications of a carotid sinus massage in both the outpatient and inpatient settings.Case presentationWe admitted a 58-year-old white male patient, with no relevant medical history, to our department with a brain stem infarct. During his stay at our stroke unit, the patient performed a self-neck massage with consecutive bradycardia and asystole, resulting in left-side hemiparesis. The underlying cause of the hemodynamic stroke is believed to be secondary to this intensive neck massage performed by the patient. The patient also suffered from unknown right internal carotid artery stenosis. ConclusionClinicians and patients must be aware that neck massage can lead to ischemic stroke. We postulate that repetitive impaired cardiac output can lead to a hemodynamic (watershed-type) stroke.