Brainstem Infarction Research Articles

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.

Erectile dysfunction (ED) after ischemic stroke: association between prevalence and site of lesion.

Stroke may cause or worsen erectile dysfunction (ED). Post-stroke ED prevalence and association with stroke location are not well established. Therefore, we assessed post-stroke ED prevalence in relation to ischemic lesion locations and stroke severity. In 57 men (62.6 ± 10.5 years) who had ischemic stroke within 24 months prior to evaluation, we used the five-item International Index of Erectile Function questionnaire (IIEF5) to evaluate ED prevalence after stroke and retrospectively 3 months prior to stroke. IIEF5 scores range from 5 to 25; scores below 22 indicate ED. We estimated stroke severity upon hospital admission, using the National Institute of Health Stroke Scale (NIHSS), and determined stroke location from cranial computed tomography or magnetic resonance imaging. We compared pre- and post-stroke results with those of 22 control persons (61.7 ± 11.2 years), calculated correlations between IIEF5 scores and NIHSS scores, and compared ED prevalence with stroke locations (significance: p < 0.05). ED was reported by 45/57 patients after stroke, 26/57 patients before stroke, and 6/22 control persons. Patients' IIEF5 values were significantly lower [median 16 interquartile range (IQR) 3.5-20.5] after than before stroke (median 23, IQR 19.0-24.0) and lower than in controls (median 24, IQR 19.8-25.0). Pre- and post-stroke IIEF5 scores did not correlate with the patients' NIHSS scores at stroke onset (p > 0.05). ED was associated with middle cerebral artery infarction in 27/34, posterior cerebral artery infarction in 4/5, anterior cerebral artery infarction in 1/1, basal ganglia infarction in 3/3, brain stem infarction in 8/10, cerebellar infarction in 2/5, and lesions in more than one region in 1/1 patients. Disruption of the central network assuring erection might contribute to increased ED severity and prevalence after stroke. Anti-erectile effects of functional and psychological impairment or medication added after stroke may also contribute to ED but must be evaluated in larger patients groups.

Types and risk factors of recurrent ischemic stroke after initial brainstem infarction

To retrospectively analyze the clinical data of 176 patients of recurrent cerebral infarction at our hospital. Based upon the treatment of acute stroke trial (TOAST) classification, the types of recurrent ischemic stroke with initial brainstem infarction were classified. And univariate and multivariate logistic analyses of risk factors were performed. The major types in a decreasing order were atherosclerotic cerebral infarction (AT, n=24, 70.6%), small arterial occlusive stroke (SA, n=8, 23.5%) and cardiogenic cerebral embolism (CE, n=2, 5.9%). Brainstem infarction was more likely to be affected by poor life habits and a history of diabetes mellitus (DM). And atrial fibrillation was a major independent risk factor for non-brainstem infarction. Multivariate logistic analysis showed that poor living habits (P=0.03), a history of DM (P=0.004), vulnerable plaque (P=0.01) and poor compliance of secondary prevention medication (P=0.02) were independent risk factors for recurrent ischemic stroke with initial brainstem infarction. Health education should be strengthened for preventing recurrent ischemic stroke with brainstem infarction. Key words: Brain infaction, relapsing; Risk factors

P191. The starch-iodine test in the topodiagnosis of Horner’s syndrome with heat hypohidrosis and gustatory sweating

Background and purpose Horner’s syndrome may result from a variety of central or peripheral lesions of the sympatho-excitatory pathway. Associated symptoms like focal anhidrosis or gustatory sweating are helpful to localize the lesion and to direct further neuroimaging procedures. The starch-iodine test according to Minor can reveal the extent of anhidrosis and therefore help to localize lesions of the sympathetic nervous system. Pharmacological pupillary testing, sympathetic skin response and autonomic testing may result in further information about the place of the lesion. Case report: We present a 44-year old male patient with clinical manifestation of right sided Horner’s syndrome after ipsilateral cervical disc herniation surgery at C6/C7. Horner‘s syndrome was accompanied by reduced sweating when exposed to heat and exercise, but enhanced gustatory sweating after consumption of spicy food, both only at the right side of the face. The patient also complained about severe neuropathic pain on his skin at the right side of his face and neck, exacerbating at times of changing weather and after performing exercise with the right arm. Neurological examination did not show any other pathological findings, especially no tonic pupils, no hyporeflexia, and no signs of a brainstem or other cerebral infarction. Laboratory diagnostics and lumbar puncture showed normal parameters. Sympathetic skin response of both hands and cardiac autonomic testing were also normal. Pharmacological pupillary testing with local cocaine showed significantly less pupil dilatation at the right side and therefore confirmed Horner’s syndrome. A sweating test was conducted to further localize the lesion of the sympatho-excitatory pathway. The starch-iodine test according to Minor was first performed after heat exposure and then again after eating spicy food (chili). It showed heat hypohidrosis on the right sight of the face, but neither on the right arm nor thorax. After intake of chili, gustatory sweating was only detected on the right facial hemisphere. MRI imaging of the brain and the cervical spine showed no abnormalities. By treatment with pregabalin, oxycodone/naloxone, and amitriptyline, we were able to reduce the neuropathic pain. A stellate ganglion block remains an option in case of refractory pain. Conclusion: By performing a starch-iodine test, we were able to localize the lesion of the sympathetic pathway at the area of the superior cervical ganglion of the sympathetic trunc. A damage at the stellate ganglion would have caused quadrant anhidrosis, while a central lesion e.g. at the hypothalamus would have caused hemianhidrosis. A more distal lesion at the carotid plexus results in only partial facial hypohidrosis or no hypohidrosis at all. We suspect a damage of the second order preganglionic sympathetic neuron, because gustatory sweating is most frequently described in preganglionic lesions. Despite the normal MRI scan, an association with the cervical surgery is probable. This case underlines the usefulness of “old” examination procedures like the starch-iodine sweat test in the topodiagnosis of focal dysautonomias like Horner‘s syndrome.

Heart beats: not to be beaten.

Heart beats: not to be beaten.

Acute pontine infarction after percutaneous coronary intervention: a very rare but devastating complication

A 64-year-old man suffering from an acute posterior wall myocardial infarction underwent primary percutaneous coronary intervention. After several aspiration attempts, tirofiban infusion and pre- and post-dilatation, a bare-metal stent was successfully implanted in the culprit right coronary artery. While the patient did not show any neurological symptoms before or during the procedure, he exhibited hemiplegia and loss of spontaneous speech. Additional magnetic resonance imaging showed an extensive brain stem infarction. This is the first report of a brain stem infarction as a complication of percutaneous coronary intervention.Electronic supplementary materialThe online version of this article (doi:10.1007/s12471-015-0717-2) contains supplementary material, which is available to authorized users.

One-year follow-up in patients with brainstem infarction due to large-artery atherothrombosis.

BackgroundPosterior circulation infarction accounts for approximately 25% of the ischemic strokes. A number of different conditions may be associated with the development of brainstem infarction. Prognosis and recurrence rate of brainstem infarction due to large-artery atherothrombosis is still controversial.MethodsA total of 826 patients with ischemic stroke were admitted to our clinic during a 15-month period. Patients with clinical and radiological evidence of brainstem infarction were comprehensively assessed with appropriate vascular imaging modalities and for cardiological causes. Subjects with an established diagnosis of large-artery atherothrombosis were followed up for 1 year in terms of prognosis and recurrence rates.ResultsOf the 101 patients with an established brainstem infarction, the diagnostic work-up indicated the presence of large-artery atherothrombosis as the causative factor in 53. A recurrent stroke was detected in the posterior circulation within the first 3 months in 5.8% and within 1 year in 9.8% of these individuals. The 1-year mortality rate was 11.7%. All patients with recurrent stroke had intracranial vascular narrowing at baseline.ConclusionOur findings demonstrate a particularly high rate of recurrence and mortality at 1 year among patients who have a brainstem infarction due to intracranial arterial stenosis.

Abstract W P22: Examining the Effects of Intra-Arterial Therapy in Acute Posterior Circulation Occlusions

Background: Recent trials have failed to show benefit of intra-arterial therapy (IAT) in acute ischemic stroke (AIS) patients. Patients with posterior circulation occlusions, however, were vastly underrepresented (only 4 patients in IMS3, MR-RESCUE and SYNTHESIS combined). IAT is often pursued, due to the inherent poor outcome associated with brainstem infarction. We sought to evaluate potential benefit with IAT in this population. Methods: A US multicenter retrospective cohort of 106 patients with AIS and LAO in the vertebrobasilar distribution presenting 01/05-3/14 within 12 hours from stroke onset was examined. Patients were divided into two groups (IAT vs No IAT). Logistic regression with good and poor (discharge mRS 0-2 and 4-6) outcome was performed. Univariate and multivariate analyses evaluated independent predictors of good outcome after IAT. Results: Patients in the IAT group (n=57) had more severe strokes (NIHSS 24 vs 12) than the medical management group (n=49); otherwise the two groups were comparable (Table 1). IAT was not associated with improved odds of good outcome (OR 0.76, 95%CI 0.27-2.14, p=0.60), even after adjusting for admission NIHSS, recanalization, and time to IAT start (OR 1.35, 95%CI 0.39-4.68, p=0.63). The subgroup with basilar occlusions also did not benefit from IAT. Stroke severity predicted treatment with IAT; each additional point in NIHSS was associated with 5% increased chances of IAT (P 0.07). There were more deaths in the IAT group (Figure 1); 73% of these, however, were associated with care withdrawal decisions. Conclusion: While vascular neurologists intervene more often on severe posterior circulation strokes, our results suggest poor outcome was not averted, even after adjusting for stroke severity. While our results are affected by the inherited limitations of a retrospective cohort and selection bias of a non- randomized design, it addressed an underrepresented stroke population. RCTs are needed to validate these results.

Abstract 128: Pittsburgh Outcomes After Stroke Thrombectomy Vertebrobasilar (POST VB) Score Predicts Outcomes After Endovascular Therapy for Basilar Artery Occlusions

Background: Basilar artery occlusion (BAO) is associated with high rates of morbidity and mortality. Endovascular therapy offers improved outcomes, but the road to recovery is often protracted necessitating aggressive supportive care. We sought to develop a prognostic score incorporating these factors to predict outcomes after endovascular therapy for BAO. Methods: The derivation cohort was obtained from a previously utilized prospectively maintained database of patients with BAO treated endovascularly at our institution prior to June 2012 (N=59). Logistic regression was performed to identify any independent predictors of good outcome (90-day mRS, 0-2). Factors were weighted based on β-coefficients to derive the Pittsburgh Outcomes After Stroke Thrombectomy Vertebrobasilar (POST VB) score. The POST VB score was then validated in a similar cohort of patients with BAO treated endovascularly at our institution after June 2012 (N=30). Results: In the derivation cohort, independent predictors (P&lt;0.1) of good outcome included final brainstem infarct volume (in cm3, β =-1.067, P&lt;0.01) (but not infarct in other locations within the posterior circulation) and age (years, β=-0.114 P=0.011). The POSTVB score was calculated as age+10хfinal infarct volume. The Hosmer Lemeshow test of the model demonstrated a good fit (p=0.92). A POST VB &lt;75 was associated with an 80% chance of good outcome compared with 0% with a score ≥125. POSTVB accurately predicted good outcomes in the derivation (AUC=0.89) and validation cohorts (AUC=0.88). Predictive accuracy was very similar across all groups. Conclusions: The POST VB score appears to accurately predict of outcome following endovascular therapy for acute stroke due to BAO and thus may aid in guiding post-interventional care. Our results await validation from larger prospectively acquired datasets.

The role of P300 event-related potentials in the cognitive recovery after the stroke

The aim of this study was to elucidate the effects of an ischemic stroke on the amplitude and latency of the P300 wave and evaluate their changes over a prospective 1-year follow-up period. We recorded the P300 wave using an auditory oddball paradigm in 60 consecutive brain infarct patients at baseline (i.e., within 4 weeks after the stroke), after 3 months, after 12 months and in 30 healthy control subjects. The P300 latencies in stroke patients were significantly longer and the P300 amplitudes were significantly smaller than those of the control group. The latency of P300 showed a highly significant average improvement 12 months after the stroke compared to the baseline. There was no significant change observed for the P300 amplitude during the same period. The P3 latency is initially more increased in the patients with hemispheric brain infarction but shows a better recovery compared to the patients with brainstem infarction. Also, the results of the P300 latency of patients with the left-sided lesions was significantly longer compared to the patients with right-sided lesions on the beginning of the study but not 3 and 12 months after the stroke. The results of our study show the importance of P300 event-related potentials in the detection and follow-up of cognitive changes after ischemic stroke.

Top of Basilar Artery Syndrome.

A 45 years old male presented in Department of Medicine at the Shree Shayaji General Hospital with sudden onset bilateral ptosis, dilatation of the pupil and paresis of extraocular muscles. There were area of restricted diffusion on diffusion weighted images with corresponding low ADC (Apparent Diffusion Coefficient) value in periaqueductal region, oculomotor nucleus and medial thalami suggestive of acute infract. In MR cerebral angiographic image filling defect is seen in the basilar artery suggestive of thrombosis [Table/Fig-1,​,22,​,3].3]. Top of the Basilar Artery Syndrome is also known as a Rostral Brainstem Infarction. It is due to the thromboembolic occlusion of the top of the basilar artery. Risk factors for the thrombosis are hypertension [1], diabetes mellitus [2], obesity [2], hyperhomocystinemia [3], and excessive alcohol intake. It may be secondary to the cardiogenic emboli like mural thrombi in myocardial infarction and atrial fibrillations or valvular thrombi in infective endocarditic and valvular heart disease. Hypercoaguable states like antiphospholipid antibodies [4], protein C deficiency [4], protein S deficiency [4] may also leads to the thrombotic events. Small vessel vaculities in sickle cell disease may be associated with it. Bilateral tha lamic ischemia occurs due to occlusion of perforator vessels. Clinically patient develops symptoms like visual and oculomotor deficits and behavioral abnormalities. However, motor dysfunction is often absent [5]. CT angiography, MR angiography and catheter angiographic are the imaging modality use to confirm the finding and demonstrate a filling defect [6]. Prognosis in patient with bilateral ocular palsy is poor. [Table/Fig-1a,b]: Axial section of diffusion weighted MR image shows (A) area of restricted diffusion in oculomotor nuclei region in midbrain (open white arrow) (B) area of restricted diffusion in bilateral medial thalami (open white arrow) [Table/Fig-2a,b]: Axial section of Apparent Diffusion map shows (A) corresponding low ADC value in oculomotor nuclei region in medulla (black solid arrow) (B) in bilateral medial thalami (solid white arrow) [Table/Fig-3a,b]: MR angiographic images shows filling defect in the basilar artery suggestive of thrombosis Top of the basilar artery syndrome is occurring due to thrombotic occlusion of the basilar artery. Patient presented with visual and oculomotor deficit and behaviour abnormalities. MR angiography demonstrate filling defect in the basilar artery.

Fatal Vertebral Artery Injury in Penetrating Cervical Spine Trauma.

Study Design. This case illustrates complications to a vertebral artery injury (VAI) resulting from penetrating cervical spine trauma. Objectives. To discuss the management of both VAI and cervical spine trauma after penetrating gunshot wound to the neck. Summary of Background Data. Vertebral artery injury following cervical spine trauma is infrequent, and a unilateral VAI often occurs without neurologic sequela. Nevertheless, devastating complications of stroke and death do occur. Methods. A gunshot wound to the neck resulted in a C6 vertebral body fracture and C5–C7 transverse foramina fractures. Neck CT angiogram identified a left vertebral artery occlusion. A cerebral angiography confirmed occlusion of the left extracranial vertebral artery and patency of the remaining cerebrovascular system. Following anterior cervical corpectomy and stabilization, brainstem infarction occurred and resulted in death. Results. A fatal outcome resulted from vertebral artery thrombus propagation with occlusion of the basilar artery triggering basilar ischemia and subsequent brainstem and cerebellar infarction. Conclusions. Vertebral artery injury secondary to cervical spine trauma can lead to potentially devastating neurologic sequela. Early surgical stabilization, along with anticoagulation therapy, contributes towards managing the combination of injuries. Unfortunately, despite efforts, a poor outcome is sometimes inevitable when cervical spine trauma is coupled with a VAI.

Molecular hydrogen in sports medicine: new therapeutic perspectives.

In the past 2 decades, molecular hydrogen emerged as a novel therapeutic agent, with antioxidant, anti-inflammatory and anti-apoptotic effects demonstrated in plethora of animal disease models and human studies. Beneficial effects of molecular hydrogen in clinical environment are observed especially in oxidative stress-mediated diseases, such as diabetes mellitus, brain stem infarction, rheumatoid arthritis, or neurodegenerative diseases. A number of more recent studies have reported that molecular hydrogen affects cell signal transduction and acts as an alkalizing agent, with these newly identified mechanisms of action having the potential to widen its application in clinical medicine even further. In particular, hydrogen therapy may be an effective and specific innovative treatment for exercise-induced oxidative stress and sports injury, with potential for the improvement of exercise performance. This review will summarize recent research findings regarding the clinical aspects of molecular hydrogen use, emphasizing its application in the field of sports medicine.

Ponatinib Safety and Efficacy in Japanese Patients with Philadelphia Positive Leukemia: Update of a Phase 1/2 Study

Background: Ponatinib is a potent pan–BCR-ABL tyrosine kinase inhibitor (TKI), active against native and mutated BCR-ABL, including T315I, and approved by the US FDA for the treatment of adult patients with chronic myeloid leukemia (CML; all phases) and Philadelphia chromosome-positive (Ph+) acute lymphoblastic leukemia (ALL) that is T315I-positive or for whom no other TKI therapy is indicated. This is the first study evaluating the safety and efficacy of ponatinib in Japanese patients.Methods: This is an ongoing phase 1/2, multi-center, open-label, dose-finding study of ponatinib in Japanese patients with CML who have experienced a failure of dasatinib or nilotinib therapy, or Ph+ ALL who have experienced a failure of prior TKIs because of resistance or intolerance (ClinicalTrials.gov ID: NCT01667133). Following completion of the dose-escalation portion, in which 2 doses of ponatinib (30 mg once daily n=6; 45 mg once daily n=6) were evaluated, 45 mg once daily was selected for further study in phase 2 (n=35) to confirm the anti-leukemic activity of ponatinib. In phase 2, the primary efficacy endpoints were major cytogenetic response (MCyR) for CP-CML and major hematologic response (MaHR) for AP, BP, or Ph+ ALL. Data from the phase 1 portion have been previously presented (Japanese Society of Hematology 2013). Herein we report data as of 3 Feb 2014 from the phase 2 portion.Results: As of 30 Sep 2013, enrollment was completed with 35 patients; median age was 62 (30-77) years; median time since diagnosis was 2 (0.2-26) years; 80% patients had received ≥2 prior TKIs. Diagnoses at baseline were 17 CP-CML, 2 AP-CML, 4 BP-CML, and 12 Ph+ ALL. Twenty-two (63%) patients were resistant to their last TKI therapy, and 17 (49%) had one or more BCR-ABL mutation at baseline; 14/35 (40%) patients had the T315I mutation. At the time of analysis, 19 (54%) patients remain on therapy (15 CP-CML, 2 AP-CML, 2 BP- CML, and 0 Ph+ ALL). Primary reasons for discontinuation include adverse events (AEs; n=2), lack of efficacy (n=4) and progressive disease (n=7, all Ph+ ALL who died). Median duration of exposure was 174 (3-539) days. Median dose intensity was 38 (11-45) mg/day. To date, 23 (66%) patients had their dose reduced. Ten (59%) CP-CML patients attained the primary efficacy endpoint of MCyR (6 CCyR, 4 MMR). The primary efficacy endpoint of MaHR was achieved by 10 (56%) patients: 2/2 AP-CML, 2/4 BP-CML and 6/12 Ph+ ALL patients. Major molecular response (MMR) was observed in 5 (14%) patients.Treatment-emergent AEs (TEAEs) were observed in all patients, most common TEAEs (≥30% any grade) were thrombocytopenia (60%), pyrexia (57%), rash (37%), and hypertension (34%). Serious TEAEs were observed in 13 (37%) patients, the most common was pyrexia (n=3). No cases of pancreatitis were observed. Overall, 4 (11%) patients experienced arterial thrombotic events, 3 (9%) patients experienced serious events (1 brain stem infarction, 2 myocardial infarctions) and 1 patient experienced a non-serious event (ECG T wave inversion).Conclusions: Initial data indicate ponatinib has substantial anti-leukemic activity in these heavily pretreated CML and Ph+ ALL Japanese patients; the primary efficacy endpoint was achieved in >50% patients. Additional follow-up will allow for a more complete assessment of the benefits and risks of ponatinib therapy in Japanese CML and Ph+ ALL patients. DisclosuresOff Label Use: Ponatinib is a BCR-ABL kinase inhibitor that has been approved by the US FDA for the treatment of adult patients with CML (all phases) or Ph+ ALL that is T315I-positive or for whom no other TKI therapy is indicated.. Tojo:Novartis: Research Funding, Speakers Bureau; BMS: Research Funding. Yamamoto:Novartis: Honoraria, Research Funding, Speakers Bureau, support of manuscript preparation, support of manuscript preparation Other; Pfizer : Research Funding, support of manuscript preparation, support of manuscript preparation Other; ARIAD: Research Funding. Takahashi:Pfizer: Honoraria, Membership on an entity’s Board of Directors or advisory committees, Research Funding, Speakers Bureau; Novartis, BMS, Kyowa Hakko Kirin, Chugai Pharma, Dainippon Sumitomo Pharma, Celgene, Janssen Pharma : Honoraria, Research Funding, Speakers Bureau; Takeda Pharma: Research Funding; Asahikasei Pharma: Honoraria. Kobayashi:ARIAD, Otsuka Pharma, Boehringer Ingelheim : Research Funding. Matsumura:Bristol-Myers Squibb: Honoraria; Novartis: Research Funding, Speakers Bureau; Pfizer: Consultancy, Speakers Bureau. Usui:ARIAD: data monitoring committee Other. Yanase:ARIAD: Employment, Equity Ownership. Hu:ARIAD: Employment, Equity Ownership. Naoe:ARIAD: Consultancy. Ohyashiki:ARIAD: Consultancy.

Brainstem Stroke-Related Restless Legs Syndrome: Frequency and Anatomical Considerations

Background: Given the discordant results of studies that have reported cases of RLS associated with brainstem stroke and the absence of RLS in large series describing the clinical spectrum of brainstem infarctions, we decided to assess RLS in all patients admitted for brainstem stroke. Methods: All patients who were consecutively referred to the Strasbourg stroke unit for brainstem infarction were prospectively evaluated for RLS. The different parameters analyzed were the topography of the ischemic lesions (magnetic resonance imaging), the different symptoms (sensory, motor, cerebellar, cranial nerves and dysarthria) and the NIH stroke scale. Statistical analyses used the Bayesian paradigm. Results: Thirty patients have been included, and RLS was observed in three patients (10%). Two patients suffered from an exacerbation of symptoms anterior to the stroke, and the other patient a de novo, but transient, RLS. Patients with stroke-induced sensory symptoms have a higher risk to develop brainstem stroke-related RLS as compared to patients without sensory symptoms. Conclusion: The results suggest that RLS should be systematically screened in patients affected with brainstem stroke, especially in the case of stroke-induced sensory symptoms. Clinicians should be aware of this association, especially as efficient treatments are available and allow improving the management of patients affected with stroke. i 2014 S. Karger AG, Basel

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.

P28 * BRAINSTEM BIOPSY: A SAFE AND ACCURATE DIAGNOSTIC TOOL

INTRODUCTION: Brainstem tumours account for 10-25% of tumours in children and 2% in adults. Accurate diagnosis is crucial for treatment planning and prognosis and despite advances in the development of medical imaging, tissue diagnosis remains the diagnostic gold standard. METHOD: Retrospective study of patients who underwent stereotactic brainstem biopsy between 2001 and 2010. Radiological and tissue diagnosis, surgical morbidity and mortality, and survival time for low and high grade gliomas after biopsy and treatment were recorded. RESULTS: 42 patients were analysed, 28 adults, 14 paediatrics. Main presenting symptoms were diplopia (52.4%) and gait disturbance (38.1%). Procedure-related mortality was 0%, and minor morbidity was 11.9%. Histological diagnosis was obtained in 95.2% of cases as follows: low grade glioma (45.2%), high grade glioma (31.0%), primary CNS lymphoma (7.1%), brainstem infarction (7.1%), metastasis (4.8%) and inconclusive (4.8%). Pre-operative radiological diagnosis was unclear in 25 cases (59.5%), and failed to identify 12 out of 13 (92.3%) high grade gliomas, and 10 out of 19 (52.4%) low grade gliomas. The 2 metastasis in our study were diagnosed pre-operatively whilst lymphomas and infarcts were unclear. The median overall survival for low grade gliomas was 13 and 7 months in adults and children respectively, whilst for high grade gliomas 12 and 6 months for adults and children respectively. CONCLUSION: Brainstem biopsy remains an important diagnostic tool despite the advances in neuro-imaging. It is an accurate and safe procedure that provides tissue diagnosis to guide tumour management as well as tumour biobanking for future research.

Do patients with neurologically isolated ocular motor cranial nerve palsies require prompt neuroimaging?

Do patients with neurologically isolated ocular motor cranial nerve palsies require prompt neuroimaging?

Management of complex intracranial aneurysms with bypass surgery: a technique application and experience in 93 patients.

Despite advances in microsurgery and the development of new endovascular techniques, the treatment of complex intracranial aneurysms remains a daunting challenge for neurosurgeons. In the present study, we retrospectively reviewed our experience of bypass surgery in the treatment of 93 cases of complex intracranial aneurysms. A series of 93 consecutive cases of complex intracranial aneurysms were treated with bypass surgery between April 2004 and July 2013. Radial artery (RA) grafts were used in 58 cases, saphenous vein (SV) grafts in 16 cases, and occipital artery (OA) grafts in 6 cases, while the remaining 13 cases were managed with superficial temporal artery (STA) grafts. In this series, the aneurysms were excised after trapping in 32 cases with mass effect and neural compression. Proximal occlusion of the parent artery was performed in 22 cases of fusiform or giant dissecting aneurysms with subsequent retrograde flow to avoid compromise of the perforators nearby. Trapping was performed after bypass surgery in the remaining 39 cases. Postoperative angiographies were performed in 91 patients and patency of the bypass graft and obliteration of the aneurysms were confirmed in 89 patients. Patency of the bypass could not be confirmed in the remaining two patients, of which one presented with cerebral infarction due to graft occlusion, and the other remained asymptomatic. Within 1 month after surgery, 88 patients had good outcome, four patients needed assistance for daily living, and one death occurred due to brainstem infarction. In 77 patients with a mean follow-up of 3.0 years, 72 patients had good outcome, 4 patients needed assistance for daily living, and 1 death occurred unrelated to surgery. Complex intracranial aneurysms present unique therapeutic challenges that require thorough surgical planning, individualized treatment strategies, and refined neurovascular techniques for successful outcome. Proper use of bypass surgery is imperative in preserving the parent artery and its major perforators. The internal maxillary artery, used as a donor in a bypass, is an effective method due to its shorter distance from the recipient vessels and relatively large diameter with resulting higher flow rate.

Aspirin Versus Heparin for Management of Cerebellar Stroke After Vertebral Artery Dissection Following C1-C2 Fracture-Dislocation: A Case Report.

Vertebral artery dissection (VAD) in the setting of a C1-C2 fracture-dislocation occurs in up to 20% of cervical spine trauma cases1-4. In young persons, it is one of the leading causes of ischemic stroke in the cerebellum5,6. It is important to recognize the signs of cerebellar and brain-stem infarctions in patients with cervical trauma and to initiate appropriate treatment. There is considerable controversy regarding the optimal course of treatment following a VAD7. We report a case of a patient with a unilateral VAD following a C1-C2 fracture-dislocation after falling from a horse. The patient was managed with heparin anticoagulation and subsequently developed a large retroperitoneal hematoma, a known complication of anticoagulation. We also review the current literature and guidelines regarding the clinical management of these patients. The patient was informed that data concerning the case would be submitted for publication, and she provided consent. A sixty-seven-year-old woman was admitted to the emergency department after falling off a horse from a height of approximately six feet and landing on her back. She reported immediate and persistent neck pain and an inability to turn the neck, but demonstrated no neurological deficits. Computed tomography (CT) of the neck showed a rotatory subluxation of C1 on C2 and a left C1-C2 facet dislocation with an associated avulsion fracture (Figs. 1-A through 1-D). The distal segments of the left vertebral artery beyond the fracture site were not visualized by magnetic resonance (MR) angiography, which is consistent with vessel compression (Figs. 2-A through 2-F). Fig. 1 Figs. 1-A through 1-F CT of the cervical spine showing the C1-C2 vertebral fracture-dislocation. Figs. 1-A and 1-B Neck CT prior to reduction. The severity of the rotatory deformity can be seen on the three-dimensional CT reconstructions. The overlapping axial CT …