Brainstem Infarction Research Articles

Evaluation of the pontine perforators of the basilar artery using digital subtraction angiography in high resolution and 3D rotation technique.

Compromise of perforating branches of the basilar artery resulting in brain stem infarctions has been described as a major complication of intracranial stent placement for basilar artery stenosis or after implantation of endovascular flow diverters. Descriptions of pontine arteries are mainly based on examinations of injection specimens; however, there is a lack of consistent presentation of the small branches of the basilar artery in the imaging literature. Therefore, we retrospectively analyzed DSA images and 3D rotational angiography with a review of literature for an imaging definition of microvascular anatomy of the brain stem. We retrospectively analyzed 2k DSA images (detector format 32 × 32 cm; image matrix 2480 × 1920 pixels) and 3D rotational angiography reconstructions (5 second DSA, subtraction technique) obtained on Axiom Artis zee biplane neuroradiologic angiography equipment using standard protocol. On 2D and 3D DSA images, small arterial side branches of the basilar artery can be demonstrated in each of the cases but with a wide variation in the visibility of these vessels. Compared with 2D DSA images, 3D DSA reconstructions allow superior visualization of the small branches of the basilar artery. Our results demonstrate that 2D DSA and 3D-rotation techniques are able to reliably visualize the penetrating branches of the brain stem in vivo. No zone of basilar artery is free from important side branches. Collateral pathways between circumferential and perforating arteries are occasionally detectable. In the future, further refinement of imaging techniques is necessary to increase the reliability of small vessel angiography to use this data for risk assessment before stent placement and aneurysm treatment.

Cerebral Infarction due to Cardiogenic Emboli Originating from Atrial Myxoma: A Case Report

Cardiogenic embolism due to atrial myxoma is a rare cause of cerebral infarction. A 51-year-old woman presented to a hospital elsewhere with sudden onset of vision loss, loss of consciousness and subsequent circulatory collapse. Computed tomography and magnetic resonance imaging of brain revealed a rostral brainstem infarction, cerebral angiography showed evidence of occlusion of the left posterior cerebral artery, and echocardiographic examination revealed the presence of a mass in the left atrium. The patient received palliative care and was discharged. Four months later, she presented with muscle weakness in both legs and was unable to walk. Ultrasonography revealed atherosclerotic plaques in the left and right carotid arteries and multiple segmental emboli in the lower extremities. In addition, physical examination revealed bilateral blepharoptosis, poor pupillary reaction to light, deficient upward and downward eye movements and limited adduction. Anticoagulants and blood-lipid lowering drugs were administered. Auscultation of the precordium revealed systolic murmurs when the patient was in a sitting position. Echocardiographic examination and computed tomography of the chest disclosed a mass in the left atrium. The patient underwent surgical resection of the atrial mass. Histopathological examination of the resected tumor revealed a glandular cardiac myxoma. At four-month follow-up, there was some improvement in neurological symptoms. A cardiac origin of cerebral infarction should be suspected in middleaged patients who present with cardiac myxoma. Early surgical resection of the cardiac myxoma is important to prevent further embolic events.

“Invisible” Brain Stem Infarction at the First Day

In specific stroke cases, serial diffusion-weighted magnetic resonance imaging (DW MRI) on day 1 was unable to show a lesion, whereas that on day 4 and later clearly revealed a lesion. However, clinical features of this phenomenon ("invisible" brain stem infarction [IBI] at the first day) have not been fully delineated. We retrospectively recruited 212 stroke patients in the Emergency Unit and Neurology Department. Among these, we studied patients with IBI. Definition of IBI is that acute and clear brain stem symptoms/signs on arrival were ameliorated at discharge and appearance of high signal intensity on serial DW images with low apparent diffusion coefficient (ADC) by 1.5T MRI with 2-mm slices. IBI were found in only 6 patients. Day 1 invisible stroke was found only in the brain stem (17%, 6 of 35) but none (0 of 177) in the hemispheric infarction (P<.05). In most patients with IBI, DW MRI turned out visible at the third/fourth day. Before the fourth day, DW/ADC signal changes in patients with IBI were minimal. In IBI, lesion size (mean 2.7mm(2)) was smaller than that of visible cases (mean 7.3mm(2)). In IBI, lesion location was mostly at the dorsolateral medulla. In IBI, sensory disturbance was significantly more common (67%) than visible cases (24%; P<.05), whereas dysarthria was less common (0%; P<.01) than visible cases (66%; P<.01). It is likely that patients with smaller stroke volume, sensory disturbance, and medullary location are prone to develop IBI. When evaluating stroke using MRI criteria, recognition of IBI is important to start early management.

Brainstem infarction and sleep-disordered breathing in the BASIC sleep apnea study

BackgroundAssociation between cerebral infarction site and poststroke sleep-disordered breathing (SDB) has important implications for SDB screening and the pathophysiology of poststroke SDB. Within a large, population-based study, we assessed whether brainstem infarction location is associated with SDB presence and severity. MethodsCross-sectional study was conducted on ischemic stroke patients in the Brain Attack Surveillance in Corpus Christi (BASIC) project. Subjects underwent SDB screening (median 13days after stroke) with a well-validated cardiopulmonary sleep apnea-testing device (n=355). Acute infarction location was determined based on review of radiology reports and dichotomized into brainstem involvement or none. Logistic and linear regression models were used to test the associations between brainstem involvement and SDB or apnea/hypopnea index (AHI) in unadjusted and adjusted models. ResultsA total of 38 participants (11%) had acute infarction involving the brainstem. Of those without brainstem infarction, 59% had significant SDB (AHI⩾10); the median AHI was 13 (interquartile range (IQR) 6, 26). Of those with brainstem infarction, 84% had SDB; median AHI was 20 (IQR 11, 38). In unadjusted analysis, brainstem involvement was associated with over three times the odds of SDB (odds ratio (OR) 3.71 (95% confidence interval (CI): 1.52, 9.13)). In a multivariable model, adjusted for demographics, body mass index (BMI), hypertension, diabetes, coronary artery disease, atrial fibrillation, prior stroke/transient ischemic attack (TIA), and stroke severity, results were similar (OR 3.76 (95% CI: 1.44, 9.81)). Brainstem infarction was also associated with AHI (continuous) in unadjusted (p=0.004) and adjusted models (p=0.004). ConclusionsData from this population-based stroke study show that acute infarction involving the brainstem is associated with both presence and severity of SDB.

Topology of brainstem lesions associated with subjective visual vertical tilt.

We aimed to determine the topology of anatomical pathways for verticality perception in the brainstem. We measured the subjective visual vertical (SVV) in 82 patients with acute unilateral infarction of the brainstem alone. The topology of the brainstem lesions responsible for pathologic SVV tilt were determined using MRI-based voxel-wise lesion-behavior mapping, from which probabilistic lesion maps were constructed. Fifty percent of patients (41/82) with acute unilateral brainstem infarcts had abnormal SVV tilt, of which 76% (31/41) had ipsiversive tilt and 24% (10/41) had contraversive tilt. Patients with contraversive SVV tilt exhibited overlapping lesions of the rostral medial vestibular nucleus, medial longitudinal fasciculus, rostral interstitial medial longitudinal fasciculus, and interstitial nucleus of Cajal. In contrast, patients with ipsiversive SVV tilt and oculomotor disturbances exhibited lesions of the medial and inferior vestibular nuclei in the caudal medulla, while those with isolated vertical perceptual changes had injury to the medial side of the medial lemniscus. Our findings provide evidence of a pathway transmitting ipsiversive otolithic signals that bypass the oculomotor system at the medial side of the medial lemniscus, called the ipsilateral vestibulothalamic tract.

Brainstem infarcts predict REM sleep behavior disorder in acute ischemic stroke.

BackgroundRapid eye movement (REM) sleep behavior disorder (RBD) is a sleep disturbance in which patients enact their dreams while in REM sleep. The behavior is typically violent in association with violent dream content, so serious harm can be done to the patient or the bed partner. The prevalence of RBD is well-known in Parkinson’s disease, Lewy body dementia, and multiple systems atrophy. However, its prevalence and causes in stroke remained unclear. The aim of this study was to determine factors influencing the appearance of RBD in a prospective cohort of patients with acute ischemic stroke.MethodsA total of 2,024 patients with first-ever or recurrent acute ischemic stroke were admitted to the Acute Stroke Unit at the Prince of Wales Hospital between January 2010 and November 2011; 775 of them received an MRI scan. Within 2 days of admission, a research nurse collected demographic and clinical data and assessed the severity of each stroke using the National Institute of Health Stroke Scale (NIHSS). One hundred and nineteen of the 775 patients meeting study entry criteria formed the study sample. All eligible participants were invited to attend a research clinic 3 months after the onset of the index stroke. In the attendance, a research assistant administered the MMSE and the 13-item RBD questionnaire (RBDQ).ResultsAmong 119 stroke patients, 10.9% were exhibited RBD, defined as an REM sleep behavior disorder questionnaire score of 19 or above. The proportion of patients with acute brainstem infarct was significantly higher in RBD patients than those without RBD. Compared with patients without RBD, RBD patients were more likely to have brainstem infarcts and had smaller infarct volumes. In a multivariate analysis, in which stroke location and infarct volume were inserted, brainstem infarcts were an independent predictor of RBD (odds ratio = 3.686; P = 0.032).ConclusionsThe results support the notion of a predominant role of brainstem injury in the development of RBD and suggest that patients with brainstem infarcts RBD should be evaluated by a clinical neurologist.

One-and-a-Half Syndrome: An Unusual Cause of Dizziness

This is a rare cause of dizziness, which can be seen in younger patients with multiple sclerosis. Uncommon in the elderly, it is usually a result of a brainstem infarct.

Abstract 52: Brainstem Infarction is Associated with Sleep Apnea: The BASIC Sleep Project

Background: Despite hypotheses that brainstem infarction is associated with sleep apnea (SA), no specific site of infarction has been associated with post-stroke SA in existing studies, which have been relatively small. Within a larger, population-based study, we assessed the association between infarction location and SA presence and severity. Methods: Ischemic stroke patients in the Brain Attack Surveillance in Corpus Christi (BASIC) project had SA screening performed (median 13 days after stroke) with a validated portable respiratory monitor (ApneaLink Plus) (n=355). The apnea-hypopnea index (AHI) was used to measure SA severity; SA was defined conservatively as an AHI ≥10. Acute infarction location was determined based on review of CT and MRI reports by board-certified neurologists and dichotomized into brainstem involvement or none. Logistic and linear regression models were used to test the associations between brainstem involvement and SA or AHI in unadjusted and adjusted models. Results: Median age was 65 (IQR: 57, 77); 55% were male. Thirty-eight (11%) had acute infarction involving the brainstem. Of those without brainstem infarction, 59% had SA; the median AHI was 13 (interquartile range (IQR) 6, 26). Of those with brainstem infarction, 84% had SA; median AHI was 20 (IQR 11, 38). In unadjusted analysis, brainstem involvement was associated with over three times the odds of SA (OR 3.71 (95% CI: 1.52, 9.13). In a multivariable model, adjusted for demographics, BMI, stroke risk factors, and stroke severity, results were similar (OR 3.76 (95% CI: 1.44, 9.81)). Similarly, brainstem infarction was associated with AHI in unadjusted (p=0.004) and adjusted models (p=0.004). Conclusion: Acute infarction involving the brainstem was associated with both presence and severity of sleep apnea in this population-based stroke surveillance study.

A pilot study on the correlation of tongue manifestation with the site of cerebral infarction in patients with stroke

To discuss the correlation of tongue manifestation with the site of cerebral infarction in patients with acute cerebral infarction. From March 2008 to February 2009, 200 cases of hospitalized patients with first unilateral cerebral infarction were chosen in the Department of Neurology, Xuanwu Hospital. The correlation of different tongue color, fur texture, fur color with the site of cerebral infarction was analyzed. The site of cerebral infarction in patients were compared between different tongue color by Chisquare test (P=0.314), and further correspondence analysis demonstrated that there was correlation between red tongue and cortical-subcortical infarction group. The site of cerebral infarction in patients were compared between thick fur group and thin fur group, cortical-subcortical infarction occurred more frequently in the former (P=0.0008). The site of cerebral infarction in patients were compared between dry fur group, moist fur group and smooth fur group, correspondence analysis demonstrated there was correlation between dry fur and cortical-subcortical group. The site of cerebral infarction in the patients were compared between white fur group, white-yellow fur group and yellow fur group (P=0.010), and correspondence analysis demonstrated there was correlation between white fur and brainstem infarction; white-yellow fur has relationship with cortical infarction; subcortical infarction was weakly related with white-yellow fur; there was closer relationship between yellow fur and cortical-subcortical infarction. The change of tongue manifestation was associated with the site of cerebral infarction in patients, providing a new combining site for diagnosing cerebrovascular diseases by integrative medicine.

Sudden unexpected death owing to unilateral medial medullary infarction with early involvement of the respiratory center

A 64-year-old woman was found dead in her home. At autopsy, although relatively fresh bruises were found on her body, no lethal injury was observed in an internal observation. Mild edematous swelling of the right half of the medulla oblongata was observed. There was acute medial medullary infarction (MMI), which mainly involved the nucleus hypoglossi, medial lemniscus, hypoglossal root, inferior olivary nucleus, and pyramidal tract. Subacute infarction of the lower part of the cerebellum was also found, and severe atherosclerosis of the right vertebral artery containing thrombi was found as the culprit lesion. Immunohistochemistry using amyloid precursor protein (APP) was positive in neuronal tissue in the nucleus ambiguus, despite not showing coagulative necrosis in the nucleus. Therefore, acute ischemic necrosis of the nucleus ambiguus, which is considered to be a component of the dorsal respiratory group, may be a significant finding for her expected death. Immunohistochemistry of APP may be useful for confirming the precise extent of acute ischemia in brain stem infarction, such as unilateral MMI.

A Case of Total Oral Intake Reestablished with Prosthetic Appliance for Swallowing Disorders and Botulinum Toxin Treatment in Conjunction with Swallowing Therapy after Cerebellar and Brain Stem Infarction

A Case of Total Oral Intake Reestablished with Prosthetic Appliance for Swallowing Disorders and Botulinum Toxin Treatment in Conjunction with Swallowing Therapy after Cerebellar and Brain Stem Infarction

Brainstem reversible leukoencephalopathy syndrome

A 39-year-old man presented with progressive headache, nauseas, blurriness and cortical blindness. Blood pressure: 230x140 mmHg. Glasgow score: 15. Fundoscopy revealed hypertensive retinopathy and papille de ma. Neurological examination was normal. Brain ma gnetic resonance imaging revealed area of swelling and high signal on FLAIR-weighted images on the brainstem and cerebral white-matter abnormalities (Figure 1). Hyperten sion management improved his clinical and radiological findings (Figure 2). Posterior reversible leukoencephalopathy syndrome (PRES), with classical reversible cerebral vasogenic edema, occurred predominantly in the posterior distribution (occipital and parietal lobes) on brain imaging1-3. The brainstem involvement is an atypical feature which may be encountered in midbrain (13%), pons (20%) and medulla oblongata (5%)1-3. This PRES variant should be differentiated from brainstem infarction, pontine glioma, infective encephalitis, central pontine myelinolysis and others demyelinating disorders because PRES is potentially full reversible after treatment1-3.

めまいで発症し超急性期MRIで異常を認めなかった脳梗塞例

Imaging diagnosis using magnetic resonance imaging (MRI) is indispensable for the diagnosis of acute cerebrovascular disturbances. Diffusion-weight imaging (DWI) MRI, in particular, has improved the diagnostic accuracy in acute ischemic stroke. However, some patients with acute stroke show no abnormal signals on DWI, despite the presence of an infarction. We present herein on a case of a hyperacute large ischemic stroke that was not detected on the initial DWI. A 85-year-old female with acute vertigo and vomiting was admitted to our hospital. In the neuro-otological examination, she had evoked direction fixed horizontal gaze and left-sided positional nystagmus. DWI examined within 2 hours after onset showed no ischemic findings. Twelve hours after onset, she developed consciousness disturbance and follow-up DWI demonstrated a large infarction on the brainstem, cerebellum and cerebrum. False-negative findings demonstrated on DWI are sometimes observed in the case of brainstem or cerebellar infarction. Careful observation of neurological findings and follow-up MR imaging are useful for closer investigation of false-negative findings in the patients with suspected as having suffered an ischemic stroke.

ゴルフによる一側椎骨動脈解離が原因となった頸髄梗塞の1例

A-68-year-old man experienced nuchal pain and bilateral shoulder weakness that occurred suddenly after he performed a golf swing. He was conscious. His cranial nerves were normal, but bilateral deltoid and biceps muscle strengths weakened. Magnetic resonance image (MRI) showed no brain stem infarctions or cervical epidural hematoma. We tentatively diagnosed him with concussion of the spinal cord because of mild recovery of his bilateral upper limb weakness after several hours; he was later discharged. The next day, he suddenly developed serious tetraplegia and was admitted to the emergency department. His breathing was controlled by a respirator as he had expectoration difficulty and respiratory muscle paralysis. A lesion in the cervical cord became apparent on MRI; the right vertebral artery was not detected on magnetic resonance angiography. Cervical MRI showed the intimal flap and a lack of flow void in the right vertebral artery. These findings revealed a right vertebral artery dissection. Cervical cord infarction due to unilateral vertebral artery dissection is rarer than posterior cerebral infarction due to the same pathogenesis; however, some such cases have been reported. We consider the present case to be caused by cervical cord infarction associated with unilateral vertebral artery dissection resulting from golf swing.

A Case of Brain-Stem Infarction Due to Embolectomy of the Left Subclavian Artery Embolism

A Case of Brain-Stem Infarction Due to Embolectomy of the Left Subclavian Artery Embolism

Dolichoectatic thrombosed aneurysm が原因と考えられた脳幹梗塞の1 例

Dolichoectatic thrombosed aneurysm が原因と考えられた脳幹梗塞の1 例

Pregnant Women with Fulminant Disseminated TB to the Omentum and Placenta

This is a case report of a young 24 year old Somali woman in her 27th week of gestation who was given Rifampicin, Ethambutol, INH, Pyridoxine and Pyrazinamide as a treatment for systemic TB. She did not respond to the treatment. She died because of brainstem infarction (brain death). According to MRI results, multiple brain tuberculomas were seen suggesting brain TB. Brain biopsy was not done and the treatment was initiated at her 27th week of gestation. Patient arrested and was transferred to ICU with GCS of 3-4/15. Cesarean section was done at the 29th week of gestation and the infant was not infected. There were query tuberculosis seeding scattered all over the patient’s omentum and placenta. A specimen was taken for histopathology, which demonstrated that the placenta and omentum contained focal areas of microinfarctions and necrotizing granulomas consistent with tuberculosis. We emphasize that screening should be done during pregnancy to discover dormant infection, asymptomatic disease and to lower the incidence of congenital TB. The aggressive early treatment for dissemination of the disease, especially when associated with pregnancy, and the importance of early diagnosis and therapy will result in regression of the lesions.

Risk factors and etiological subtype analysis of brainstem infarctions

ObjectiveTo evaluate the features of risk factors and etiological subtypes of brainstem infarctions (BSIs) patients in China. MethodsOne hundred and ninety-nine cerebral infarction patients with brainstem involvement were categorized into five groups according to Trial of Org 10172 in Acute Stroke Treatment classification: large artery disease (LAD), cardioembolism (CE), small vessel disease (SVD), stroke of other determined etiology (SOE) or stroke of undetermined etiology (SUE). The risk factors and percentage of the different etiological subtypes were assessed. ResultA total of 199 patients were enrolled in this study. The number and percentage of patients in SVD, LAD, SUE, CE and SOE were 77 (38.7%), 74 (37.2%), 25 (12.6%), 23 (11.6%) and 0, respectively. There were significantly different incidences of hypertension, diabetes and coronary heart disease (CHD) without atrial fibrillation (AF) among different stroke subtypes (P=0.006, P=0.002, P=0.016, respectively). Hypertension was more prevalent in LAD than in SVD and CE (P=0.001 and P=0.039, respectively) while the incidence of diabetes in LAD was higher than those in SVD and CE (P<0.001 and P=0.015, respectively). CHD without AF was more prevalent in CE than in SVD and LAD (P=0.044 and P=0.012, respectively). LAD was significantly associated with hypertension (OR=3.18, P=0.009) and diabetes (OR=2.84, P=0.003) in BSIs. ConclusionThe pattern of etiological subtypes of BSIs in China has its own characteristics. It might result from the features of risk factors in Chinese patients.

UNILATERAL PLEURAL EFFUSION REVEALING BOERHAAVE‘S SYNDROME

A 72yearold man who was initially admitted because of a brain stem infarction, was referred to the respiratory intensive care unit because of acute onset respiratory distress, following vomitting. In the weeks preceding this deterioration he had multiple episodes of sputum impaction due to swallowing dysfunction. A Chest X-ray showed a rightsided massive pleural effusion. A chest CT-scan revealed an important pleural effusion and a paraesophageal air collection, highly suggestive of rupture of the distal esophagus. A chest drain was placed with evacuation of 1200cc “coffee ground”-looking pleural fluid with high amylase content, suggestive of gastric juice. Because of the unfavorable neurological prognosis due to the brain stem infarction, the decision was made not to perform any surgical procedures. The patient was treated with broad spectrum antibiotics and started on total parenteral nutrition. Esophagoscopy revealed a 2 cm long tear with fistulisation at 5 cm above the diaphragm. A covered stent was placed endoscopically to cover the fistula to prevent further leakage to the pleural cavity. Despite successfully stenting of the esophageal tear, the patient died a few days later due to a hospital acquired pneumonia. Boerhaave’s syndrome is a spontaneous rupture of the esophagus, mostly located on the lower third of the esophagus. The average tear is 2.2 cm long and 3-6 cm above the diaphragm (1). The most common findings on chest X-ray are pleural effusions with an incidence of 91%. This occurs mostly on the left side (75-90%), sometimes bilateral (5-10%), but rarely, as in this case, on the right (2). Diagnostic errors are prevalent; the most common misdiagnosis is a perforated ulcer, followed by myocardial infarction, pulmonary embolism, dissecting aneurysm and pancreatitis. Diagnosis can be made earlier and more accurate with additional radiological examinations such as CT scan (1).

Persistent trigeminal artery: In situ thrombosis and associated perforating vessel infarction

We report a patient with progressive brainstem infarction despite medical therapy. The patient was transferred to our institution for potential angioplasty of basilar stenosis. Imaging review demonstrated persistent trigeminal artery in situ thrombosis and associated perforating vessel infarction. Persistent trigeminal arteries are commonly associated with an atretic basilar artery and interventional treatment can result in significant morbidity and mortality.