Brainstem Stroke Research Articles

Real-time detection of spoken speech from unlabeled ECoG signals: A pilot study with an ALS participant.

Brain-Computer Interfaces (BCIs) hold significant promise for restoring communication in individuals with partial or complete loss of the ability to speak due to paralysis from amyotrophic lateral sclerosis (ALS), brainstem stroke, and other neurological disorders. Many of the approaches to speech decoding reported in the BCI literature have required time-aligned target representations to allow successful training - a major challenge when translating such approaches to people who have already lost their voice. In this pilot study, we made a first step toward scenarios in which no ground truth is available. We utilized a graph-based clustering approach to identify temporal segments of speech production from electrocorticographic (ECoG) signals alone. We then used the estimated speech segments to train a voice activity detection (VAD) model using only ECoG signals. We evaluated our approach using held-out open-loop recordings of a single dysarthric clinical trial participant living with ALS, and we compared the resulting performance to previous solutions trained with ground truth acoustic voice recordings. Our approach achieves a median error rate of around 0.5 seconds with respect to the actual spoken speech. Embedded into a real-time BCI, our approach is capable of providing VAD results with a latency of only 10 ms. To the best of our knowledge, our results show for the first time that speech activity can be predicted purely from unlabeled ECoG signals, a crucial step toward individuals who cannot provide this information anymore due to their neurological condition, such as patients with locked-in syndrome. ClinicalTrials.gov, registration number NCT03567213.

From Science Fiction to Reality: Exploring Brain-Computer Interfaces and their Human Applications

Direct control of mechanical or electrical equipment through mental activity is made possible by brain-computer interfaces (BCIs), often referred to as brain-machine interfaces (BMIs). Using only brain signals, users of BCIs can operate external systems without using neurostimulators, which trigger neural tissues. This allows users to avoid using peripheral neurological and muscle systems. The brain's ability to incorporate and regulate mechanical devices as extensions of its own physiological processes is demonstrated by this capability.When it comes to helping those with severe impairments, BCI systems have a lot of potential uses. For people who suffer from neurological conditions like amyotrophic lateral sclerosis, brainstem stroke, or spinal cord injury who are completely paralyzed or "locked in," they provide a substantial benefit in terms of communication. By directly converting brain intent into executable commands, BCI technology aims to enable communication. This is especially helpful for those who are unable to speak.Neuroprosthetics, which attempt to restore lost motor and sensory functions, have been the main focus of BCI research and development. These systems make use of artificial devices to treat brain-related illnesses, take over for faulty nervous system functions, and compensate for compromised sensory organs. As this science develops, brain-computer interfaces (BCIs) have the potential to improve cognitive capacities and the quality of life for people with severe disabilities.

Moya-Moya Disease in Basal Cortical Areas in a Man with a Family History of Vascular Disorders: A Case Report

Introduction: Moya-Moya disease (MMD) is a rare, chronic, and spontaneous steno-occlusive condition that leads to recurrent strokes due to the occlusion of the terminal internal carotid arteries. This article aims to highlight the significance of familial risk for MMD and other vascular disorders among first-degree relatives in Iran. Case Presentation: We report the case of a 55-year-old male who was admitted to our hospital with complaints of transient ischemic attack, left-sided hemiparesis, and decreased vision that occurred during the night. The initial diagnosis was a brain stem stroke. After undergoing digital subtraction angiography, he was diagnosed with MMD. Moya-Moya disease is a rare cause of cerebral stroke and is seldom reported in Iran. The patient was treated conservatively and had a favorable outcome. His family history was notable, with five of his eight siblings having various cardiovascular diseases. Conclusions: These findings may be useful for guiding future genetic studies and preventive counseling, with a focus on the clinical evaluation of serious adverse events.

Clinical and Radiological Differences between Patients Diagnosed with Acute Ischemic Stroke and Chameleons at the Emergency Room: Insights from a Single-Center Observational Study.

Scarce data exist about clinical/radiological differences between acute ischemic strokes diagnosed in the emergency room (AISER) and stroke chameleons (SCs). We aimed at describing the differences observed in a comprehensive stroke center in Chile. Prospective observational study of patients with ischemic stroke syndromes admitted to the emergency room (ER) of Clínica Alemana between December 2014 and October 2023. 1,197 patients were included; of these 63 (5.2%, 95% CI: 4.1-6.6) were SC; these were younger (p < 0.001), less frequently hypertensive (p = 0.03), and they also had lower systolic (SBP) (p < 0.001), diastolic blood pressures (DBP) (p = 0.011), and NIHSS (p < 0.001). Clinically, they presented less frequently gaze (p = 0.008) and campimetry alterations (p = 0.03), facial (p < 0.001) and limb weakness (left arm [p = 0.004], right arm (p = 0.041), left leg (p = 0.001), right leg p = 0.0029), sensory abnormalities (p < 0.001), and dysarthria (p < 0.001). Neuroradiological evaluations included less frequently large vessel occlusions (p = 0.01) and other stroke locations (p = 0.005); they also differed in their etiologies (p < 0.001). Brainstem strokes (p < 0.001) and extinction/inattention symptoms (p < 0.001) were only seen in AISER. In multivariate analysis, younger age (OR: 0.945; 95% CI: 0.93-0.96), DBP (OR: 0.97; 95% CI, 0.95-0.99), facial weakness (OR: 0.39; 95% CI: 0.19-0.78), sensory abnormities (OR: 0.16.18; 95% CI, 0.05-0.4), infratentorial location (OR: 0.36; 95% CI, 0.15-0.78), posterior circulation involvement (OR: 3.02; 95% CI, 1.45-6.3), cardioembolic (OR: 3.5; 95% CI, 1.56-7.99), and undetermined (OR: 2.42; 95% CI, 1.22-4.7; 95%) etiologies, remained statistically significant. A stepwise analysis including only clinical elements present on the patient's arrival to the ER, demonstrates that age (OR: 0.95; 95% CI: 0.94-0.97), DBP (OR: 0.97; 95% CI, 0.95-0.99), the presence of atrial fibrillation (OR: 2.22; 95% CI, 1.04-4.75, NIHSS (OR: 0.88; 95% CI, 0.71-0.89) and the presence in NIHSS of 1a level of consciousness (OR: 5.66; CI: 95% 1.8-16.9), 1b level of consciousness questions (OR: 3.023; 95% CI, 1.35-6.8), facial weakness (OR: 0.3; CI: 95% 0.17-0.8), and sensory abnormalities (OR: 0.27; 95% CI, 0.1-0.72) remained statistically significant. SC had clinical and radiological differences compared to AISER. An additional relevant finding is that neurological symptoms in a patient with atrial fibrillation, even with a negative diffusion-weighted imaging, should be carefully evaluated as a potential stroke until other causes are satisfactorily ruled out.

Location matters: altered interhemispheric homotopic connectivity in post-stroke dyskinesia.

Motor impairment is the most prevalent consequence following a stroke. Interhemispheric homotopic connectivity, which varies regionally and hierarchically along the axis of the somatomotor-association cortex, plays a critical role in sustaining normal motor functions. However, the impact of strokes occurring in various locations on homotopic connectivity is not fully understood. This study aimed to explore how motor deficits resulting from acute strokes in different locations influence homotopic connectivity. Eighty-four acute ischemic stroke patients with dyskinesia were recruited and divided into four demographically-matched subgroups based on stroke locations: Group 1 (G1; frontoparietal, n = 15), Group 2 (G2; radiation coronal, n = 16), Group 3 (G3; basal ganglia, n = 30), and Group 4 (G4; brain stem, n = 23). An additional 37 demographically-matched healthy controls were also recruited in the study. Multimodal MRI data, motor function assessments, and cognitive tests were gathered for analysis. Interhemispheric homotopic functional and structural connectivity were measured using resting-state functional MRI and diffusion tensor imaging, respectively. These measurements were then correlated with motor function scores to investigate the relationships. Voxel-mirrored homotopic connectivity (VMHC) analysis showed that strokes in the frontoparietal and basal ganglia regions led to diminished homotopic connectivity in the somatosensory/motor cortex. In contrast, strokes in the radiation coronal and brainstem regions affected subcortical motor circuits. Structural homotopic connectivity analysis using diffusion tensor imaging showed that frontoparietal and basal ganglia strokes predominantly affected association fibers, while radiation coronal and brainstem strokes caused widespread disruption in the integrity of both cortical-cortical and cortical-subcortical white matter fibers. Correlation analyses demonstrated significant associations between the Fugl-Meyer Assessment (FMA), Modified Barthel Index (MBI), and National Institutes of Health Stroke Scale (NIHSS) scores with the VMHC in the inferior temporal gyrus for G1 (G1; r = 0.838, p < 0.001; r = 0.793, p < 0.001; and r = -0.834, p < 0.001, respectively). No statistically significant associations were observed in Groups 2, 3, and 4. Our results suggest that motor deficits following strokes in various regions involve distinct pathways from cortical to subcortical areas. Alterations in lesion topography and regional functional homotopy provide new insights into the understanding of neural underpinnings of post-stroke dyskinesia.

Comparative Analysis of Physical Therapy Outcomes in Acute Ischemic and Hemorrhagic Stroke Rehabilitation

Background: Stroke rehabilitation demands an effective therapeutic approach to enhance functional recovery. This study aims to compare the outcomes of physical therapy in patients with acute ischemic and hemorrhagic stroke using the Motor Relearning Programme (MRP). Methodology: Based on stroke type, confirmed via CT thirty-eight participants were stratified into ischemic &amp; hemorrhagic stroke group. Eligible participants were over 35 years old, had a Glasgow Coma Scale score above 5, and presented with hemiplegia. Exclusion criteria included trauma-induced hemorrhage, cerebellar or brainstem stroke, severe cognitive impairment, or pre-existing disabilities. The participants underwent a standardized four-week physiotherapy regimen based on the MRP, with assessments using the Motor Assessment Scale (MAS) and Functional Independence Measure (FIM) to evaluate the outcomes. Results: These results underscore the significant improvements in the functional outcomes observed in both ischemic and hemorrhagic stroke patients following physical therapy, with hemorrhagic stroke patients showing more substantial gains in both MAS and FIM scores. Conclusion: Our study contributes to a nuanced understanding of stroke rehabilitation, emphasizing that while both ischemic and hemorrhagic stroke patients significantly benefit from structured physical therapy interventions like MRP, the specifics of their recovery processes vary.

Application of bedside HINTS, ABCD2 score and truncal ataxia to differentiate cerebellar–brainstem stroke from vestibular neuritis in the emergency room

Background and purposeAcute vestibular syndrome (AVS) typically manifests as isolated dizziness or vertigo with no apparent neurological impairments. However, distinguishing life-threatening stroke from innocuous peripheral vestibular lesions in the emergency...

Correlation between lesion location and dysphagia characteristics in post-stroke patients

ObjectiveTo assess the correlation between lesion location and swallowing function characteristics in post-stroke dysphagia (PSD) patients. Materials and methodsWe enrolled 133 PSD. The patients were divided into supratentorial and infratentorial stroke groups. We compared the measurements in the videofluoroscopic swallowing study (VFSS) with 3ml and 5 ml of diluted and thickened barium liquid data between supratentorial and brainstem stroke groups. We further compared the difference of VFSS measurements between patients with left hemispheric or right hemispheric lesions (further divided into unilateral hemispheric cortical and subcortical subgroups) and brianstem leison stroke group.To explore the lesion location's effect on different bolus volume, the VFSS measurements of 3ml and 5ml in each subgroups were compared respectively. The measurements of VFSS included the oral transit time, soft palate elevation duration, hyoid bone movement duration (HMD), UES opening duration, pharyngeal transit duration (PTD), stage of ansition duration, and laryngeal closure duration (LCD), the upper esophageal sphincter opening (UESO), hyoid bone superior horizontal displacement, and hyoid bone anterior horizontal displacement. General swallowing function was assessed using the Penetration Aspiration Scale (PAS) and Functional Oral Intake Scale (FOIS). We performed the paired t-test, Spearman's correlation, and Kruskal–Wallis test analysis to characterize the parameters among the groups. ResultsFifty-eight patients were assessed in the final analysis. The HMD (p = 0.019), PTD (p = 0.048) and LCD (p = 0.013) were significantly different between the supratentorial and brainstem lesion groups in 5ml volume. The HMD was significantly different (p = 0.045) between the left cortical and brainstem lesion groups. Significant differences in the HMD (p = 0.037) and LCD (p = 0.032) between the left subcortical and brainstem lesion groups were found in 5ml volume bolus. There was no group different when taking the 3ml volume bolus. Regarding the relationship between food bolus volume and swallowing functions, only the UESO demonstrated a significant difference in the subcortical lesion of the right hemisphere (p = 0.0032) compared the 3 ml and 5 ml volume bolus. The PTD demonstrated a moderate correlation with the PAS scores (r = 0.38, p = 0.0044). The HMD (r = 0.32, p = 0.018) and LCD (r = 0.29, p = 0.039) demonstrated weak correlations with the PAS scores. We did not identify any correlation between the VFSS parameters and FOIS scores in each subgroup level. ConclusionThe PSD with brainstem lesion shows more sever dysfunction in the pharyngeal phases. The left hemisphere was engaged in both the oral and pharyngeal phases. Lesions in the bilateral cortical, subcortical, and brainstem regions may impair sensory input.

Fronto-Cerebellar Diaschisis and Cognitive Dysfunction after Pontine Stroke: A Case Series and Systematic Review.

It is well known that cortical damage may affect cognitive functions, whereas subcortical damage, especially brainstem stroke, would be far less likely to cause cognitive decline, resulting in this condition being overlooked. Few studies have focused on cognitive dysfunction after a pontine stroke. Here, we begin with describing our nine new case reports of in-depth neuropsychological findings from patients with pontine stroke. The dominant domain of cognitive dysfunction was commonly characterized by executive dysfunction, almost in line with previous studies. The severity was relatively mild. We give an overview of the available literature on cognitive decline following a pontine stroke. This is followed by discussions regarding the prognosis of the cognitive disabilities. Based on previous neuroimaging findings, we would like to get to the core of the neuropathology underlying the cognitive declines in the context of "diaschisis", a phenomenon of a broad range of brain dysfunctions remote from the local lesions. Specifically, our unique paper, with two modalities of neuroimaging techniques, may help us better understand the pathology. SPECT scans yield evidence of frontal and thalamic hyper-perfusion and cerebellar hypo-perfusion in patients with pontine stroke. Functional near-infrared spectroscopy, when focusing on the supplementary motor area (SMA) as one of the hyper-perfusion areas, exhibits that SMA responses may be subject to the severity of cognitive decline due to a pontine stroke and would also be related to the recovery. Finally, we posit that cognitive decline due to pontine stroke could be explained by the failure of hierarchical cognitive processing in the fronto-ponto-cerebellar-thalamic loop.

Brain-Computer Interface: The Construction of Artificial Highways

One of the nifty advent of technology in terms of neurobionics is the Brain-Computer Interface (BCI). It will be no wrong to regard its principle somewhat likely to a real-time chip robot that deciphers human impulses, traversing on the nerve highways, into commands that modulate human actions which have been rendered paradoxical due to any physical or congenital nervous injuries. BCI technology has empowered the disabled, enabling them to operate cursors and smart home devices using their minds. The famous NeuraLink is emerging to be an advocate of the latest BCI technology, having performed a new brain implant successfully; but deep research puts forward the name of Synchron as an instigator of BCI industry. &#x0D; A tailed-electrode, with sixteen electric arrays, is pushed up-stream near to the brain’s motor cortex region via a small incision made in the jugular vein [1]. Upon reaching the destination it tubes out against the interior wall of the blood vessel, functioning as an antenna to detect the tissues’ electrical activity of the proximal cortex region such as moving a leg or scrolling through a screen. These signals are demodulated into muscle-translatable commands by a transmitter fitted in the chest, that disseminates the waves to an external digital device which performs the specified actions through a connected effector device. Primeval BCIs incorporated a mesh of protruding wires. Trials are underway to replace it with a home-based BCI setup. For now, fifty severely paralyzed people, including brain-stem stroke patients, have received these stents with a few Australians and Americans roaming around freely with implants in their blood vessels as part of BCI contemporary testing. &#x0D; Despite such bamboozling invention by Synchron, it has its limitations owing to the inferiority of brain signals espied across the curtains of membranes in way. A Synchron user can only scroll through the web pages. NeuraLink enters the competition by offering a 1024 electrodes’ matrix of ultrathin conducting bio-friendly fibers, integrated onto 1 centimeter’s cube film that can be inserted by a robot [1]. In January 2024 the first brain-film implant was performed on a brain-disabled patient which is showing signs of recovery. BCI current research revolves around inculcating the electrode bearing agent(s) directly into the brain regions without invasive procedures, which will be a breakthrough in neurosciences of the current era. &#x0D; Despite of its unprecedented utility, the BCI system also opens the gate for controversial scrutiny. For instance, there might be an undesired compulsion on BCI industry to escalate the amplitudes of cognition, memory, motor functions, and intellect even of normal individuals. Peculiarities like infrared vision and memory augmentation pose a danger towards informed consent and privacy. An environment of disparity, ascribable to the unequal approach of the interface, may be created that will lead to socio-political issues of genocide [2]. &#x0D; The anatomy of the human brain has this inherent tendency to reject any foreign agent playing with its natural traffic, thus for how long these electrodes can co-exist normally with human biology is a debate not yet started. In research a robot sensitive to empathy was generated and named ‘cobot’. With the use of an electroencephalographic (EEG) sensor worn by the human agent, its BCI was built. The cobot responds to the threat and passes it on to the recipient human agent, creating a virtuous cycle of caring and security. Consequently, when the patient was exposed to unsettling motion, an increase in the EEG signal was recorded [3]. The brain-computer interface fails to stamp out the placebo effect associated with the recovery. Is it really the chip or the unwavering willingness of the human mind to adapt and thrive ?

One and a Half Syndrome and Internuclear Ophthalmoplegia as Neuro-Ophthalmological Manifestations in Patients with Brainstem Stroke: A Case Series

Background: Brainstem stroke syndrome accounts for 10-15% of all types of strokes, which may result in relatively rare neuroophthalmological manifestations. The aim of this case report is to report findings of one and a half syndrome (OAHS) and internuclear ophthalmoplegia in a patient with brainstem stroke.&#x0D; Case presentation: First case, female, 56 years old, came with sudden weakness on the right side of the body. One and a half syndrome was found, namely when asked to glance to the left, conjugate gaze palsy was obtained horizontally, and when asked to glance to the right, there was adduction inability of the left eye (ipsilateral). Right eye abduction was normal with present nystagmus. Paresis of right central CN. VII, XII was present, along with hemiparesis dextra (contralateral). Head CT scan shows hemorrhage in pons and intraventricular. Second case, female, 65 years old, came with a protruding mouth, vertigo, and sudden double vision Internuclear ophthalmoplegia was present, namely an adduction inability of the left eye (ipsilateral) when asked to glance to the right. Right eye abduction was normal with present nystagmus. no abnormalities were seen in the primary position and when asked to glance to the left. Paresis of right peripheral CN. VII, hemiparesis and right (contralateral) hemihypesthesia was present. MRI shows multiple chronic infarcts as well as subacute infarcts in bilateral parietal and pons.&#x0D; Conclusion: Clinical knowledge is necessary for topic determination, rehabilitation process and evaluation.

Untoward outcomes of successful chronic subdural hematoma evacuation, cortical blindness and brain stem stroke: A Case series

Chronic subdural hematoma (CSDH) is one of the most commonly encountered emergencies in neurosurgery practice. Burr hole with drainage of hematoma has been a time-tested standard treatment with good results and in itself a simple procedure to relieve patient clinical status. However, apparently simple surgery may at times have an unexpected surgical outcome of bilateral vision loss. All bilateral CSDHs should be treated diligently with early recognition of any visual deterioration in post-operative phase if any and due to possible interventions to be offered to the patients for prevention of permanent vision loss.

Hemodynamic signal changes during volitional swallowing in dysphagia patients with different unilateral hemispheric stroke and brainstem stroke: A near-infrared spectroscopy study

Background and objectivesStrokes will result in decreased in cortical excitability and changed in the balance between the affected and unaffected hemispheres. Previous studies have focused on cortical changes in healthy subjects during swallowing, while they remain unknown in patients with stroke at different locations. Thus, the purpose of this study was to research cortical activation patterns of swallowing in patients with dysphagia and healthy subjects by the functional near-infrared spectroscopy (fNIRS). We also focus on the comparability of brain activation areas associated with swallowing between patients with different stroke locations and healthy subjects. Methodstotal of 104 participants were invited to our study, involving 86 patients with dysphagic unilateral hemispheric stroke and 18 age and sex matched healthy controls. The stroke patients were categorized into patients with left unilateral stroke lesions (n = 30), patients with right unilateral stroke lesions (n = 32) and patients with brainstem injury (n = 24) according to different stroke sites. All patients underwent a series of clinical swallowing function assessments, such as the Fiberoptic endoscopic dysphagia severity scale (FEDSS), penetration-aspiration scale (PAS) of Rosenbek, the gugging swallowing screen (GUSS) and the functional oral Intake scale (FOIS) after informed consent has been signed. All participants received the fNIRS system assessment. ResultsThe results showed that extensive areas of the cerebral cortex activated during the swallowing tasks in healthy participants (P < FDR 0.05). For patients with left unilateral stroke lesions, the HbO concentration were strongest over the right hemisphere (P < FDR 0.05). In addition, a less severe activation was also observed in the left hemisphere. Comparable to patients with left unilateral stroke lesions, the strongest activation during swallowing task were found in the left hemisphere in patients with right unilateral stroke lesions (P < FDR 0.05). Similarly, the right hemisphere also has activated less. In contrast, patients with brain stem injury showed more bilaterally activation patterns. ConclusionOur finding states that cortical activation areas differ between patients with different stroke locations and healthy subjects during swallowing. There was a more bilateral activation in healthy participants and patients with lesions in the brainstem while more cortical activation in unaffected hemisphere in patients with unilateral hemispheric stroke. It also provides a basis for the future treatment of dysphagia after stroke.

A narrative review on cervical artery dissection-related cranial nerve palsies.

This study aimed to emphasize the importance of cranial nerve (CN) palsies in spontaneous cervical artery dissection (sCeAD). A search term-based literature review was conducted on "cervical artery dissection" and "cranial nerve palsy." English and German articles published until October 2023 were considered. Cranial nerve (CN) palsy in sCeAD is evident in approximately 10% of cases. In the literature, isolated palsies of CN II, III, VII, IX, X, and XII have been reported, while CN XI palsy only occurs in combination with other lower cranial nerve palsies. Dissection type and mural hematoma localization are specific to affected CN as CN palsies of II or III are solely evident in those with steno-occlusive vessel pathologies located at more proximal segments of ICA, while those with CN palsies of IX, X, XI, and XII occur in expansive sCeAD at more distal segments. This dichotomization emphasizes the hypothesis of a different pathomechanism in CN palsy associated with sCeAD, one being hypoperfusion or microembolism (CN II, III, and VII) and the other being a local mass effect on surrounding tissue (CN IX, X, XI, and XII). Clinically, the distinction between peripheral palsies and those caused by brainstem infarction is difficult. This differentiation is key, as, according to the reviewed cases, peripheral cranial nerve palsies in sCeAD patients mostly resolve completely over time, while those due to brainstem stroke do not, making cerebrovascular imaging appraisal essential. It is important to consider dissections as a potential cause of peripheral CN palsies and to be aware of the appropriate diagnostic pathways. This awareness can help clinicians make an early diagnosis, offering the opportunity for primary stroke prevention.

Cortical blindness and brain stem ischemia following burr hole evacuation of chronic subdural hematoma

Background: Chronic SDH is commonly performed in neurosurgery. The surgery usually has good surgical outcomes. There have been few cases reports reporting cortical blindness and brain stem stroke as a dreaded complication of the same. Materials and methods: It is a retrospective, observational, descriptive type of study with analysis of patients operated for chronic SDH from March 2021 to March 2023 and reported an untoward outcome of vision loss or brainstem stroke following surgery. The cases have been reported with possible aetiology underlying the unfavourable outcome. The literature was reviewed for similar cases and a comparative analysis was done with possible hypotheses for the outcome. Observation and results: An overall 5 such cases have been reported during this period. Two cases of bilateral and three cases of unilateral chronic SDH have been reported. Out of five, two cases did not have a preceding history of trauma probably spontaneous in nature. Possibility of PRES in one case, transtentorial herniation, thrombosis, and spontaneous intracranial hypotension with kinking of vessels have been proposed. Further studies are required to address this untoward complication following evacuation of chronic subdural hematoma. Conclusions: A high index of suspicion, prompt recognition and management of reversible causes, slow decompression of hematoma especially in bilateral cases, and good hydration to prevent the possibility of thrombosis are key to preventing such complications. Also keeping the possibility in mind add on better counselling and prognostication of case in pre-surgery period.

Successful recovery of a young man with traumatic brainstem ischemia in a motor vehicle accident

Introduction: The most common etiological factors of brainstem stroke and ischemia are atherosclerosis, thromboembolism, tumours, arterial dissection, and trauma. Infarction of the medulla oblongata in 73% of cases occurs as a result of stenosis of the vertebral arteries, 26% due to arterial dissection, while the topic of traumatic brainstem ischemia is still under-researched and under-represented. Case report: We present a case of a 26-year-old male patient who was admitted to the Emergency Department due to multiple injuries of the head, chest, and upper, and lower extremities sustained as a motorcyclist in a traffic accident. A cranial CT scan revealed the presence of a minor subdural hematoma, traumatic brainstem ischemia, and a ruptured peduncular artery. From a neurosurgical perspective, surgical treatment was not indicated, thus a conservative therapeutic approach was adopted. After five days after admission, initial radiographic signs of ischemia regression were recorded, followed by complete absence. Conclusion: Timely patient transportation from the accident site to the Emergency Center, followed by an appropriate multidisciplinary treatment approach and intensive neuroprotective and neuroregenerative therapy, along with organism reperfusion, played a pivotal role in the neurological, and subsequently, overall patient recovery in this case presentation.

High-flow bypass for giant dolichoectatic vertebrobasilar aneurysms: illustrative cases

BACKGROUND Giant fusiform dolichoectatic vertebrobasilar artery aneurysms are challenging lesions with a poor natural history. When there is progressive brainstem compression from these lesions, endovascular treatment can be insufficient, and bypass surgery remains a possible salvage option. High-flow bypass surgery with proximal occlusion can potentially arrest aneurysm growth, promote aneurysm thrombosis, and reduce rupture risk. The authors describe their experience in two patients with giant fusiform dolichoectatic vertebrobasilar artery aneurysms treated with high-flow bypass. OBSERVATIONS Both patients presented with enlarging giant dolichoectatic vertebrobasilar aneurysms causing symptomatic brainstem compression. The authors performed staged treatment involving high-flow bypass from the external carotid artery to the posterior cerebral artery using a saphenous vein graft, Hunterian proximal vertebrobasilar occlusion, and finally posterior fossa decompression with or without direct aneurysm thrombectomy and debulking. Postoperative angiography revealed successful flow reversal, aneurysm exclusion, and no brainstem stroke. Clinically, one patient had improvement in their modified Rankin Scale (mRS) score from 3 preoperatively to 1 at 12-month follow-up. The second patient had a deterioration in their mRS score from 4 to 5 at 12-month follow-up. LESSONS High-flow bypass strategies remain high risk but can be a viable last resort in patients with neurological deficits and enlarging giant fusiform dolichoectatic vertebrobasilar artery aneurysms.

Stroke in a young adult: looking beyond the diffusion-weighted imaging sequence.

A 37-year-old migrainous woman was referred several hours after a sudden dysarthria lasting less than 1min. Brain MRI undertaken a few hours later showed no acute cerebral infarction on the diffusion-weighted imaging (DWI) sequence. However, an intraluminal thrombus within a distal branch of the middle cerebral artery (MCA) was seen on the T2*-weighted gradient echo images as well as hyperintense vessels related to slow flow beyond the occlusion's site. Control MRI 24h later confirmed the presence of a small infarct affecting the distal portion of the MCA territory but the thrombus was no longer visible. A comprehensive etiologic workup revealed the presence of a patent foramen ovale, as the underlying cause of the patient's stroke. Though the sensitivity of DWI sequence for acute ischemia is high, false negative exist particularly in cases of transient ischemic attack, brainstem or lacunar strokes. A careful brain MRI examination or the use of perfusion weighted imaging sequences are useful to avoid misdiagnosis particularly in young patients.

Plenary E: Learning from patients: people who have changed my way of thinking

Abstract &amp; Learning Objectives:This presentation discusses six patients with different problems, referred for rehabilitation, who challenged my views on how to apply neuropsychological principles to their treatment. We begin with Derek, who had sustained a traumatic brain injury from a gunshot wound. I was asked to reduce his weight, but he could not read or write because of the brain injury so I had to find another way to achieve the weight loss. This made me realize that neuropsychologists have to "think on their feet" and be flexible. The second patient is Kate, who developed brain stem encephalitis. Expected to die, and unable to speak, she convinced me that, however severe the injury, we should not give up and recovery can continue for many years. Kate, managed to speak intelligibly fourteen years after her illness! The next patient, Claire, a school nurse, had herpes simplex encephalitis which left her with prosopagnosia and extreme anxiety. Her story made me realize the personal consequences of prosopagnosia that is typically overlooked by most neuropsychologists. The fourth patient, Gary, was attacked by a gang while saving his father. He remained in a state of unconsciousness for 19 months and, thus, had a very poor prognosis. Nevertheless, he defied the predictions of all medical staff, woke up and did very well. The penultimate patient is Natasha, who, as far as we know is the only person in the world to have two syndromes, "Sheehans Syndrome" which is very rare in developed countries and "Sickle cell disease" which is not rare. As a result of the Sheehan's she developed Balint's Syndrome. Her case made me learn about Sheehan's Syndrome and accept that Natasha's main goal in life, was not what I expected it to be. The final patient is Paul, an opera singer, who was diagnosed with" Locked-in Syndrome" following a brain stem stroke. Not only was he a good communicator once a good system was found, but he felt he had a good quality of life by" living within his head". Although many of us feel that to be fully conscious but totally dependent on others, is a very cruel situation to be in, Paul did not feel this. All these patients taught me a great deal and I thank them for this.Upon conclusion of this course, learners will be able to: 1.Describe the main purposes of neuropsychological rehabilitation2.Discuss about six patients who challenged typical concepts about neuropsychological rehabilitation3.Gain some knowledge about Sheehan's syndrome4.Explain the three components of Balint's syndrome5.Summarize the difference between Locked-in syndrome and the minimally conscious state6.Recognize some of the anatomy associated with these syndromes

A rare case report: isolated midbrain lacunar infarct affecting the ipsilateral medial longitudinal fasciculus causing internuclear ophthalmoplegia effect

Isolated medial longitudinal fasciculus infarct is rare and can also be associated with cranial nerve nuclei or extra-nuclear regions leading to respective neurological deficit. We report a case of 73-year-old woman presenting with a 24 hour of confusion, abnormal eye movement and unsteady gait on a background history of uncontrolled diabetes mellitus (DM), hypertension and Alzheimer’s disease. Her examination found to have dysdiadokinesia in left upper limb and inability to adduct right eyeball on left lateral gaze, without affecting the pupil. She was not oriented to time and place while before this event she could. Her examination found to have normal power in limbs and sensation. Her computed tomography (CT) brain showed no evidence of acute infarction or intracranial bleed. Magnetic resonance imaging (MRI) brain demonstrated acute lacunar infarct involving the ipsilateral medial longitudinal fasciculus. This case demonstrates rare brainstem infarct affecting medial longitudinal fasciculus region below the IIIrd cranial nerve nucleus giving features of internuclear ophthalmoplegia affecting medial rectus muscle without affecting autonomic fibres of IIIrd cranial nerve due to which the pupil is not affected. We recommend strict control of predisposing conditions, mainly diabetes and hypertension to reduce the incidence of brainstem stroke.