Left Thalamic Hemorrhage Research Articles

Functional dissociation between Kana and Kanji: agraphia following a thalamic hemorrhage

We report the case of a 61-year-old woman with a left thalamic hemorrhage causing agraphia of Kanji (morphograms). Single-photon emission computed tomography (SPECT) showed a decrease in the blood flow in the left thalamus from the superior temporal convolution to the parietal lobe, as well as in the frontal lobe while computed tomography showed no remarkable lesions in the cortex. The agraphia in this case may be due to the thalamic lesion itself, but the SPECT findings strongly suggest that a secondary cortical lesion may be involved in producing the higher cognitive disorder.

Dynamic-intentional thalamic aphasia: a failure of lexical-semantic self-activation

Background: Previous research has described patients with aphasia from thalamic lesions, some of whom were non-fluent with intact comprehension, others who were fluent with impaired comprehension, and some of whom are non-fluent with impaired comprehension. Whereas these three subtypes usually have normal repetition, they had impaired naming, suggesting a deficit in lexical (phonological word forms)-semantic processing. We report a patient with a left thalamic hemorrhage in which lexical-semantic representations appear to be intact but the patient demonstrates an inability to spontaneously activate his lexical-semantic system Methods: A 82-year-old, right-handed man presented with decreased verbal fluency and memory loss following a thalamic hemorrhage. Neuropsychological assessment revealed significant decrements in verbal fluency with intact naming, comprehension, repetition and vocabulary. Conclusions: To the best of our knowledge this pattern of language disturbance, which mirrors dynamic aphasia induced by frontal lesions, has not previously been described with thalamic injury. The thalamus has strong connections with the frontal lobe and rather than degradation of lexical-semantic representations, this patient's thalamic lesion probably induced frontal lobe dysfunction with a failure to spontaneously active lexical semantic representations.

Factor XIII deficiency related recurrent spontaneous intracerebral hemorrhage: A case and literature review

Spontaneous intracerebral hemorrhage (ICH) in young adults under 50 years of age is an uncommon occurrence associated with considerable morbidity and mortality. The differential diagnosis of ICH in this population differs from that of older individuals and includes vascular, toxic, inflammatory, oncologic, infectious and hematologic conditions. We present a case based observation of a spontaneous and recurrent ICH in a 25-year-old female secondary to undetected Factor XIII (FXIII) deficiency with no prior associated stigmata of hematologic disturbance admitted to a tertiary care neuroscience intensive care unit (NICU). Our patient was admitted after spontaneous development of left thalamic hemorrhage with ventricular extension. Initial management included external drain placement (EVD) and fresh frozen plasma administration. Diagnostic evaluation was unrevealing including CT angiography, magnetic resonance imaging (MRI) with venography, conventional cerebral angiogram, and hematologic and rheumatologic screens. Our patient recovered but represented 6 months later with five foci of spontaneous ICH. She underwent vascular, infectious, oncologic, hematologic, and rheumatologic evaluations. She expired secondary to ICH expansion with uncal herniation. The results of our investigation revealed markedly diminished FXIII activity. The pathophysiology, diagnosis and treatment of this disease are reviewed. FXIII deficiency should be considered in a case of cryptogenic ICH presenting with multifocal, recurrent ICH and a normal coagulation profile. Early diagnosis and initiation of factor replacement therapy offer the best strategies to reduce the morbidities associated with this disease.

Bleeding Is a Cause of False Positive Brain Tl-201 SPECT CT

A 30-year-old man with a history of cranial radio-surgery for arteriovenous malformation was admitted for acute brain hemorrhage. Magnetic resonance imaging (MRI) demonstrated a left thalamic hemorrhage associated with an intracranial mass. Brain Tl-201 SPECT CT demonstrated uptake (index uptake = 3.5) considered as a potential astrocytic malignant tumor. F-18 fluorodeoxyglucose positron emission tomography-computed tomography (F-18 FDG PET-CT) performed 1 month later revealed hypometabolism on early and delayed images considered as radionecrosis. The outcome history, surgical removal, and 2-year follow-up confirmed the diagnosis of radionecrosis. Bleeding could be a source of false-positive uptake of thallium. Brain Tl-201 SPECT CT should not be recommended in the early stage of parenchymal hemorrhage to differentiate malignancies from radionecrosis.

Single hole cerebral arteriovenous fistula between the anterior choroidal artery and the basal vein of Rosenthal in a child

The purpose of this study was to show the first reported case of a cerebral arteriovenous fistula (CAVF) from the anterior choroidal artery (AChoA) to the basal vein of Rosenthal in a Child. A 4-month-old male infant with no previous history presented a left thalamic intraparenchymal hemorrhage with secondary intraventricular spread and hydrocephalus. An external ventricular drainage was placed, and a digital subtracted angiography showed a left single hole CAVF. The left AChoA was the single arterial feeder directly connected to the ipsilateral basal vein of Rosenthal. After stabilization and good recovery, he was transferred to our institution for endovascular treatment. He was embolized using the arterial feeder with four Guglielmi detachable coils that produced complete exclusion of the fistula. The patient was discharged 10 days after the procedure without new neurological deficit. CAVFs are exceptional, with an incidence between 4.7% and 17% of all brain AVMs in large reported series. They can arise from any artery of the brain with a great dominance at the supratentorial location. This is the first reported case of a CAVF from the AChoA draining to the basal vein of Rosenthal.

99mTc-TRODAT-1 SPECT study in evaluation of Holmes tremor after thalamic hemorrhage

Holmes tremor is also known as rubral or midbrain tremor. The tremor usually involves lesions near the red nucleus and the nerve fiber tracts originating in the cerebellum and the substantia nigra. We report a case of a 62-year-old woman who presented with Holmes tremor 5 months after a left thalamic hemorrhage, with a partial recovery 3 years later. Sequential technetium-(99m)TRODAT-1 single-photon emission computed tomography (SPECT) of the patient's brain revealed partially improved tracer uptake reduction in the striatums, particularly on the left side. We propose that involvement of both the nigrostriatal and the dentate-rubro-thalamic pathways are essential in the pathogenesis of Holmes tremor after a thalamic lesion, and regeneration of the nigrostriatal system is possible in this type of tremor after the initial degeneration. The (99m)Tc-TRODAT-1 SPECT study is a useful and convenient tool for evaluating the nigrostriatal dopamine function in patients with Holmes tremor.

Clinical and angiographic long-term outcomes of vertebral artery–subclavian artery transposition to treat symptomatic stenosis of vertebral artery origin

Although angioplasty and stent placement for vertebral artery (VA)-origin stenosis have been performed using endovascular techniques, a high likelihood of restenosis has been observed in the long term. Therefore, the authors assessed the long-term clinical and angiographic outcomes in patients after VA-subclavian artery (SA) transposition. Thirty-six patients (31 men, 5 women; mean age 64.3 years, range 46-76 years) underwent clinical evaluation (modified Rankin Scale [mRS]) and cervical angiographic evaluation preoperatively and within 1 month of and 6 months after VA-SA transposition undertaken to treat symptomatic stenosis of VA origin. Postoperative neurological deficits due to intraoperative brain ischemia did not occur, and MR imaging demonstrated no new postoperative ischemic lesions in any of the patients. One patient died of acute myocardial infarction 2 months after surgery and another developed a left thalamic hemorrhage (mRS score of 5) at 42 months postsurgery. None of the remaining 34 patients experienced further ischemic events, and the mRS score in all of these patients remained unchanged during a mean follow-up period of 54 months. The degree of VA-origin stenosis (preoperative mean 84%) was reduced to < or = 30% after surgery (mean 2%). Long-term follow-up angiography in 29 patients (81%) revealed the absence of restenosis, defined as > 50% luminal narrowing, in all of them. The clinical and angiographic long-term outcomes demonstrated here suggest that VA-SA transposition will be useful in patients with symptomatic stenosis of VA origin.

Intracranial arterialized venous angioma: case report with new insights from functional brain MRI

We present the case of a 58-year-old man who suffered a left thalamic intracerebral hemorrhage. Brain magnetic resonance imaging (MRI) revealed an incidental venous angioma in the left frontal lobe. Further elucidated by cerebral angiography and functional MRI, this venous angioma exhibited arteriovenous shunting. The arterialized venous angioma represents an uncommon, "mixed" intracranial vascular lesion whose natural history remains unknown.

Wyburn-Mason Syndrome Associated with Thyroid Arteriovenous Malformation: A First Case Report

A 31-year-old woman with a prior history of Wyburn-Mason syndrome, complicated previously by a left thalamic intracerebral hemorrhage at age 21, complained of sudden left vision loss due to a central retinal vein occlusion. Angiography revealed a left thyroid arterio-venous malformation (AVM) in addition to ones found intracerebrally. The pathogenesis and embryogenesis of this finding including the management of AVMs in Wyburn-Mason syndrome are discussed.

Global aphasia due to left thalamic hemorrhage

Global aphasia is an acquired language disorder characterized by severe impairments in all modalities of language. The specific sites of injury commonly include Wernike's and Broca's areas and result from large strokes--particularly those involving the internal carotid or middle cerebral arteries. Rarely, deep subcortical lesions may cause global aphasia. We present three cases with global aphasia due to a more rare cause: left thalamic hemorrhage. Their common feature was the large size of the hemorrhage and its extension to the third ventricule. HMPAO-SPECT in one of the cases revealed ipsilateral subcortical, frontotemporal cortical and right frontal cortical hypoperfusion. Left thalamic hemorrhage should be considered in the differential diagnosis of global aphasia.

A Patient with Inclusion Body Myositis suffering from Left Thalamic Hemorrhage

We report a case of a 74-year-old man with dual disabilities. The patient suffered from inclusion body myositis for 13 years, and then suddenly developed right hemiplegia due to a left thalamic hemorrhage, and was transferred to our department for further rehabilitation after undergoing conservative treatment at the acute stage. Although his hemiplegia considerably improved at admission(Brunnstrom stage V/V), he experienced a severe disturbance when standing up and walking because of muscle weakness in the pelvic girdle and upper thighs, and sensory disturbance in his right lower extremity, and therefore had to wear a waist belt for assistance during standing up and a plastic Ankle Foot Orthosis(AFO)with a solid ankle on the right side for stability during walking. To improve his impairment, he underwent muscle strengthening training for the pelvic girdle and lower extremities as much as an ordinary hemiplegic patient, and his muscle strength increased without any muscle pain or blood CK rise. After 12 weeks of the training, he could stand up and walk independently 80m with a tripod cane and AFO, requiring no assistance. In conclusion, this patient with dual disabilities was able to improve his ability to stand up and walk in spite of mild hemiplegia, and the muscle strengthening training he underwent was not harmful even though the patient also suffered from inclusion body myositis.

Pathophysiology of language switching and mixing in an early bilingual child with subcortical aphasia

Acquired aphasia after circumscribed vascular subcortical lesions has not been reported in bilingual children. We report clinical and neuroimaging findings in an early bilingual boy who incurred equally severe transcortical sensory aphasia in his first language (L1) and second language (L2) after a posterior left thalamic hemorrhage. Following recurrent bleeding of the lesion the aphasic symptoms substantially aggravated. Spontaneous pathological language switching and mixing were found in both languages. Remission of these phenomena was reflected on brain perfusion SPECT revealing improved perfusion in the left frontal lobe and left caudate nucleus. The parallelism between the evolution of language symptoms and the SPECT findings may demonstrate that a subcortical left frontal lobe circuity is crucially involved in language switching and mixing.

脳出血片麻ひ後に関節リウマチを発症し，健側手関節に骨破壊を生じた一例

We reported a case of rheumatoid arthritis (RA) with asymmetrical manifestation of wrist arthropathy in a hemiplegic stroke patient. The patient was a 61-year-old woman who had a left thalamic hemorrhage and now suffered right hemiplegia. Six months after her apoplectic stroke she complained of left wrist pain. X-ray examination indicated that her left wrist joint was destroyed. The sparing effect was observed in her paralyzed right wrist. The test for serum rheumatoid factor was positive and the patient's inflammatory signs were elevated. Consequently, she was administered anti-rheumatic drugs and fitted with a left wrist orthosis and her left wrist pain diminished. We also discuss the mechanism of unilateral RA.

Supernumerary Phantom Limbs Associated with Left Hemispheric Stroke: Case Report and Review of the Literature

Supernumerary phantom limb (SPL) is extremely rare. Literature reports noted 17 cases that occurred after right cerebral hemispheric stroke and 2 cases that occurred after left cerebral hemispheric stroke, but without imaging diagnoses. A 45-year-old male patient complained of SPLs on the right side after recurrent left thalamic hemorrhage. Computed tomography and magnetic resonance imaging demonstrated the lesion causing the left hemispheric stroke. The patient was treated conservatively. Computed tomographic scans demonstrated that the lesion had disappeared by 15 days after admission. The sensation of SPLs disappeared after 28 days. SPL may occur among patients with left hemispheric stroke, especially those with lesions in the thalamus, spastic paresis on the right side immediately after stroke, and psychiatric disorders such as alcohol and tobacco intoxication.

A case of central post-stroke pain with beneficial response to electroconvulsive therapy: a proton magnetic resonance spectroscopy study

Abstract We present a 58-year-old male chronic post-stroke central pain patient, whose pain resulted from left thalamic hemorrhage, and whose pain had failed to respond to standard pain treatment, but was resolved by electroconvulsive therapy (ECT). To investigate the potential role of neural function in ECT's analgesic effect, the patient underwent a proton magnetic resonance spectroscopy (1H-MRS) on a 2 × 2 × 2 cm voxel in the thalamus bilaterally before and after a course of unilateral ECT.The N-acetylaspartate-to-creatine (NAA/Cr) ratio, which reflects neural function, was calculated on the voxel of the thalamus. Before ECT, the left to right thalamus NAA/Cr ratio was 62.3%. The NAA/Cr ratio of the left thalamus increased 32.0% after ECT,compared to the ratio before ECT.The results from the 1H-MRS suggest that improvement of neural dysfunction in the thalamus may be related to the analgesic efficacy of ECT.

Artificial Nutritional Support: The Daughters’ Dilemma

Mrs. W is a 73-year-old woman with a history of type II diabetes mellitus and coronary artery disease. She has been at an acute rehabilitation hospital for 10 days after the onset of a left thalamic hemorrhage with resultant aphasia, confusion, right hemiplegia, right neglect, and severe dysphagia. She had been living at home with her husband who has been diagnosed with moderate dementia. Mrs. W has been his primary caregiver. Since admission, the patient has been consistently somnolent. She had a nasogastric (NG) tube placed in the acute care facility to sustain her nutrition and hydration secondary to severe dysphagia. The patient’s right nares had become very swollen and irritated, and the tube was removed and replaced in her left nares. The patient pulled the NG tube out during the following night. Mrs W’s left nares were then similarly swollen, and it would be difficult or impossible to place another tube down that side. The patient does not have a formal advance directive. Her two daughters (her only children) have been serving as her proxy decision-makers. They have been asked to provide consent to allow Mrs. W to have a percutaneous gastrostomy (PEG) tube placed to sustain nutrition and hydration. The patient’s speech-language pathologist does not recommend a videofluoroscopic swallow evaluation at this time, because the patient is not even able to recognize that she has food in her mouth during a clinical examination. The daughters indicate that this is a very difficult decision for them to make. They report that in past conversations, their mother stated that she would not want to live with a feeding tube. These discussions had been prompted by the illness of Mrs. W’s sister, who recently died after a battle with esophageal cancer. Mrs. W’s sister had

Clinical improvement related to thrombolysis of third ventricular blood clot in a patient with thalamic hemorrhage

Intraventricular extension of hemorrhage after intraparenchymal hemorrhage is associated with significant morbidity and mortality. Clinical improvement is reported in a patient with thalamic hemorrhage with intraventricular extension after third and fourth ventricular blood clot resolution with instillation of urokinase intraventricularly. A 49-year-old man with hypertension collapsed while at work. A computed tomography (CT) scan of the head revealed a left thalamic hemorrhage with extension into the lateral, third, and fourth ventricles and associated hydrocephalus. A left frontal intraventricular catheter (IVC) was placed and intraventricular urokinase was administered at a dose of 25,000 U every 12 hours. The CT scan revealed resolution of the lateral ventricular dilatation and blood clot but no decrease in third or fourth ventricular hemorrhage. No clinical improvement was noted. The IVC was reinserted on the right side with the catheter tip placed through the foramen of Monroe into the third ventricle. Twelve hours after receiving the first dose of urokinase through the new catheter, the patient's condition improved. The CT scan showed a reduction in the volume of blood of the third and fourth ventricles. This case report shows that treatment of hydrocephalus with an IVC was not sufficient to provide a therapeutic effect. Substantial clinical improvement occurred only after the blood clot was cleared from the third and fourth ventricles. Copyright © 2001 by National Stroke Association

脳室腹腔シャント留置患者のリスク管理 転倒により脳挫傷に至った１例

We report a case of cerebral contusion in a patient with ventricle peritoneal shunt (VP shunt) caused by a simple fall. Described is a 50-year-old man admitted with left thalamic hemorrhage with resultant severe consciousness disturbance and right hemiparesis. Although his general condition and consciousness were improved after conservative treatments, two weeks later decreased mental status and anisocoria were noted. Head computed tomography (CT) scan revealed hydrocephalus which needed VP shunt following emergent ventricular shunting. After that, intensive rehabilitation programs were started. Independent ambulation was not achieved, however he was enable to transfer with minimal assistance. CT scan showed that the size of ventricular system was extremely reduced, which is so called “slit like ventricle.” During transfer from his bed to the chair he fell and his head hit the bed. Immediately after that, he fell into deep coma state. CT scan showed left subdural hematoma, contusion and diffuse brain swelling. Overdrainage is a rare complication in VP shunt, however it caused a catastrophic event followed by traumatic brain injury.

Ideomotor Apraxia in Left Thalamic Hemorrhage: Discrepancy between Clinical Course and SPECT.

We present a patient who developed severe ideomotor apraxia (IA) and subcortical aphasia after a hemorrhage involving the posterior part of the left thalamus and the posterior limb of the internal capsule. The cerebral blood flow (CBF) of the left hemisphere as measured by 99Tc-HM-PAO SPECT was initially diminished as compared to the right hemisphere. The apraxia and aphasia eventually resolved. Despite this clinical improvement CBF of the left hemisphere worsened. Our findings do not support the view that apraxia and aphasia following lesion of deep subcortical structures is due to cortical derangement induced by disruption of unspecific activating thalamo-cortical pathways. The results call for caution in the functional interpretation of perfusion deficits detected by SPECT.

Ideomotor Apraxia in Left Thalamic Hemorrhage: Discrepancy between Clinical Course and SPECT

We present a patient who developed severe ideomotor apraxia (IA) and subcortical aphasia after a hemorrhage involving the posterior part of the left thalamus and the posterior limb of the internal capsule. The cerebral blood flow (CBF) of the left hemisphere as measured by 99Tc-HM-PAO SPECT was initially diminished as compared to the right hemisphere. The apraxia and aphasia eventually resolved. Despite this clinical improvement CBF of the left hemisphere worsened. Our findings do not support the view that apraxia and aphasia following lesion of deep subcortical structures is due to cortical derangement induced by disruption of unspecific activating thalamo-cortical pathways. The results call for caution in the functional interpretation of perfusion deficits detected by SPECT.