Medullary Infarction Research Articles

Breathing patterns in relation to sleep stages in acute unilateral lateral medullary infarction: An exploratory study

Our aim was to perform an exploratory study of various irregular breathing patterns (IBPs) across different sleep stages in patients with acute unilateral lateral medullary infarction (ULMI) and compare them to apparently healthy individuals. Polysomnography (PSG) was analyzed for IBPs, such as periodic breathing, ataxic breathing and tachypnea. IBPs were found in 52 % of healthy and 90 % of ULMI subjects (p = 0.001) and occurred in long (≥ 10 min) episodes in 8% of healthy and 68 % of ULMI (p < 0.001). In healthy subjects, short (< 10 min) episodes of mild to moderate ataxic breathing were observed in wakefulness and light sleep and short episodes of periodic breathing upon sleep onset. In ULMI, the most common IBPs were ataxic and periodic breathing (80 % of patients), followed by shallow tachypnea (28 %). Ataxic breathing predominated in wakefulness, ataxic or periodic breathing in light sleep, while breathing tended to normalize in deep and REM sleep. Considering the IBPs occurring in the healthy group as physiological, probably pathological breathing patterns (tachypnea, long episodes of moderate/severe ataxic or long episodes of periodic breathing) occurred in 67 % of ULMI patients. Our findings suggest that ULMI might exacerbate physiological sleep-stage-dependent breathing pattern irregularities, such as ataxic and periodic breathing, in terms of intensity and duration or might even induce non-physiological IBP, such as shallow tachypnea with sustained hypoxia.

Pseudothalamic pattern of sensory loss in lateral medullary syndrome- A clinicoanatomic correlation

Context: Lateral medullary infarction is typically associated with loss of pain and temperature over ipsilateral face and contralateral body. However, sensory loss in contralateral face and body has been described in lateral medullary syndrome- the pseudothalamic pattern or type IV sensory loss of Stopford classification. Aims: This article aims at identifying lateral medullary syndromes associated with sensory impairment over contralateral face and body, and reviewing the neuroanatomical substrate leading to the same. Settings and Design: This was a prospective study conducted at Department of Neurology, at a tertiary level teaching hospital, Kerala, India, over a period of 5 years, among patients with acute ischemic stroke. Methods and Material: We studied all patients with acute ischemic stroke, who were admitted to our department, over a five-year period. Patients presenting with lateral medullary syndrome, with a pseudothalamic pattern of sensory loss were shortlisted and were assessed by investigators independently. All patients underwent MRI brain, which was assessed by investigators 1 and 2, independently. The demographic profile, risk factors, clinical features, neuroimaging findings and outcomes were analysed. Results: A total of 1492 patients with acute ischemic strokes were identified, of which 6 with lateral medullary syndrome with a pseudothalamic pattern of sensory loss were included in the study. Of the 6 patients, two had central post stroke pain, which was refractory to treatment. Conclusions: The type IV sensory loss of Stopford classification or the pseudothalamic pattern of sensory loss is a less described pattern in lateral medullary syndrome. The central post stroke pain (CPSP) which may develop in these patients is difficult to treat. Keywords: Pseudothalamic pattern, Stopford classification, Lateral medullary syndrome, Central post.

Bilateral Medial Medullary Infarction (Dejerene Syndrome) Patient Suffering from Quadriplegia Treated by Korean Traditional Medicine: a Case Report

Bilateral Medial Medullary Infarction (Dejerene Syndrome) Patient Suffering from Quadriplegia Treated by Korean Traditional Medicine: a Case Report

Respiratory movement in Ondine’s curse after unilateral medullary infarction: A case report

AbstractOndine's curse secondary to unilateral medullary infarction has been reported. However, the mechanism remains unclear. This case of a patient with an infarction extending from the right side of the medulla oblongata to the spinal cord at the C1 level showed absence and decrease of respiratory movement on the right and left sides of the chest, respectively, during automatic respiration. The physiological respiratory findings implied that Ondine's curse due to unilateral medullary infarction could be caused by both the impaired regulation of automatic respiration and the disconnection of the projection to ipsilateral phrenic motoneurons.

Risk factors for medullary infarction after endovascular trapping of vertebral artery dissecting aneurysms

Internal trapping (IT) is a treatment option for intracranial vertebral artery dissecting aneurysms (VADAs). Medullary infarction (MI) is a complication linked to this treatment. This study aims to clarify the outcomes of IT for VADAs and the risk factors for MIs. We retrospectively reviewed the databases from 2010 to 2017 to identify patients with VADAs treated by IT at seven collaborating institutions. Radiological findings, clinical courses, and outcomes were analyzed. Perforating arteries were classified into terminal or longitudinal types using preoperative angiography. IT was completed in 90 patients (74 ruptured and 16 unruptured VADA). Postoperative rebleeding did not occur in any ruptured VADA patients. Postoperative MRI detected MIs in 26 patients (28.9%). The incidence of MIs in the ruptured VADA (32%) was higher compared with that in the unruptured VADA (13%), though it was not significant. In the MI group, the occlusion or blind alley of the terminal-type and longitudinal-type perforator was confirmed in 23 patients (88%) and 11 patients (42%), respectively. The occlusion or blind alley of the terminal-type perforator was an independent risk factor for MIs in the logistic regression analysis (OR 5.81; 95% CI 1.34-25.11; p = 0.018). In ruptured VADA, postoperative MI (OR 12.2; 95% CI 3.19-64.55; p = 0.0001) and high-grade SAH (OR 8.02; 95% CI 2.32-37.70; p = 0.0006) were independent risk factors of an unfavorable clinical outcome. In conclusion,MIs were an independent risk factor for unfavorable outcomes after IT, especially for a ruptured VADA. The occlusion or blind alley of the terminal-type perforator caused by the IT was associated with postoperative MIs.

Case of Treatment Using Adaptive Servo-Ventilation in a Patient with Central Sleep Apnea after a Lateral Medullary Infarction

중추성 수면 무호흡은 수면 중 상기도 저항이 없을 때 흉부와 복부의 호흡 노력 없이 10초 이상의 호흡부전을 보이는 것이 특징이다. 본 증례에서 뇌자기공명영상 확산 강조 영상검사를 통해 외측 연수 경색의 진단을 받은 환자가 수면다원검사를 통해 중추성 수면 무호흡 진단 기준에 미치지 못하는 호흡부전과 중추성 수면 무호흡이 관찰되었다. 호흡부전과 중추성 수면 무호흡에 대한 일차 치료는 CPAP을 사용하였다. CPAP을 사용한 후수면다원검사와 이전의 수면다원검사를 비교한 결과 무호흡-저호흡 지수(42.5/hr→82.8/hr)와 각성 지수(21.7/hr→40.8/hr)는 악화되었다. 이에 이차 치료로 ASV를 사용하여 적정압력검사를 시행하였다. 이전의 수면다원검사와 비교한 결과 무호흡-저호흡 지수(42.5/hr→8.6/hr)가 상당히 호전되었다. 이러한 결과로 ASV는 중추성 수면 무호흡과 호흡부전에 대한 좋은 치료방법이 될 수 있다.

Delineability and anatomical variations of perforating arteries from normal vertebral artery on 3D DSA: implications for endovascular treatment of dissecting aneurysms.

Endovascular trapping of the vertebral artery dissecting aneurysms (VADAs) carries a risk of medullary infarction due to the occlusion of the perforating arteries. We evaluated the detectability and anatomical variations of perforating arteries arising from the vertebral artery (VA) using three-dimensional DSA. In 120 patients without VA lesions who underwent rotational vertebral arteriography, the anatomical configurations of perforating arteries from the VA were retrospectively evaluated on the bi-plane DSA and reconstructed images to reach the consensus between two experienced reviewers. The images were interpreted by focusing on the numbers and types of perforating arteries, the relationships between the number of perforators and the anatomy of the VA and its branches. Zero, 1, 2, 3, 4, and 6 perforators were detected in 2, 51, 56, 9, 1, and 1 patient, respectively (median of 2 perforators per VA). The 200 perforators were classified into 146 terminal and 54 longitudinal course types and into 32 ventral, 151 lateral, and 17 dorsolateral distribution types. All ventral type perforators were also terminal type. In contrast, the longitudinal type was seen in 28.5% of lateral types and in 65% of dorsolateral types. Regarding the difference in the origin of the posterior inferior cerebellar artery (PICA), non-PICA type VAs gave off larger number of perforators than the other types of VAs. Non-PICA type VAs give off a significantly larger number of perforators than other types, indicating that the trapping of non-PICA type VAs is associated with a risk of ischemic complications.

Medial Medullary Infarction With Acute Bilateral Vertebral Artery Occlusions

Medial Medullary Infarction With Acute Bilateral Vertebral Artery Occlusions

Severe Unilateral Proprioceptive Loss in Medullary-rostral Spinal Cord Infarction. A Posterior Spinal Artery Syndrome

Introduction. The symptoms and signs found in patients with lateral medullary infarction have been described for more than 200 years. The major symptoms are vestibulo-cerebellar and dysphagia and dysphonia attributable to structures innervated by the ambiguous nucleus. Sensory symptoms and signs are often present in the ipsilateral face and contralateral limbs and trunk and sometimes the face. Case Report. A 29 year old woman had headache and left neck pain during weeks. Her left side suddenly became “completely dead and lacked feeling.” She saw double and was dizzy. Her right side remained normal. MRI showed infarction in the left lateral caudal medulla extending into the medulla-spinal junction. Vascular imaging showed a dissection of the left vertebral artery . Second case is A retired man with his neurological symptoms and signs developed in steps. He first noticed while shaving that his left face was numb, A week later, while showering, he became unsteady and had discomfort behind his left ear and in his left neck. MRI showed an infarct limited to the caudo-medial portion of the left dorsolateral medulla that extended into the rostral spinal cord. Discussion. Loss of position sense in the limbs ipsilateral to a medullary infarct has only rarely been reported. Lesions of the vertebral artery just above or below dural penetration are most likely to cause medullary infarcts that are tegmental rather than basal and to cause rostral spinal cord infarction. This region of the vertebral artery is rarely affected by atherosclerosis and the commonest lesion is dissection.

Dysphagia prognosis prediction via corticobulbar tract assessment in lateral medullary infarction: a diffusion tensor tractography study.

We investigated the capacity for dysphagia prognosis prediction using diffusion tensor tractography (DTT) to assess the state of the corticobulbar tract (CBT) during the initial period following lateral medullary infarction (LMI). Twenty patients with LMI and 20 control subjects were recruited for this study. The patients were classified into two subgroups: subgroup A (16 patients with nasogastric tube required for six months or less after LMI onset) and subgroup B (4 patients with nasogastric tube required for more than six months after onset). DTT was used to reconstruct the CBTs of each patient and control subject, and the fractional anisotropy (FA) and tract volume (TV) measurements were obtained. In the affected hemisphere, the FA value of the CBT was significantly lower in subgroup B than in subgroup A and the control group (p < 0.05), with no significant difference between subgroup A and the control group. In the affected and unaffected hemispheres, the TV values of CBT in subgroups A and B were lower than those of the control group (p < 0.05), with no significant difference between subgroups A and B. In addition, among the four patients of subgroup B, reconstruction of the CBT was not possible in three patients, and the remaining patients exhibited on old lesion in the corona radiate involving descending pathway of the CBT in the affected hemisphere. We found that the injury severity of the CBT in the affected hemisphere appeared to be related to a poor dysphagia prognosis following LMI. Our results suggest that evaluation of the CBT state during the early post-LMI could be useful for dysphagia prognosis prediction.

Lateral Medullary Syndrome Following Injury of Lateral Vestibulospinal Tract: Diffusion Tensor Imaging Study

BackgroundUnilateral lesions of vestibular nucleus can cause lateral medullary syndrome. Little is known about injury of medial and lateral vestibulospinal tract (VST) after dorsolateral medullary infarct. We investigated injury of the lateral VST in patients with typical central vestibular disorder using diffusion tensor tractography (DTT). MethodsSeven patients with lateral medullary syndrome and ten control subjects were recruited. For the medial VST, we determined seed region of interest (ROI) as medial vestibular nuclei of pons and target ROI on posteromedial medulla. For the lateral VST, the seed ROI was placed on lateral vestibular nuclei of pons, and the target ROI on posterolateral medulla. Fractional anisotropy (FA), mean diffusivity (MD), and tract volume were measured. ResultReconstructed lateral VST on both sides had significantly lower FA values in patients than controls (p<0.05). Tract volume of lateral VST in affected side was significantly lower than unaffected side and control group (p<0.05). However, no DTI parameters of the medial VST differed between patients and controls (p>0.05). ConclusionInjury of the lateral VST was demonstrated in patients with lateral vestibular syndrome following dorsolateral medullary infarct. Analysis of the lateral VST using DTT would be helpful in evaluation of patients with lateral medullary syndrome.

Network Localization of Central Hypoventilation Syndrome in Lateral Medullary Infarction.

The brainstem plays a key role in the control of respiration. Strokes involving the lateral medulla can rarely produce a central hypoventilation syndrome (CHS) characterized by loss of automatic respiration called Ondine's curse. In this study, we investigated the neuroanatomical correlates of CHS in patients with lateral medullary infarction (LMI). Cases of CHS following LMI were identified from searching our medical records and literature. Voxel-based lesion-symptom mapping and lesion network-symptom-mapping (LNSM) analysis was performed to identify the regions connected to the lesion sites based on normative functional connectome data. Sixteen patients with CHS and 32 controls were included. The ventro-lateral region of the rostral medulla showed a significant association with CHS. LNSM analysis showed connections of this region to the rostral ventro-lateral medulla and caudal pons. In patients with LMI, disruption of the respiratory control network, at the level of ventro-lateral region of the rostral medulla, could result in CHS.

Clinical Characteristics and Clinical Course of Body Lateropulsion in 47 Patients with Brainstem Infarctions

BackgroundIn patients with lower lateral medullary infarction (LMI) located under the vestibular nucleus, proprioceptive impairment due to dorsal spinocerebellar tract (DSCT) is considered a pathological condition for body lateropulsion. In patients with brainstem infarction located at or above the level of the vestibular nucleus, other pathways, such as the crossed vestibulothalamic tract (CVTT), are considered responsible. Research questionThe clinical course of body lateropulsion between each anatomical level of infarction remains unclear. Further, whether body lateropulsion refers to a static or a dynamic symptom also remains unclear. MethodsWe examined 47 patients who exhibited body lateropulsion and categorized them into four groups: lower LMI under the vestibular nucleus, LMI at the level of the vestibular nucleus, pontine infarction, and midbrain infarction. The patients’ time to acquire static upright standing position and gait in a straight line were statistically analyzed by a log-rank test using the Kaplan–Meier method. ResultsBody lateropulsion in the static upright position was less frequent in the lower LMI group than in the other groups. SignificanceLower LMI primarily affected body lateropulsion in gait. DSCT damage could affect ipsilateral hip joint or leg coordination, causing body lateropulsion in dynamic situation.

Heart sign in Neurology - A Radiological sign

Bilateral medial medullary infarction is a rare stroke syndrome. The common symptoms are quadriparesis, dysarthria and hypoglossal palsy. However, the early diagnosis of bilateral medial medullary infarction may be difficult as it may mimic other conditions like Guillain Barre syndrome and brainstem encephalitis. With the advent of magnetic resonance imaging, it can be easily diagnosed, as the diffusion weighted sequences demonstrate hyperintensity involving bilateral medulla in a heart shaped pattern, described as the “Heart sign”. We hereby report a patient who presented with progressive quadriparesis, and dysarthria, progressing to respiratory failure, whose MRI brain showed the characteristic “heart sign” on diffusion sequences and was diagnosed to have bilateral medial medullary infarction.

Patient characteristics with negative diffusion-weighted imaging findings in acute lateral medullary infarction.

Diffusion-weighted imaging (DWI) on magnetic resonance imaging (MRI) shows limited sensitivity in the acute-phase brainstem infarctions, including lateral medullary infarction (LMI), and the detailed characteristics of acute LMI patients with initially negative DWI-MRI findings have not been reported previously. Therefore, we aimed to investigate the differences in the backgrounds or symptoms of acute LMI patients with initially negative findings in standard axial DWI-MRI and those with positive findings. In this retrospective cohort study, we collected the data for 35 consecutive acute LMI patients who were hospitalized in our hospital from January 2011 to December 2018. Initial standard axial DWI-MRI was assessed, and the patients were divided into positive and negative groups. The characteristics of the two groups were compared, and the usefulness of additional thin-slice coronal DWI-MRI was also investigated. Nine (26%) acute LMI patients were initially negative on standard axial DWI-MRI. The patients were independently associated with smoking history (78% vs. 23%, p = 0.021) and headache (78% vs. 31%, p = 0.046). Thin-slice coronal DWI-MRI showed positive findings in 50% of the patients with negative findings in standard axial DWI-MRI. All four patients with negative findings in both standard axial and thin-slice coronal DWI-MRI had smoking history and headache. Smoking history and headache were associated with initial negative results in standard axial DWI-MRI in acute LMI. Additional thin-slice coronal DWI-MRI was sometimes useful in detecting acute LMI. Follow-up MRI is important for patients showing negative findings in initial DWI-MRI.

Morphometric study for the intracranial portion of the vertebral artery in human cadavers

Among posterior circulation arteries, the intracranial vertebral artery (ICVA) has been given the least attention, especially concerning treatment of occlusive lesions. Early clinicopathological studies showed that the ICVA was often occluded in patients with lateral medullary and posterior inferior cerebellar infarcts. Therefore, identification and description of ICVA variations existing in length, degree of union of the left & right vertebral arteries is crucial as it accounts for the arterial blood delivery to the hindbrain and will be more displayed if pathologies exist. Cerebral angioarchitecture is so valid in interventional radiology to address diagnosis as well for neurosurgeons.Ten human formalin fixed brain specimens obtained from cadavers, donated for study purpose, were under examination in the Department of Biology at Chatham University (Pittsburgh, Pennsylvania). Dissection procedure was undertaken according to the dissection manual Grant dissector, with modifications. Variations existing in length, degree of union of left & right vertebral arteries using the digital Vernier caliper, were observed with a magnifying glass. Results indicate the mean external diameter as 3.72 mm for the LVA and 3.79 mm for the RVA. The angle between LVA & RVA ranged from 51° degrees to 91° degrees. There is a significant correlation between the angle and the differences in the external diameter of the LVA & RVA [r = −0.656, n = 10, p = 0.0394]. These factors play a crucial role in the arterial blood delivered to the hindbrain and will be more displayed if pathologies exist.

Improvement of activities of daily living in a patient with bilateral medullary infarction: A case report

Improvement of activities of daily living in a patient with bilateral medullary infarction: A case report

Heart in the brain: classical imaging sign in bilateral medial medullary infarction

Bilateral medial medullary infarction is a rare type of posterior fossa stroke due to occlusion of blood supply to the anteromedial aspect of the medulla. It can be diagnosed by its classical imaging appearance - the "heart sign".

Fabry disease presenting as bilateral medial medullary infarction with a \u201cheart appearance\u201d sign: a case report

BackgroundThe etiologic determinants of cryptogenic stroke remain a diagnostic challenge in clinical practice. Fabry disease (FD) is one of the monogenic causes of stroke that may remain unrecognized as a potential contributing causative factor, because of its rarity and difficulty in diagnosis. We report a case with rare bilateral medial medullary infarction manifesting as “heart appearance” who was diagnosed with FD.Case presentationA 51-year-old Chinese man presented with acute dysarthria and mild tetraparesis. In the 24 h following admission, the patient rapidly developed progressive flaccid quadriplegia and tongue weakness, necessitating ventilator support. Immediate magnetic resonance imaging of the brain showed heart-shaped appearance of bilateral medial medullary infarction. The patient suffered two new subcortical infarcts 40 days after the first. Detailed Family history and physical examination indicated symptoms consistent with FD, which was confirmed by very low alpha galactosidase A levels and a missense mutation of the alpha-galactosidase A gene.ConclusionsWe report what appears to be the first case of FD manifesting as bilateral medial medullary infarction. Our case suggests that clinicians should consider the possibility of FD in patients with cryptogenic stroke, especially when combined with infarction in the vertebrobasilar artery system, renal insufficiency, or cardiomyopathy. A detailed analysis of subtle historical clues and performing a complete physical examination on stroke patients would help promote earlier diagnosis of FD.

Neurological Impact of Wallenberg Syndrome on the Visual-Vestibular Systems

Purpose: This case discusses the neurological impact of Wallenberg syndrome on the visual-vestibular system and provides a clinical pathologic correlation between neuro-anatomic involvements with the manifesting symptoms. Case Report: A 50-year-old male presented for consultation following a left lateral medullary infarct occlusion of the left vertebral artery (Wallenberg syndrome) with complaints of intermittent binocular diplopia, vertigo, and oscillopsia. Assessment revealed an intermittent central nystagmus, a right skew deviation, and a left Horner’s syndrome. Video recordings of the nystagmus and ocular motor responses were documented. Conclusion: Wallenberg syndrome has very defined characteristics which can be used clinically to make a definitive diagnosis.It is important for eye care professionals to understand the neuro-anatomic involvements associated with this condition and make the clinical correlation to aid in the treatment and management of these patients.