Midbrain Hemorrhage Research Articles

Study on the CT value of intracisternal hemorrhage around the dorsal midbrain the early diagnosis of primary brain stem injure

Objective To analyze the CT manifestation of intracisternal hemorrhage around the dorsal midbrain in the patients of acute brain injures, and explore the value of intracisternal hemorrhage around the dorsal midbrain in the early diagnosis of primary brain stem injure. Methods The clinical and imaging data of 52 patients with head injure were retrospectively analyzed, and all patients underwent the CT scans within 48 hours and MRI scans within 1 week, the routine CT scan mode, T1 WI and T2 WI sequences of MRI were adopted. Results The manifestations of CT in all the cases were compared with the routine MRI images of T1 WI、T2 WI sequence, the locations of hemorrhage were showed on early CT scanning at the cisterns around the dorsal midbrain (ambient cistern or quadrigeminal cistern ) in 39 patients, coupled with diffuse cerebral swelling in 19 cases, solitary or multiple foci of intraparenchymal hemorrhage less than 2 cm in diameter in 11 cases, while the manifestations of brainstem injure were showed on routine MRI images in 37 patients. Conclusion The early CT manifestations of intracisternal hemorrhage around the dorsal midbrain in the patients of severe acute brain injures (GCS < 9) strongly suggestes the possibility of primary brainstem injure, the research can offer an important reference for the improvement of diagnostic level of primary brainstem injure in the early stage. Key words: Brain injury, brain stem; Computerized tomography; MRI; Midbrain hemorrhage,traumatic; Early diagnosis

Isolated trochlear nerve palsy with midbrain hemorrhage

Midbrain hemorrhage causing isolated fourth nerve palsy is extremely rare. Idiopathic, traumatic and congenital abnormalities are the most common causes of fourth nerve palsy. We report acute isolated fourth nerve palsy in an 18-year-old lady due to a midbrain hemorrhage probably due to a midbrain cavernoma. The case highlights the need for neuroimaging in selected cases of isolated trochlear nerve palsy.

Synchronised Paroxysmal Ocular Tilt Reaction and Limb Dystonia

ABSTRACTA case of paroxysmal ocular tilt reaction due to a midbrain cavernoma showing co-existing limb dystonia is described with particular reference to the synchronisation of eye and limb paroxysms. The single case has been observed over a 20-year period with video documentation of eye and limb movements. The function of the relevant neuro-anatomical circuits have been investigated. The now 51-year-old female patient suffered from a right midbrain haemorrhage 20 years earlier. She developed a synchronized paroxysmal ocular tilt reaction and focal limb dystonia, associated with a unilateral startle-like response. Video-oculography and electromyography during paroxysms demonstrated left forearm electromyography spikes time locked with bursts of ocular torsion. Whilst the ocular tilt reaction may be explained by a single irritative lesion of the right interstitial nucleus of Cajal, additional involvement of the right rostral interstitial nucleus of the medial longitudinal fasciculus was suggested by abnormal binocular scleral coil recordings of the torsional vestibulo ocular response. There was a marked unilateral acoustic startle-like response, not explained by damage to either nucleus. Treatment with acetazolamide abolished the attacks. The observations suggest that the coexistence of skew deviation, conjugate ocular torsion and limb dystonia in meso-diencephalic lesions may occur because neural centres controlling these eye and limb movements are closely related anatomically, rather than through the activation of a “hard wired” physiological synkinesis. We propose that the paroxysms are generated within the zona incerta where excitatory auditory, somatosensory and motor neurons are densely packed and extensively project to centres of gaze and motor control.

Acute progressive midbrain hemorrhage after topical ocular cyclopentolate administration

Cyclopentolate is a synthetic anti-cholinergic agent widely used in ophthalmology clinics. It can cause cardiovascular side-effects such as hypertension, ventricular arrhythmias and tachycardias. A 55-year-old male lost his consciousness after topical cyclopentolate hydrocloride (1%) administration for routine fundoscopic examination in another center. An urgent cranial magnetic resonance imaging examination revealed a midbrain hemorrhage and he was transferred to our hospital. The Glasgow Coma Scale score was at 4 points at admission. The patient was transferred to the intensive care unit and mechanically ventilated. Despite vigorous medical treatment, spontaneous respiration and brainstem reflexes disappeared 12 h after his administration. A control cranial computerized tomography showed enlargement and opening of the hemorrhage into the ventricular system. The patient died on the 12th day of his administration. Systemic side-effects of topical ocular cyclopentolate administration and prevention methods were discussed with regard to the current literature.

Isolated complete third nerve palsy due to midbrain hemorrhage: Clinico-radiological correlation

Isolated complete third nerve palsy due to midbrain hemorrhage: Clinico-radiological correlation

Bruising of the third cranial nerve and the pathogenesis of midbrain haemorrhage.

Journal Article Bruising of the third cranial nerve and the pathogenesis of midbrain hæmorrhage Get access C M Weintraub C M Weintraub District Surgeon, and Lecturer in Forensic Medicine University of the Witwatersrand, Johannesburg Search for other works by this author on: Oxford Academic Google Scholar British Journal of Surgery, Volume 48, Issue 207, July 1960, Pages 62–68, https://doi.org/10.1002/bjs.18004820711 Published: 06 December 2005

Midbrain and thalamic haemorrhage as first presentation of intracerebral glioma

A case of spontaneous intracerebral haemorrhage (midbrain and thalamic, with intraventricular extension) as the first presentation of an anaplastic astrocytoma is presented. Multiple CT scans and cerebral angiography failed to identify any vascular or neoplastic cause for the haemorrhage, and a presumptive diagnosis of hypertensive haemorrhage was made. Shunting of hydrocephalus was followed by early clinical improvement. However, delayed progressive deterioration necessitated MRI scan, which demonstrated a mass lesion in the basal ganglia and midbrain. This was subsequently found to be anaplastic astrocytoma on biopsy. The literature regarding this uncommon presentation of spontaneous intracerebral haemorrhage from an occult brain tumour is reviewed. The need for investigation and close follow-up of presumed hypertensive haemorrhage is emphasised by this case.

Cheiro-oral-pedal syndrome due to brainstem hemorrhage

Cheiro-oral-pedal syndrome is characterized by specific sensory disturbance around the corner of the mouth, in the hand and in the foot on the same side. Lesions responsible for causing this syndrome vary. We report two cases of cheiro-oral-pedal syndrome due to midbrain and pontine hemorrhage, respectively. Pontine hemorrhage producing cheiro-oral-pedal syndrome has been reported in three cases, but this is the first case that midbrain hematoma exhibits this syndrome. Damage in the sensory pathway can cause cheiro-oral-pedal syndrome. Difference in the threshold may explain the specific sensory pattern in this syndrome. Cheiro-oral-pedal syndrome is caused by lacunar infarction in majority of the cases. However, it should be kept in mind that hematomas can cause cheiro-oral-pedal syndrome.

Posterior canal-type ocular tilt reaction caused by unilateral rostral midbrain hemorrhage

A 56-year-old man receiving treatment for hypertension experienced sudden-onset dizziness and was admitted to our hospital. Computed tomography of the brain revealed a small high-density lesion in the right rostral midbrain. Subsequent magnetic resonance imaging revealed a small hemorrhagic lesion in the same position. The patient complained of double vision affecting the right side when viewing a horizontal linear target. Vergence was intact, but vertical gaze was severely restricted downward and moderately restricted upward. Vestibulo-ocular reflex maneuvers did not alleviate the patient's vertical gaze palsy. By 40 days after the incident, his motility had recovered and he could begin to tilt his head to the left. Consecutive Hess tests demonstrated a skew deviation of right hypertropia, which continued for over two years. Funduscopic examination revealed left extorsion but no right intorsion. A diagnosis of posterior canal-type ocular tilt reaction (OTR) was made from these signs. The patient's course indicated that periaqueductal syndrome dominated in the acute stage whilst unilateral symptoms became more apparent in the chronic stage. The rostral interstitial nucleus of the medial longitudinal fasciculus and the posterior commissure were estimated to contain the main causative lesion for the acute symptoms, whereas the interstitial nucleus of Cajal (INC) was implicated in the chronic stage. Posterior canal-type OTR caused by unilateral INC lesion has been reported only rarely.

Midbrain hemorrhage presenting with oculomotor nerve palsy: case report

BACKGROUND We report a case of isolated oculomotor nerve palsy caused by a midbrain hemorrhage. CASE DESCRIPTION A 75-year-old man visited our hospital complaining of double vision and left eye ptosis without headache. Neuro-ophthalmic examination showed that his left and right pupils were 3.5 mm and 3 mm in diameter, respectively, that left downward eye movement was limited, and that convergence of the right eye was limited. Magnetic resonance imaging (MRI) demonstrated that there was a hematoma located in the anterior tegmentum of the left midbrain. Two weeks after admission and treatment, including conservative therapy, his double vision gradually disappeared. CONCLUSION To date, 73 cases have been reported in the literature. Most cases of isolated oculomotor nerve palsy have been caused by diabetes mellitus, aneurysm, or infarction. However, focal midbrain hemorrhage incidentally produces third nerve palsy. MRI is extremely helpful in diagnosing a small hemorrhage of the midbrain in such cases.

Parálisis combinada de la mirada vertical tras hemorragia unilateral del mesencéfalo

Acute vascular lesions limited to the midbrain can yield varied disturbances of eye movements. They are more often infarcts than hemorrhages. We present the case of a 49 year old, non-hypertensive man who presented with sudden onset of bilateral up and down gaze palsy. CT defined a unilateral hemorrhage in the right mesencephalic tegmentum. Cases of upward and downward gaze palsy in association with unilateral upper midbrain hemorrhage are very uncommon. We present a new case.

Isolated Fourth Nerve Palsy From Midbrain Hemorrhage

Isolated ocular motor palsies caused by brainstem strokes have been considered uncommon. However, since the development of magnetic resonance imaging (MRI), the occurrence of isolated ocular motor palsies resulting from brainstem strokes have become more frequently recognized (1-5). We report a patient who developed a fourth nerve palsy contralateral to a small dorsal mid-brain hemorrhage.

Case study: Pharmacologic management of movement disorder after midbrain haemorrhage

Movement disorders following midbrain haemorrhage are infrequently encountered in rehabilitation, and are uncommonly corrected by pharmacologic means. This report describes a 20 year-old male with a prior history of cocaine abuse who presented with a 4 day history of dysarthria and blurred vision following methamphetamine abuse. Physical examination demonstrated hypertension, left facial hemispasm, bilateral upward gaze paresis and ataxic gait. Magnetic resonance imaging/magnetic resonance angiography (MRI/MRA) showed multifocal parenchymal haematomas in the mesencephalic tegmentum, subcortical left front region and right anterior thalamus consistent with cavernous angiomas. The patient was transferred to rehabilitation on hospital day 5. The following day, he developed choreoathetoid movements, dystonia, and aphasia, secondary to an extension of the midbrain haemorrhage. Cogentin was initiated with slight improvement in choreoathetoid movements. The patient began intensive multidisciplinary rehabilitation therapy but after 18 days of therapy, the patient remained totally dependent in activities of daily living (ADLs), transfers, mobility and was unable to communicate in any manner. A trial of Sinemet was initiated, with resultant steady improvement in functional ability over the next month. By discharge, the patient was independent in ADLs and ambulation. By 9 months post discharge follow-up, the patient was fully independent with normal cognition, and had self tapered all medications without ill effect. Dopamine agonist trials of appropriate duration appear indicated in cases of movement disorder (paucity or excess) following midbrain lesions.

Dorsal Midbrain Syndrome due to Mesencephalic Hemorrhage Case Report with Serial Imaging

Spontaneous, nontraumatic, nonhypertensive, midbrain hemorrhage is an uncommon cause of the dorsal midbrain syndrome. We describe a patient with this syndrome in whom the initial neuroimaging studies failed to clearly identify the lesion. Subsequent magnetic resonance imaging studies disclosed a dorsal midbrain hemorrhage. The patient experienced gradual spontaneous resolution of her dorsal midbrain signs and symptoms over several months. The evolution on serial neuroimaging studies of the dorsal midbrain hemorrhage in this patient is described.

Somatosensory evoked potentials for prediction of outcome in acute severe brain injury

The purpose of this study was to evaluate prospectively short-latency somatosensory evoked potentials (SEPs) as a predictor of outcome in acute, severe brain injury, and to compare this with the predictive power of the motor component of the Glasgow Coma Scale score and computed tomographic scan. Outcome was measured with the Glasgow Outcome Scale at a minimum of 6 months after injury. We studied 109 patients (aged 0.1 to 16.8 years) with SEPs within 4 days of the onset of coma. Four patients had absent SEPs and a favorable outcome by the Glasgow Outcome Scale (full recovery or moderate disability); two of these patients had meningitis with bilateral subdural effusions, one had a midbrain hemorrhage, and one had a decompressive craniectomy for uncontrolled intracranial hypertension. Normal SEPs had a positive predictive value for favorable outcome of 93% (95% confidence interval (CI), 77% to 99%), and absent SEPs had a positive predictive value for unfavorable outcome by the Glasgow Outcome Scale (severe disability, survival in a persistent vegetative state, or death) of 92% (95% CI, 80% to 98%). If the above identifiable clinical situations in which a physical barrier existed to impede cutaneous reception of the electrical impulse were excluded, the positive predictive value of absent SEPs for poor outcome reached 100% (95% CI, 92% to 100%). An absent motor response to painful stimulus also had 100% positive predictive value (95% CI, 84% to 100%) for unfavorable outcome; however, 23% of patients could not be evaluated because of the effects of muscle relaxants or sedatives. In patients with traumatic brain injury, results of computed tomography did not reliably predict outcome. Of the 59 patients with unfavorable outcome, 76% could be identified with SEPs compared with 36% with examination of motor function. We suggest that SEPs be performed in children with acute severe brain injury because they add an important tool to the physician's prognostic armamentarium. We conclude that in the absence of the above mentioned identifiable clinical situations, absent SEPs predict 100% unfavorable outcome, and this finding may warrant consideration of withdrawal of treatment in children with brain injuries. (J P EDIATR 1995;126:44-9)

Ophthalmoplegia with bilateral ptosis secondary to midbrain hemorrhage. A case with clinical and radiologic correlation

A 65-year-old white female presented with the sudden onset of headaches, bilateral ptosis, and complete ophthalmoplegia. Other than a mild decrease in mental status, she was neurologically intact. Magnetic resonance imaging (MRI) and computed tomography (CT) examinations showed a midline hemorrhage extending from the caudal diencephalon to the pontomesencephalic junction affecting the oculomotor complex, the medial longitudinal fasciculus (MLF), and the rostral parapontine reticular formation (PPRF). Ischemic changes were also noted in the midline pontine tegmentum possibly affecting root fibers from the abducens nuclei. Angiography was negative for a vascular anomaly. The radiologic findings are correlated with current models of oculomotor organization to provide an explanation for this patient's unique clinical presentation.

Oculomotor nuclear complex syndrome as a single sign of midbrain haemorrhage

A 73-year-old male patient presented with a mesencephalic dorsal tegmental haemorrhage involving the oculomotor nuclear complex. Clinically the patient exhibited ipsilateral palsy of the third nerve associated with internuclear ophthalmoplegia, transient upbeat nystagmus, bilateral ptosis and paresis of the superior rectus muscle of the contralateral eye, due to involvement of the subnucleus that mainly innervates the contralateral superior rectus muscle. No other neurological deficits were seen. Isolated midbrain haemorrhages are very uncommon and they usually produce combined supranuclear and nuclear disturbances of eye movement.As documented by high resolution CT-scan, these exceptional findings were caused by haemorrhage in the territory of a penetrating branch from a long circumferential midbrain artery.The results of this case are in accordance with Warwicks investigations on the organisation of the oculomotor system in primates.

Olivary degeneration after cerebellar or brain stem haemorrhage: MRI.

Magnetic resonance (MR) images of seven patients with olivary degeneration caused by cerebellar or brain stem haemorrhages were reviewed. In four patients with cerebellar haemorrhage, old haematomas were identified as being located in the dentate nucleus; the contralateral inferior olivary nuclei were hyperintense on proton-density- and T2-weighted images. In two patients with pontine haemorrhages, the old haematomas were in the tegmentum and the ipsilateral inferior olivary nuclei, which were hyperintense. In one case of midbrain haemorrhage, the inferior olivary nuclei were hyperintense bilaterally. The briefest interval from the ictus to MRI was 2 months. Hypertrophic olivary nuclei were observed only at least 4 months after the ictus. Olivary degeneration after cerebellar or brain stem haemorrhage should not be confused with ischaemic, neoplastic, or other primary pathological conditions of the medulla.

Spontaneous midbrain hemorrhage: Report of seven new cases

Spontaneous midbrain hemorrhage is a unique brain-stem vascular lesion. Sixty-six cases have been reported in the literature, to which we add seven. Of the total of 73 patients reviewed, most presented acutely (66%), but subacute (22%) and chronic onsets (12%) also occurred. Neuro-ophthalmologic abnormalities were found in 88% of patients. Some alteration of consciousness and headache occurred in most patients. Hemiparesis, hemisensory loss, and ataxia were less frequent manifestations. Vascular malformations were suspected or proved in 37% of patients, hypertension was present in 21%, and a bleeding diathesis was noted in 5%. No underlying cause was apparent in 37%. Most patients improved with supportive care only. At follow-up, 23% of patients had no neurologic deficits. In 51% of patients, minor neurologic deficits persisted, related chiefly to cranial nerves III and IV. Moderate deficits persisted in 16% of patients, and 5% of patients died.

CT and MRI Demonstrate Midbrain Hemorrhage in Acute Wernicke's Encephalopathy

Wernicke's encephalopathy is a common but underrecognized condition occurring primarily but not solely in alcoholics. In an alcoholic patient with acute panophthalmoplegia and intermittent retraction nystagmus, computed tomography demonstrated gross midbrain hemorrhage initially mistaken for atypical hypertensive bleeding. Magnetic resonance imaging revealed periaqueductal hemorrhage and edema. The cerebrospinal fluid was xanthochromic. Substantial resolution of the ophthalmoplegia followed intravenous administration of thiamine. In appropriate clinical circumstances, “hypertensive” hemorrhage in the midbrain should arouse the suspicion of Wernicke's encephalopathy.