Midbrain Stroke Research Articles

Isolated Vertical Gaze Palsy due to Unilateral Rostral Midbrain Stroke.

Isolated Vertical Gaze Palsy due to Unilateral Rostral Midbrain Stroke.

Unveiling Benedikt’s syndrome: A rare midbrain stroke presenting with oculomotor nerve palsy

A 34-year-old female presented to the neuro-ophthalmology outpatient department with the primary complaint of ptosis of the right eyelid experienced over the course of 3 days. Clinical evaluation unveiled a right oculomotor nerve palsy, accompanied by compromised motor function in the left upper and lower extremities. Neuroimaging studies subsequently revealed the presence of an acute non-hemorrhagic infarct localized within the right paramedian midbrain region, specifically encompassing the red nucleus and the oculomotor nerve fascicles, a presentation conclusively indicative of Benedikt’s syndrome.

A Cross-Sectional Study of Clinical Spectrum and Outcome of Pure Midbrain Strokes.

Pure mesencephalic infarcts are uncommon, the main clinical manifestations being oculomotor signs and ataxia. Primary objective was to determine the incidence of pure midbrain strokes. We also evaluated the clinical spectrum, syndromes, arterial territories involved, risk factors, and outcome at 3 months. This cross-sectional study was conducted at the Neurology department of a tertiary teaching hospital in Kerala. We recorded clinical examination and radiological details of all the patients who presented with isolated midbrain strokes from December 2014 to December 2019. The clinical spectrum and outcomes of the patients at 3 months were analyzed. Of the 520 posterior circulation stroke patients, 48 (9.2%) had isolated mesencephalic infarcts. Clinical manifestations included gait ataxia in 40 patients (83.3%), third nerve palsy in 29 (60.41%), fourth nerve palsy in 4 (8.3%), internuclear ophtalmoplegia in 9 (18.8%), upgaze paresis in 3 (6.3%), hemiparesis in 4 (8.3%), and cheiro-oral paraesthesia in 4 (8.3%). Of the 48 patients, 21 (43.8%) had Claude syndrome, 9 (18.8%) had Wernekink commisure syndrome, 6 (12.5%) had ataxic hemiparesis, 3 (6.3%) had Parinaud syndrome, 3 (6.3%) had Weber syndrome, 4 (8.3%) had Nothnagel syndrome, and 1 patient had a pure sensory stroke (2.1%). The anteromedial territory was frequently affected, in 37 (77%), characterized by oculomotor manifestations and ataxia. Posterior lesions were noted in three (6.3%), anterolateral lesions in three (6.3%), and lateral lesion in one (2.1%) patient. Combined lesions in posterior and paramedian territory were seen in four (8.3%). At the end of 3 months, 30 patients (62.5%) had a modified Rankin score of one. Our study provides the incidence of midbrain stroke over 5 years. It also highlights the heterogeneity of clinical features of pure midbrain infarcts.

Midbrain stroke syndrome: Weber's syndrome in two male HIV-positive patients with cerebral toxoplasmosis

Midbrain stroke syndrome: Weber's syndrome in two male HIV-positive patients with cerebral toxoplasmosis

Teaching Neuro Images : Holmes tremor after midbrain stroke

A 69-year-old man presented with a continuous right upper extremity resting tremor with a 3-Hz frequency ([video 1][1]). The tremor developed gradually, 4 months after a left midbrain stroke. MRI showed an infarct in the left medioventral midbrain ([figure 1][2]). [123I]-2β-carbomethoxy-3β-(4-

IoT-Enabled Healthcare Data Analysis in Virtual Hospital Systems Using Industry 4.0 Smart Manufacturing

Background: The world is transitioning to Industry 4.0, representing the transition to digital, fully machine-driven environments and cyberphysical systems. Industry 4.0 comprises various technologies and innovations that enable development in multiple perspectives, which are implemented in many different sectors. Problem: The major challenges are the high cost, high rate of failure, security and privacy issues, and there is a need for highly skilled labor for applying healthcare data analysis. Aim: To resolve these issues, we employ the proposed system of Industry 4.0 smart manufacturing for IoT-enabled healthcare data analysis in virtual hospital systems with machine learning (ML) techniques. Methods: The proposed system contains five alternative solutions under smart manufacturing. First, the healthcare data analysis is applied for Weber’s syndrome. That is, this will be used to analyze Weber’s syndrome during its consistent treatment. Second, the IoT-enabled healthcare data handling system works based on edge-assisted edge computing that is used to apply IoT to the healthcare data handling system. The healthcare data analysis in virtual hospital systems uses machine learning for driving data synthesis. Finally, the Industry 4.0 smart manufacturing is applied to the IoT-enabled healthcare data analysis to realize efficient data digitization, especially in smart hospitals with smart sensors for virtual IoT-enabled devices surveillance of Weber’s syndrome. Result: The data digitization based on Industry 4.0 smart manufacturing analysis is considered for data processing, storage and transmission. The proposed system is 62% more efficient than the other analyzed methods. The identification of Weber’s syndrome is 69.8% more efficient than the existing midbrain stroke syndrome identification. The processing and storage of data results are 45.78% more efficient than the current encryption method. Finally, the priority-aware healthcare data analysis based on ML provides 63.4% efficient, faster and more accurate diagnoses in the personalized treatment.

Claude Syndrome in Childhood Associated with Probable Neuro-Behcet Disease.

Claude syndrome is a rare midbrain stroke syndrome characterized by ipsilateral third cranial nerve palsy and contralateral hemiataxia. So far, only a few cases have been reported in childhood. We present two children with Claude syndrome at 9 and 15 years of age. The typical clinical picture was consistent with brain magnetic resonance imaging findings. A thorough investigation regarding the underlying etiology revealed no definite diagnosis but clues suggestive of probable neuro-Behcet disease. Awareness of pediatric neurologists on arterial ischemic stroke has been increasing over the past decades, enabling timely diagnosis and appropriate management of rare childhood cases with midbrain stroke.

Acute Onset Quadriplegia and Stroke: Look at the Brainstem, Look at the Midline.

Acute onset quadriplegia with or without facial sparing is an extremely rare vascular syndrome, and the main focus of attention is on the cervical and upper thoracic spinal cord as the putative site of the damage. Quadriplegia has been occasionally reported in brainstem strokes within well-defined lesion patterns, but these reports have gained little attention so far because of the rarity of this clinical syndrome. The clinical, neuroanatomical and neuroimaging features of ischemic stroke locations associated with quadriplegia have been collected and reviewed in a pragmatical view, which includes a detailed description of the neurological signs associated with the damage of the pyramidal pathways. Two clinical examples have been added to raise practical suggestions in neurovascular practice. Ischemic stroke sites determining quadriplegia have some main well-defined midline locations in the brainstem, involving the pyramidal pathways of both sides in a single synchronous ischemic lesion in the medulla oblongata and in the pons. Several accompanying neurological signs have been described when the ischemic lesion involves tracts and nuclei other than the pyramidal pathways, and they can be useful as localizing clues. In some cases, the typical neuroimaging appearance of the ischemic lesion on Magnetic Resonance Imaging (MRI) has been reported as being a "heart appearance sign". This last sign has been described in midbrain strokes too, but this location is not associated with quadriplegia. The main etiology is atherothrombosis involving the intradural segment of the vertebral artery (VA) and their perforating branches. Two clinical examples of these rare vascular syndromes have been chosen to support a pragmatical discussion about the management of these cases. A midline ischemic stroke in the brainstem is a very rare vascular syndrome, and the acute onset quadriplegia is a distinctive feature of it. The awareness of this cerebrovascular manifestation might help to recognize and treat these patients.

235 EYES WIDE SHUT: A CASE OF BILATERAL PTOSIS FOLLOWING STROKE

Abstract Background Bilateral ptosis is a rare manifestation of midbrain stroke. It has been reported in case studies only, with no data on incidence rate, and no published case report in Ireland to date. Methods This is a retrospective case study of a man admitted to an acute stroke unit following collapse and unresponsiveness. A review of his medical records and radiological database was conducted. A PUBMED database search was conducted to search for similar cases. Results We present the case of a man who had a witnessed collapse whilst farming and was brought to hospital and presented with a Glasgow Coma Scale of 3. Imaging showed a normal CT Brain. MRI revealed 2cm acute bilateral thalamic and midbrain infarction. Following a brief period in ICU he was transferred to the acute stroke unit for multidisciplinary care. Despite improvements in his medical status and communication efforts, his inability to open his eyes contributed to a persistently low GCS. Neurological assessment revealed bilateral ptosis, fixed dilated pupils and oculomotor paralysis. These symptoms had a profound impact on his stroke recovery, impeding assessments and interventions and engagement in all realms (swallow and communication; mobility and function, cognitive-perceptual) whilst also limiting opportunities for social interaction. Once staff became aware of the ophthalmoplegia, strategies were implemented to optimise his participation and provide opportunities of recovery. Three months post stroke, he began to experience some return of unilateral eye-opening and bilateral horizontal movements (with diplopia) which greatly improved his overall performance. He was then transferred to the rehabilitation unit where he continues to progress. Conclusion Bilateral ptosis post stroke is rare and has a debilitating effect on participation in all aspects of living and interaction with the environment. This presentation has previously been described as “reverse locked-in-syndrome” which accurately represents its impact.

Revisiting the classics: Midbrain stroke presenting as a weber syndrome

Revisiting the classics: Midbrain stroke presenting as a weber syndrome

Pupil sparing Cranial Nerve III Palsy and Hemiparesis, Weber Syndrome: A Case Report and literature review

Midbrain stroke especially Weber syndrome is a rare case seldom reported in the literature. It involves oculomotor nerve palsy and contralateral hemiparesis. A 46-year-old female presented with sudden onset of blurring of vision along with right-sided hemiparesis, right upper motor neuron type cranial nerve (CN) VII palsy, left-sided CN III palsy, and left-sided ptosis. Magnetic resonance imaging (MRI) revealed T2 flair/hyperintensity in the left side of the midbrain, bilateral gangliocapsular regions, and centrum semi vale indicating acute infarct and chronic ischemic changes respectively as well as a high signal area on the T2/FLAIR sequence, indicating sinusitis. Ocular manifestations of a midbrain stroke are highlighted in this case study, particularly Weber syndrome, which also entails contralateral hemiparesis. A better prognosis can be achieved with early diagnosis and treatment. In our case report, a CT scan was found to be normal and the diagnosis of Weber syndrome was made only after MRI confirming its sensitivity to detect intracranial lesions.

Uncovering Levodopa-Responsive Dystonic Tremor after Midbrain Stroke.

Uncovering Levodopa-Responsive Dystonic Tremor after Midbrain Stroke.

Abstract P717: Central Midbrain Strokes Are More Liable for Respiratory Failure Then Other Brain Stem Strokes

Background: Respiratory centers are known to be present in the central medulla oblongata and pons. There are multiple complex respiratory networks involving these centers. The midbrain periaqueductal grey is believed to act as a regulator of the respiratory function. The effect of brain-stem strokes on respiration remains understudied. There is a lack of clear understanding of the anatomical influence of such strokes on respiration. We attempted to identify brain-stem locations with the highest liability for respiratory failure in case of stroke. Methods: We included all ischemic and hemorrhagic brain-stem strokes from our stroke-registry between 2016 and 2018 then performed univariate/multivariate regression-analyses on variables that might predict respiratory failure and the need for intubation. The brain stem was divided into nine locations (right lateral, central, left lateral in each of the midbrain, pons, and medulla oblongata). Results: Out of 128 brain-stem strokes of different sizes and etiologies, central midbrain strokes were the only significant and independent affected location associated with respiratory failure and endotracheal intubation (coefficient= 0.1256, 95%-CI= 0.0175, 0.2338, p= 0.023). R-squared was equal to 15% when only central midbrain strokes stayed in the model. Conclusions: While one might assume that central medullary and pontine strokes have the most impact on respiration; our results show that central midbrain is the most impactful, accounting for about 15% of respiratory instability associated with brain-stem strokes. This can be explained by the adaptive nature of respiratory circuits within the medulla and pons. Central periaqueductal grey within the midbrain controls the rate and depth of respiration and might not have the same flexibility present elsewhere.

Bedside Assessment of Vergence in Stroke Patients.

Given the widely distributed network of midbrain, pontine, cerebellar, and cortical areas involved in the neural control of vergence, one might expect various vergence deficits in stroke patients. In this article, we investigated the localizing value of bedside vergence testing with respect to different supratentorial and infratentorial infarction locations. Three hundred five stroke patients and 50 age-matched controls were examined prospectively by means of bedside tests to assess slow and fast binocular (i.e., symmetrical) as well as slow and fast monocular (i.e., asymmetrical) convergence. Infarction locations, as identified on MRI, were correlated with vergence performance using multinomial logistic regression. Vergence deteriorated with age in both stroke patients and healthy controls. Most infarction locations did not show significant associations with vergence parameters, apart from cases with parietal lobe lesions, which exhibited insufficient asymmetrical, slow and fast vergence for both the left and the right eye. Finally, patients with severe ischemic small vessel disease showed a slight but significant decrease in their fast binocular vergence performance. There is only a limited localizing value of vergence deficits in stroke. Parietal lobe infarctions are more frequently associated with insufficient binocular and monocular vergence. Midbrain strokes were too few to draw final conclusions. However the most robust factor to emerge from our data is age. Older subjects show poor slow binocular as well as slow and fast monocular vergence. Extended white matter lesions are also correlated with deficient vergence ability suggesting a role for subcortical wide range connections in maintaining an intact vergence circuitry.

Wernekink commissure syndrome: clinico-radiological criteria

Introduction: Wernekink commissure syndrome is a rare midbrain syndrome selectively affecting the Wernekink commissure, characterized by bilateral cerebellar ataxia and eye movement disorders, especially internuclear ophthalmoplegia. This article aims at proposing clinico-radiological criteria for Wernekink commissure syndrome with review of the neural circuitary responsible, to aid in recognition and reporting.
 Methods: This was a prospective study conducted at Department of Neurology, at Pushpagiri institute of medical sciences and research centre, Thiruvalla, Kerala, India, over a period of 5 years among patient with pure midbrain syndromes. All patients with pure midbrain infarction were studied. Subjects presenting with clinical features of Wernekink commissure syndrome were shortlisted and were assessed by investigators independently. Neuroradiology was assessed by investigators 1 and 2, independently. The demographic profile, risk factors, clinical features, neuroimaging findings and outcomes were analysed using SPSSv21.
 Results: Details of 43 subjects with pure midbrain stroke were included in the study. 8 had clinical features of Wernekink commissure syndrome. The most common findings were bilateral ataxia and unilateral or bilateral internuclear ophthalmoplegia. None of our patients had palatal tremor. Unilateral caudal paramedical infarction was seen on MRI in 5 patients, whereas it was bilateral in 3 patients.
 Conclusions: The proposed clinico-radiological criteria consisting of all of the essential criteria (Ipsilateral internuclear ophthalmoplegia, Unilateral or bilateral ataxia and Neuroradiological evidence of Caudal midbrain involvement) with or without one among the supportive criteria (Rubral Tremor, Palatal myoclonus) can safely point at a diagnosis of Wernekink commissure syndrome.

Isolated Unilateral Oculomotor Nerve Paresis: An Uncommon Presentation of Midbrain Stroke

Isolated Unilateral Oculomotor Nerve Paresis: An Uncommon Presentation of Midbrain Stroke

Double-eye trouble after cardiac catheterization: A case report

Strokes with neuro-ophthalmologic complications after cardiac catheterizations have been reported, with potentially debilitating consequences to patients. We present an interesting case of a 55-year-old male who was managed for new-onset heart failure with reduced ejection fraction. He complained of diplopia and became drowsy immediately after a diagnostic coronary angiogram, a concomitant right heart catheterization study, and left ventricular catheterization. Neurological examination showed that he had bilateral vertical gaze palsy. Magnetic resonance imaging of the brain revealed a left paramedian midbrain stroke. His symptoms resolved within 3 days, and he was discharged well on medical therapy after a period of observation.

Paramedian Midbrain Infarction Presenting as Bilateral Asymmetric Ptosis: A Case Report and Review of Literature

Brainstem strokes can have protean ophthalmological manifestations including pupillary and extraocular muscle pareses. Incomplete paresis of oculomotor function is more common than complete paresis owing to the selective involvement of subnuclei or fascicles for various extraocular muscles. Here, we report a case of right paramedian midbrain stroke presented with asymmetric bilateral ptosis. We discuss the anatomical correlation of this presentation with the structure of oculomotor nerve nuclei and its fascicles.

Why acute unilateral vestibular midbrain lesions rarely manifest with rotational vertigo: a clinical and modelling approach to head direction cell function

A retrospective clinical study focused on the frequency of rotational vertigo in 63 patients with acute unilateral midbrain strokes involving the vestibular and ocular motor systems. In contrast to unilateral pontomedullary brainstem lesions, rotational vertigo in midbrain lesions occurred with a low frequency (14%) and transient (< 1 day) course. Swaying vertigo or unspecific dizziness (22%) and postural imbalance (31%) were more frequent. Midbrain strokes with transient rotational vertigo manifested with lesions chiefly in the caudal midbrain tegmentum, while manifestations with swaying, unspecific, or no vertigo chiefly occurred in rostral mesencephalic or meso-diencephalic lesions. We hypothesize that these different manifestations can be explained by the distribution of two separate cell systems based on semicircular canal function: the angular head-velocity cells and the head direction cells, both of which code for head rotation. Animal experiments have shown that angular head-velocity cells are located mainly in the lower brainstem up to the midbrain, whereas the head direction cells are found from the midbrain and thalamic level up to cortical regions. Due to the differences in coding, unilateral dysfunction of the angular velocity cell system should result in the sensation of rotation, while unilateral dysfunction of the head direction cell system should result in dizziness and unsteadiness. We simulated the different manifestations of vestibular dysfunction using a mathematical neural network model of the head direction cell system. This model predicted and confirmed our clinical findings that unilateral caudal and rostral brainstem lesions have different effects on vestibular function.

Isolated Fourth Nerve Palsy Due to Midbrain Stroke

Isolated Fourth Nerve Palsy Due to Midbrain Stroke