Pontine Infarction Research Articles

Abstract 107: Endovascular Therapy for Tandem Vertebral and Basilar Artery Occlusion in a Patient with Low NIHSS

Introduction Basilar artery occlusion (BAO) is a devastating minority stroke subtype with variable clinical presentations and high mortality.1,2 The National Institute of Health Stroke Scale (NIHSS) cutoff for poor outcomes is lower in BAO compared to anterior circulation large vessel occlusions (LVO) due to the scale’s weighted scoring towards cortical signs.3,4 To bridge this gap, Alemseged et.al created the underutilized posterior circulation (PC) NIHSS as an improved stroke assessment tool in PC LVO to better identify endovascular therapy (EVT) candidates. 5 Current randomized trials point to mixed evidence regarding EVT for BAO; although recent studies such as Endovascular Treatment for Acute Basilar Artery Occlusion (ATTENTION)6 and Basilar Artery Occlusion Chinese Endovascular Trial (BAOCHE)7 suggest positive results of EVT within 24hrs. Smaller retrospective subgroup analyses demonstrated EVT for BAO with low NIHSS has good clinical outcome of modified Rankin Scale (mRS) 0‐2 at 3 months in 60‐70% of patients4,8. We present a case of tandem vertebrobasilar artery occlusion in a patient with subacute symptoms and low NIHSS treated with mechanical thrombectomy. Methods '‐ Results 41‐year‐old male with past medical history of hypertension, insulin dependent diabetes and active smoking presented with worsening vertigo, nausea and vomiting for 3 weeks with progression to right sided headache and syncope. EMS noted right facial weakness prompting transport to nearest primary stroke center where CT head non‐contrast showed right cerebellar infarct and CT angiogram (CTA) head and neck showed right vertebral artery occlusion with basilar extension. Intravenous thrombolytic (IVT) was deferred due to unclear last known well. He was treated with aspirin 324mg and transferred to our tertiary stroke center. Arrival NIHSS was 1 for right upper extremity ataxia. Premorbid mRS was 0. Repeat CTA redemonstrated right vertebrobasilar artery tandem occlusion. CT perfusion was without mismatch. Patient underwent emergent mechanical thrombectomy with ADAPT to TICI3 revascularization with future plan for possible angioplasty and stenting of R vertebral stenosis. Subsequently admitted to neurocritical care unit and treated with dual antiplatelet therapy. Initially maintained on aspirin and Cangrelor infusion, then transitioned to aspirin and Plavix without hemorrhagic conversion. Diffusion weighted MRI brain showed right cerebellar and right pontine infarcts. Hospital course was complicated by severe intractable hiccups due to area postrema syndrome; ultimately resolved with baclofen and gabapentin after extensive unsuccessful medication trails. NIHSS remained 1 for ataxia throughout admission, although exam also revealed mild unsteady gait requiring home physical therapy and a walker on discharge. Post‐stroke mRS was 1 on discharge; 3‐month mRS is pending. Conclusion Evidence regarding EVT for low NIHSS BAO remains varied with some studies showing superior benefit with IVT alone9 while others suggest improved outcomes with EVT in mild to moderate deficits.4,8 One prospective study particularly revealed better outcomes in EVT for BAO due to tandem occlusions similar to this case.10 Given the potential devastating sequalae of BAO and limited overall treatment options, EVT should remain a strong contender for treatment of PC LVO, especially in patients with milder neurologic deficits or tandem occlusions. Additionally, heightened use of PC‐NIHSS may better prognosticate candidates for EVT.

Endovascular Treatment of Symptomatic Basilar Artery Stenosis.

While symptomatic basilar artery (BA) stenosis is associated with a higher risk of recurrent stroke or death, there is no consensus on the management of these patients who are refractory to antiplatelet therapy. This study retrospectively assesses the outcomes of endovascular treatment (EVT) for symptomatic BA stenosis. We conducted a retrospective review of patients with symptomatic BA stenosis who underwent EVT, including angioplasty or stenting, from 2006 to 2018. A total of 15 patients, who experienced transient ischemic attacks or strokes despite dual antiplatelet therapy, were included. EVT was performed under local anesthesia after pretreatment with antiplatelet medications. Angiographic follow-up was performed at 12 and 24 months post-EVT. Clinical outcomes were evaluated using the modified Rankin Scale (mRS). EVT was successfully completed in all patients. Peri/post-procedural complications occurred in 33% of cases, including in-stent thrombosis, intracranial hemorrhage, and pontine infarction. At long-term follow-up (mean 98.5±80.5 months), 73.3% of patients achieved a favorable functional outcome (mRS≤2) without disability or mortality. Patients with unfavorable outcomes had previous infarcts, with 2 experiencing new pontine infarctions after stenting. This study suggests that EVT, including angioplasty and stenting, may offer promise as a treatment option for symptomatic BA stenosis refractory to medical therapy. However, the procedure carries a notable risk of complications, especially in patients with severe stenosis and previous infarcts. Careful patient selection, based on clinical and radiological criteria, is crucial.

The association between monocyte to high-density lipoprotein cholesterol ratio and clinical prognosis of acute ischemic stroke after intravenous thrombolysis therapy.

The monocyte-to-high-density lipoprotein cholesterol (HDL) ratio (MHR) is accepted as a novel marker for demonstrating inflammation. We investigated whether the monocyte-to-HDL ratio is related to the 90-day clinical prognosis of acute ischemic stroke (AIS) after intravenous thrombolysis (IVT). Patients with AIS treated with alteplase IVT were included consecutively, and clinical information and laboratory data were collected. The 90-day prognosis of all patients was determined with a clinical assessment using the modified Rankin Scale (mRS). The optimal cutoff values for patients were evaluated by the receiver operating characteristic (ROC) curve method. Then, a multivariate logistic regression model was used to evaluate the risk factors for poor prognosis of IVT in AIS. We retrospectively enrolled 192 patients who were diagnosed with AIS and received IVT between February 2020 and July 2022, with final follow-up on September 30, 2022. The patients in the poor prognosis group had significantly higher monocyte counts, lower HDL levels, and higher MHR values than the good prognosis group. The optimal cutoff value of the MHR for predicting the 3-month outcome of acute pontine infarction was 0.621. Multivariate logistic regression revealed that the MHR (OR = 4.626, 95% CI: 1.156-18.512, P = .030) was strongly associated with poor prognosis in AIS. The MHR is an independent risk factor for the clinical prognosis of AIS patients receiving IVT therapy and shows a certain predictive value.

One and a half syndrome: A rare phenomenon in pontine infarction

No abstract available

A Rare Case of Isolated Infarcts of the Pons with Sudden Vertigo: Clinical Features and Imaging Findings

Isolated infarcts of the pons (IIP) are a rare subtype of ischemic stroke, accounting for less than 1% of all strokes. It refers to a specific type of ischemic stroke that occurs within the pons region of the brain. IIP can be associated with vertebrobasilar insufficiency in certain cases. This case report describes a 64-year-old female patient who presented with acute vertigo and spontaneous nystagmus to the lesion side, ultimately diagnosed with IIP in the posterior right side of pons. Tegmental pontine infarcts typically manifest as oblique small (lacunar) infarctions that are localized in the mediolateral tegmental area of the middle to upper pons. The patient’s symptoms resolved spontaneously, but a 2-mm infarct was confirmed by brain diffusion magnetic resonance imaging. This case highlights the distinctive symptoms associated with IIP and emphasizes the importance of careful neurological examination and advanced neuroimaging techniques for accurate diagnosis.

Stereotactic Radiosurgery for Medically Refractory Trigeminal Neuralgia Secondary to Stroke: A Systematic Review and Clinical Case Presentation

Trigeminal neuralgia (TN) is a paroxysmal, unilateral, brief, shock-like pain in ≥1 divisions of the trigeminal nerve. It can result from multiple causes; however, TN secondary to stroke is very rare. We present the case of TN secondary to pontine infarction treated with incremental doses of neuropathic pain medication for >5 years before conservative management failed. He was then treated with stereotactic radiosurgery (SRS). Additionally, we conducted a systematic review using standard PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines for all the cases of TN with brainstem stroke from 1976 to2022. Our patient was an 82-year-old man. Magnetic resonance imaging demonstrated a pontine lesion consistent with stroke. The Barrow Neurological Institute (BNI) score at presentation was 5. He received a marginal dose of 60 Gy to the 80% isodose line in a single fraction to a volume of 0.05 cm3. The immediate post-treatment BNI score was 0 and remained at 0 for 3 months, when he experienced recurrence. The recurrence was treated with oxcarbazepine. His pain remained well controlled with a lower dose of oxcarbazepine, and he had no adverse effects at 1 year of follow-up with a BNI score of 3. The systemic review identified 21 case reports with a combined cohort of 25 patients with TN secondary to stroke. Only 3 patients were treated with SRS, 2 of whom reported symptom improvement at 6 months and 8 months of follow-up with no adverse events. Our case and literature review demonstrate durable and effective treatment with SRS, which can be considered a safe and effective treatment option for patients with stroke-associated TN.

Pontine Infarction Presenting as Millard-Gubler Syndrome

Pontine Infarction Presenting as Millard-Gubler Syndrome

Eight-and-a-half syndrome – A rare presentation of pontine infarction

Eight-and-a-half syndrome is clinically characterized by conjugate gaze palsy and internuclear ophthalmoplegia along with lower motor neuron type facial nerve palsy. Usually, it occurs because of infarction or demyelinating disease at paramedian tegmentum of lower pons. It emphasizes the importance of checking ocular movements. A 55-year-old male patient presented with sudden onset of double vision, headache, and vomiting and found to have horizontal gaze palsy, internuclear ophthalmoplegia, and facial palsy of the left side. High blood pressure was noted. Clinically, eight and a half syndrome was identified. MRI brain showed infarct at pons. The patient was stabilized systemically. A detailed clinical neuro-ophthalmic examination, along with a clear understanding of the neuro-anatomical pathways, gives clinicians a good diagnostic opportunity to localize precisely lesions in the brainstem. The disease should be evaluated for etiology.

Altered resting-state neurovascular coupling in patients with pontine infarction

The risk for motor and cognitive impairment is increased in patients with chronic pontine infarction (PI). In this study, we attempted to explore the alterations of neurovascular coupling (NVC) in order to understand the neural basis of behavioral impairment after PI. Three-dimensional pseudo-continuous arterial spin labeling (3D-pcASL) and resting-state functional magnetic resonance imaging (rs-fMRI) were applied in 49 patients with unilateral PI (left-sided, n = 26; right-sided, n = 23) and 30 matched normal subjects to assess whole-brain cerebral blood flow (CBF) and functional connectivity strength (FCS). We evaluated NVC in each subject by calculating the correlation coefficient between the whole-brain CBF and FCS (CBF-FCS coupling) and the ratio between voxel-wise CBF and FCS (CBF/FCS ratio). The FCS maps were then divided into long-range and short-range FCS to identify the influence of connection distance. The results indicated that the CBF-FCS coupling in the whole-brain level was significantly interrupted in PI patients, and the CBF/FCS ratio in cognition-related brain regions was abnormal. Distance-dependent results demonstrated that PI had a more serious effect on long-range neurovascular coupling. Correlation analysis revealed that the changes in neurovascular coupling were correlated with working memory scores. These findings imply that disruption of neurovascular coupling in the remote-infarction brain regions may underlie the impaired cognitive functions in chronic PI.

Wide symptom variability of cerebellar infarction and comparison with pons infarction

Cerebellar infarction (CI) is a serious cerebrovascular disease that may present with non-focal neurological deficits, leading to delay of clinical recognition and treatment. The aim of this study is to investigate the variability of symptoms, diagnostic outcomes and early prognosis in patients with cerebellar infarction compared with pontine infarction (PI). Between 2012 and 2014, a total of 79 patients (68±14years, female sex 42%, median NIHSS score: 5) with CI (43) and PI (36) were included and analyzed. CI patients were admitted to emergency department one hour earlier compared with patients with PI. The most common symptoms in CI were dysarthria (67%), impaired coordination (61%), limb weakness (54%), dizziness/vertigo (49%), gait and stance uncertainty (42%), nausea or/and vomiting (42%), nystagmus (37%), dysphagia (30%) and headache (26%). Nineteen patients (44%) had symptomatic stenosis and two patients had vertebral artery dissection on duplex sonography and MR angiography.Four patients (9%) received a systemic intravenous thrombolysis with rt-PA and three patients received mechanical thrombectomy.Three months after the event, five patients (12%) had died and 15 (40) had disability with mRS (3-5). Cerebellar infarction occurs with a high variability of symptoms and should be considered when non-focal symptoms are present.

Neuroimaging markers of early neurological deterioration in acute isolated pontine infarction.

Imaging indicators of early neurological deterioration (END) in patients with acute isolated pontine infarctions (AIPI) remained ambiguous. We aimed to find more specific neuroimaging markers for the development of END in patients with AIPI. Patients with AIPI within 72 h of stroke onset were screened from a stroke database from January 2018 to July 2021 in the First Affiliated Hospital of Zhengzhou University. Clinical characteristics, laboratory tests, and imaging parameters were collected. The layers having the largest infarct area on diffusion-weighted imaging (DWI) and T2 sequences were chosen. On the transverse plane of DWI and sagittal plane of T2-Flair images, the maximum length (a, m) and maximum width (b, n) vertical to the length of the infarcted lesions were measured respectively. On the sagittal plane of T2-Flair image, the maximum ventrodorsal length (f) and rostrocaudal thickness (h) were measured. On the sagittal plane, lesions were evenly split into upper, middle, and lower types based on the lesion's location in the pons. The ventral and dorsal types of location were separated based on whether the ventral borders of the pons were involved on transvers plane. END was defined as a ≥2 point increase in the National Institutes of Health Stroke Scale (NIHSS) total score or a ≥1 point increase in the motor items within 72 h after admission. Multivariate logistic regression analyses were used to explore risk factors associated with END. The receiver operating characteristic (ROC) curve analysis and the area under the curve (AUC) was performed to estimate the discriminative power and determine the optimal cut-off points of imaging parameters on the prediction of END. A total of 218 patients with AIPI were included in the final analysis. END occurred in 61 cases (28.0%). Multivariate logistic regression analysis showed that the ventral type of lesion location was associated with END in all models adjusted. In addition, in Model 1, b (odds ratio (OR) 1.145, 95% confidence interval (95% CI), 1.007-1.301) and n (OR 1.163, 95% CI 1.012-1.336); in Model 2, b*n (OR 1.010, 95% CI 1.002-1.018); in Model 3, n (OR 1.179, 95% CI, 1.028-1.353); and in Model 4, b (OR 1.143, 95% CI 1.006-1.298) and n (OR 1.167, 95% CI 1.016-1.341) were found to be associated with END respectively after different adjustments. ROC curve analysis with END showed that the AUC, the optimal cut-off value, and its sensitivity and specificity were 0.743 (0.671-0.815), 9.850 mm, and 68.9% and 79.0% for b; 0.724 (0.648-0.801), 10.800 mm, and 57.4% and 80.9% for n; and 0.772 (0.701-0.842), 108.274 mm2, and 62.3% and 85.4% for b*n, respectively (b*n vs b: P =0.213; b*n vs n: P =0.037; b vs n: P =0.645). Our study revealed that besides the ventral type of lesion location, the maximum width of lesion on the transverse plane of DWI and sagittal plane of T2 image (b, n) may be imaging markers for the development of END in AIPI patients, and the product of the two (b*n) showed a better prediction value on the risks of END.

Influencing factors of early dramatic recovery of neurological function after intravenous thrombolysis in patients with branch atheromatous disease.

Intravenous thrombolysis can significantly improve the neurological function of patients with acute ischemic stroke. However, the expected early dramatic recovery (EDR) of neurological function after thrombolysis is not achieved in some patients with branch atheromatous disease (BAD). Here we evaluated the factors associated with EDR after thrombolysis in BAD patients. We conducted a retrospective study on 580 consecutive BAD patients. All patients met the diagnostic criteria of BAD and received intravenous recombinant tissue-type plasminogen activator (rt-PA). EDR was defined when the improvement of National Institutes of Health Stroke Scale (NIHSS) score was >8 points within 2 or 24 hours after rt-PA, or the total NIHSS score was 0 or 1. The factors associated with EDR were analyzed with multivariate logistic regression analysis. Among 580 patients, the incidence of EDR was 35.2% (204 cases). Compared with patients without EDR, patients with EDR had lower incidence of diabetes (15.7% vs 29.3%, P < .001), lower NIHSS scores at 2 and 24 hours after rt-PA (P < .001), less cerebral hemorrhage (0% vs 5.3%, P = .001), and shorter onset to treatment time (OTT) (P < .001). Multivariate logistic regression analysis in propensity score-matched cohort showed that EDR was associated with OTT (adjusted OR = 0.994; 95% CI, 0.989-0.999) and NIHSS score after rt-PA (adjusted OR = 0.768; 95% CI, 0.663-0.890). Notably, diabetes (adjusted OR = 0.477, 95% CI, 0.234-0.972) was an independent factor related to EDR of neurological function in BAD patients. In the subgroup analysis, a lower incidence of diabetes (adjusted OR = 0.205, 95% CI: 0.059-0.714, P = .013) and a lower NIHSS score after thrombolysis in patients with paramedian pontine infarction (adjusted OR = 0.809, 95% CI: 0.656-0.997, P = .047) were significantly associated with EDR. Diabetes is not conducive to EDR of neurological function in patients with BAD, especially in patients with paramedian pontine infraction. Low NIHSS score and short OTT after thrombolysis may be closely related to EDR after intravenous thrombolysis.

Invasive Bacterial Sinusitis Causing Pontine Infarct In An Immunocompromised Patient (P12-5.032)

<h3>Objective:</h3> The goal of this case report is to educate neurologists on a unique stroke presentation in an immunocompromised patient. <h3>Background:</h3> Malignancy has been shown to increase risk of ischemic stroke. About 50% of cancer-related strokes have cryptogenic etiology, however they are hypothesized to typically be related to thromboembolic events and hypercoagulability of malignancy. New diagnosis of solid tumors is associated with increased risk of hypercoagulability. However, hematologic malignancy such as chronic lymphocytic leukemia (CLL) is not typically associated with hypercoagulability. Cancer in general can increase stroke risk in other ways, including intracranial radiation, heightened systemic inflammation and atherosclerosis, and even increased psychological stress. In patients with hematologic malignancy who have a stroke, further investigation into etiology is often warranted, including infectious evaluation due to possible immunocompromised status. <h3>Design/Methods:</h3> N/A <h3>Results:</h3> <h3>Case description:</h3> We present a case of a A 77 year old male with active CLL, on acalabrutinib, admitted for neutropenic fever, who developed acute-onset right-sided hemiparesis five days into his hospital stay. Imaging was consistent with a left pontine infarct, initially believed to be small vessel etiology from hypertension. Subsequent fluctuation of symptoms resulted in further imaging demonstrating worsening infarct, to eventually a full pontine infarct. Review of serial imaging showed progressive sinus infection causing erosion of patient’s skull base and subsequent irritation of pontine arteries, causing a small vessel injury and resultant infarct. <h3>Conclusions:</h3> <h3>Discussion:</h3> This case demonstrates a unique stroke etiology in an immunocompromised patient. It reveals the importance of comparing serial imaging, broadening differentials in stroke workup, and having a thorough infectious evaluation for immunocompromised patients. <b>Disclosure:</b> Mr. Verma has received personal compensation in the range of $50,000-$99,999 for serving as a Resident with University of Utah. Mr. Verma has received personal compensation in the range of $10,000-$49,999 for serving as a Medical Student with University of South Dakota. Dr. Das has nothing to disclose.

E032 Deficiency of Adenosine Deaminase 2: a rare diagnosis in a case of suspected vasculitis

Abstract Background/Aims Deficiency of adenosine deaminase 2 (DADA2) is a rare autosomal recessive condition first described in 2014 which is characterised by vasculitis, systemic inflammation, immunodeficiency and cytopenias. The vasculitis is difficult to differentiate from polyarteritis nodosa and typically presents with recurrent strokes. It can also affect the skin and present with livedo racemosa. Clinical presentation varies widely; from vasculitic manifestations which tend to present later in life to severe haematological abnormalities such as bone marrow failure which tend to present earlier in life. Treatment with TNF inhibitors reduces the risk of additional strokes and controls inflammation in the presence of vasculitis but is not very effective against bone marrow failure. Methods We present the case of a 44-year-old gentleman who was being investigated for possible vasculitis by the rheumatology team in view of a history of Raynaud’s, 20-year history of recurrent leg ulcers and a previous pontine infarct. He presented acutely to the emergency department with numbness below the midthoracic level, weakness of his lower limbs and hands and urinary retention. His symptoms had progressed over a period of a few hours. On examination power was 4/5 on the MRC power scale for shoulder abduction and elbow flexion, 2/5 for elbow extension, 3/5 for wrist extension and 1/5 for finger extension. Power was 1/5 on his lower limbs. Sensation to pain was reduced with a T6 sensory level. Proprioception and vibration sense were intact. Upper limb reflexes were brisk. Knee jerks and left ankle jerk were difficult to elicit. Plantars were downgoing. Cranial nerves were normal. Results Bloods showed a white cell count of 6.7x109/l, haemoglobin of 96g/l (microcytic), platelets of 243x109/l, creatinine 119μmol/l (baseline 85μmol/l) and CRP of 42.9mg/l. Vitamin B12 was 200ng/l and folate levels were 2.2μg/L. ANA, ANCA, cryoglobulins and hepatitis serology were negative. MRI brain showed a 4mm area of hyper-density in the left pons. MRI whole spine was unremarkable. CSF showed normal protein, white cell count and glucose level. The patient was transferred to a tertiary neurology centre and a diagnosis of anterior spinal cord infarction was made. A nerve biopsy was performed which showed evidence of vasculitis and he was pulsed with methylprednisolone and commenced on high dose oral steroids. Genetic testing showed a pathogenic mutation in the adenosine deaminase 2 gene. He is currently awaiting to commence treatment with TNF inhibitors. Conclusion We conclude that DADA2 is an important differential in a young patient with suspected vasculitis especially in the presence of infarction. Identification of DADA2 allows initiation of treatment with TNF inhibitors which reduces the risk of additional strokes. Disclosure M. Xenophontos: None. J. Gan: None. A.C. Seneviratne: None.

Foville syndrome due to peripontine infarction: A case report

Introduction. Stroke is the most common cause of mortality and morbidity. Pontine infarction leads to an ischemic stroke in pontine. Variability of its clinical presentation depends on the location of infarct. One of them is Foville syndrome, which features contralateral motor hemiparesis or hemiplegia, ipsilateral cranial nerve palsy, and facial palsy. There were few cases reported especially in Indonesia. We report a case of an elderly female with Foville syndrome due to stroke in Peripontine caused by infarction. Case presentation. A 63-years-old female presented with acute vertigo, sudden deafness, slurred speech, and hemiparesis on the right side of her body. The onset was 14 hours before hospital admission. The patient had a history of poor controlled diabetes and hypertension. The results of the neurological examination showed left facial nerve weakness, facial numbness, peripheral deafness in the left ear, and right-side weakness of body. Radiological examination of the Head CT-scan showed lesions in the left paramedian pontine region, bilateral cerebellum and multiple lacunar infarction. Patient was given dual antiplatelet therapy, and vascular risk factor medication. Pasien was discharged after 8 days under treatment with minor disability. Conclusion. We report a rare case of Foville syndrome due to pontine infarction. Clinical signs and symptoms correlate well with anatomic involvement. The treatments depend on the etiologies and risk factors.

Morphological predictors of neurological deterioration in patients with acute isolated pontine infarct.

To investigate morphological predictors of neurological deterioration (ND) in patients with acute isolated pontine infarct. Acute isolated pontine infarct patients within 7days after onset of stroke symptoms were included retrospectively and classified into ND and non-ND groups. Morphological phenotypes (paramedian pontine infarct [PPI], atypical PPI, small deep infarct, and other types), topographical location, and lesion size were evaluated on axial diffusion-weighted imaging. There were 210 eligible patients, of whom 62 patients had ND (29.5%). The proportion of PPI was significantly higher in ND than that in non-ND (62.9% vs 39.6%). ND occurred more frequently in PPI patients than non-PPI patients (39.8% vs 20.5%). PPI located more frequently in lower pontine (20.4% vs 8.0%) and less in upper pontine (17.3% vs 30.4%, P = 0.028), and had larger ventro-dorsal length (13.8 ± 3.8 vs 9.9 ± 3.1) and width (8.3 ± 2.3 vs 6.2 ± 1.8) than non-PPI patients. The morphological phenotype of PPI was an independent risk factor for ND (OR 4.81, 95%CI 1.54-15.07, P = 0.007) in patients with isolated pontine infarct. The ventro-dorsal length of pontine infarct lesion was associated with ND (OR 1.18, 95%CI 1.01, 1.37, P = 0.034) in PPI patients. The morphological phenotype of PPI was a potential predictor for ND in patients with acute isolated pontine infarct. The ventro-dorsal length of pontine infarct lesion was possibly associated with ND in PPI patients.

Altered static and dynamic spontaneous neural activity in patients with ischemic pontine stroke.

The purpose of the study was to investigate the abnormality both of static spontaneous brain activity and dynamic temporal variances following a pontine infarction. Forty-six patients with chronic left pontine infarction (LPI), thirty-two patients with chronic right pontine infarction (RPI), and fifty healthy controls (HCs) were recruited for the study. The static amplitude of low-frequency fluctuations (sALFF), static regional homogeneity (sReHo), dynamic ALFF (dALFF), and dynamic ReHo (dReHo) were employed to detect the alterations in brain activity induced by an infarction. The Rey Auditory Verbal Learning Test and Flanker task were used to evaluate the verbal memory and visual attention function, respectively. Receiver operating characteristic curve analysis was used to reveal the potential capacity of these metrics to distinguish the patients from HCs. There were significant variations of these static and dynamic metrics in patients with chronic pontine infarction. The altered regions involved the supratentorial regions, including cortex and subcortical. Moreover, the altered metrics were significantly correlated with verbal memory and visual attention. In addition, these static and dynamic metrics also showed potential in distinguishing stroke patients with behavior deficits from HCs. The pontine infarction-induced cerebral activation changes are observed in both motor and cognitive systems, indicating the functional damage and reorganization across the global cerebral level in these patients with subtentorial infarction, and there is a reciprocal effect between motor and cognitive impairment and repair.

Basilar artery plaque distribution is associated with pontine infarction and vertebrobasilar artery geometry.

Basilar artery (BA) atherosclerosis is a common cause of posterior-circulation ischemic stroke. In this study, we investigate the relationship between BA plaque distribution and pontine infarction (PI), further, explore the influence of vertebrobasilar artery (VBA) geometries on BA plaque distribution. 303 patients were performed with MRI in this study, patients were divided into three groups: no cerebral infarction (NCI), anterior circulation cerebral infarction (ACCI), and posterior circulation cerebral infarction (PCCI), the VBA geometry was classified into four configurations: Walking, Tuning Fork, Lambda, and No Confluence. The AP-Mid-BA, Lateral-Mid-BA, and VA-BA angles were measured on three-dimensional time-of-flight magnetic resonance angiography. Patients underwent high-resolution magnetic resonance imaging to evaluate the BA plaque distribution (either anterior, posterior, or lateral wall). Acute and subacute cerebral infarction [including pontine infarction (PI)] were identified by T2 weighted imaging-fluid-attenuated inversion recovery and diffusion-weighted imaging. The presence of BA plaque (P < 0.001) were associated with PCCI. Eighty-six patients all with BA plaque were further analyzed, compared with patients without pontine infarction, patients with pontine infarction were more likely to have plaque distributed at the posterior wall (P = 0.009) and have larger VA-BA anger (38.72° ± 26.01° vs. 26.59° ± 17.33°, P = 0.035). BA plaques in patients with pontine infarction were more frequently located at the posterior wall (50.00%) than at the anterior (10.00%) and lateral (37.50%) walls (P = 0.028). In Walking, Lambda and No Confluence geometry, BA plaques were prone to located at the lateral wall than at the anterior and posterior walls (all P ≤ 0.05). In the Tuning Fork group, BA plaques were evenly distributed. BA plaque was related to PCCI, BA plaque distribution was associated with PI, and VBA configuration strongly influences BA plaque distribution.

Prevalence and predictive factors of progression in pure motor, ataxic hemiparesis and mixed sensorimotor lacunar syndrome

Objectives: To explore the prevalence and predictive factors of progressive lacunar stroke (PLS). Methods: Consecutive patients with acute lacunar stroke, who were admitted at King Chulalongkorn Memorial hospital during 1st July 2015-30th June 2018, were retrospectively recruited. The clinical lacunar stroke was defined as acute motor deficit lasting more than 24 hours and clinical syndrome compatible with pure motor hemiparesis, ataxic hemiparesis or sensorimotor stroke. The patients with cardioembolism or imaging shown cortical involvement was excluded. PLS was considered if there was an increase in NIHSS more than 2 points during admission. Patient characteristics, clinical data, imaging findings and medical treatment during admission was statistically analyzed. Functional outcome was assessed based on the modified Rankin Scale at discharge and 3 months. Results: Of 302 patients, 70 (23.2%) had PLS. Multivariate logistic regression analysis revealed that age at stroke onset more than 60 years (adjusted odd ratio [aOR], 2.17; 95% confidence interval [CI], 1.16-4.06, p=0.016), initial systolic blood pressure (SBP) more than 165 mmHg (aOR 2.40, 95%CI 1.25-4.61, p=0.008), white blood cell (WBC) more than 8500/ microliters (aOR 1.95, 95%CI 1.05-3.62, p=0.034), pontine infarction (aOR 1.99, 95%CI 1.07-3.71, p=0.031), branch atheromatous disease (BAD) (aOR 2.47, 95%CI 1.37-4.48, p=0.003), and significant vessels stenosis relevant to infarction (aOR 2.41, 95%CI 1.09-5.36, p=0.031) were independent predictors of PLS. Conclusion: Age more than 60 years, initial SBP more than 165mmHg, WBC more than 8500/microliters, pontine infarction, BAD and significant symptomatic artery stenosis are associated with PLS.

Abstract Number ‐ 118: Compressive Vertebrobasilar Dolichoectasia: A Rare Etiology of Acute Pontine Ischemic Stroke Undeterred by Anticoagulation

Introduction Dolichoectasia is a term used to describe dilated, elongated and tortuous arteries due to defects within the medial layer of their walls secondary to loss of elasticity. Multiple pathophysiological processes might lead to the development of dolichoectatic vessels, and activation of metalloproteinases and irregular turbulent blood flow seem to cause irreversible disruption of the internal elastic lamina. Consequences often include mass effects and ischemic and hemorrhagic stroke. Blood flow within dolichoectatic arteries is turbulent predisposing to thrombus formation with resultant ischemic strokes. Ideally, with optimal anticoagulation therapy, such strokes can be prevented. However, in rare instances, they can still occur despite anticoagulation, likely due to direct compression of pontine perforators from dolichoectasias or persistent turbulent flow. Methods Case report Results A 66‐year‐old woman with hypertension, diabetes mellitus, atrial fibrillation (taking warfarin at home), and left‐sided trigeminal neuralgia due to compressive left vertebrobasilar dolichoectasia with a focal fusiform aneurysm, presented with transient dysarthria and lightheadedness lasting for less than an hour. MRI brain did not show any acute pathology. CTA head showed worsening left vertebrobasilar dolichoectasia with transitional fusiform aneurysm (24 mm in diameter) with mass effect on the anterior part of the pons and lower midbrain. Next day, the patient developed dysarthria and right‐sided weakness, and a repeat MRI brain showed a left acute paramedian pontine infarct. Warfarin was discontinued, and the patient was started on a heparin drip and later transitioned to Apixaban. Eventually, a diagnostic cerebral angiogram and surpass stent placement within the aneurysm were attempted which went uneventful and the flow through the aneurysm regularized. The patient was eventually discharged home on Apixaban and Prasugrel with interval follow‐up. Conclusions Compression of perforating vessels supplying brainstem structures, branching off the pathologic vertebrobasilar dolichoectasia is a rare etiology of acute pontine ischemic stroke, not with standing the anticoagulation. It warrants immediate neurosurgical intervention to optimize blood flow and prevent a recurrence.