Posterior Inferior Cerebellar Artery Infarction Research Articles

End-to-end revascularization between the occipital Artery(OA) and the p1 segment of posterior inferior cerebellar Artery(PICA) for a patient with posterior circulation ischemia via a far-lateral approach:2-Dimensional Operative video

Vertebral artery （VA）Aneurysms involving the origin of the posterior inferior cerebellar artery (PICA) ,occasionally, induce cerebellum and brainstem infarction due to intraluminal thrombus and calcific VA stenosis. At times, vessel occlusion and revascularization is necessary for successful obliteration of these aneurysms.2 The occipital artery (OA) is often the preferred donor graft for lesions of the posterior fossa. Although most OA-PICA bypasses can be performed using the p3 segment as the recipient site for an end-to-side anastomosis, a more feasible alternative to conventional OA-p3 PICA bypass in cases of high-riding caudal loops , aberrant anatomy or p3 multiple perforators is to free the p1 PICA, transpose it away from the lower cranial nerves, and perform an end-to-end OA-p1 PICA bypass instead. This video captures the dissection of the OA using an orientational anterograde harvesting technique and the end-to-end anastomosis of the OA to the PICA at the p1 segment. This was performed in a 56-year-old man who presented with posterior circulation ischemia from a fusiform aneurysm with calcific vertebral artery stenosis located at the origin of the right PICA. The patient tolerated the procedure well and suffered no major complications related to the operation. He did experience some mild, posterior neck rigidity at the time of his 6-month follow-up, likely due to nerve injury that occurred while harvesting the OA. Overall, the patient remains in good neurologic status 1 year after the operation. The operation proved the feasibility of end-to-end bypass in OA-p1 PICA.

How Topographic Diffusion-Weighted Imaging Patterns can Predict thePotential Embolic Source.

To develop an imaging prediction model for patients with embolic stroke of undetermined source (ESUS), we investigated the association of topographic diffusion-weighted imaging (DWI) patterns with potential embolic sources (PES) identified by transesophageal echocardiography. From atotal of 992 consecutive patients with embolic stroke, 366 patients with the ESUS group were selected. ESUS was defined as no atrial fibrillation (Af) within 24h from admission and no PES after general examination. Clinical variables include age (> 80years, 70-80 years), sex, vascular risk factors and left atrial diameter > 4 cm. Age, sex and vascular risk factors adjusted odds ratio of each DWI for the different PESs were calculated. DWI was determined based on the arterial territories. Middle cerebral arteries were divided into 4segments, i.e., M1-M4. Moreover, M2segments were subdivided into superior and inferior branches. The 366 patients consisted of 168 with paroxysmal Af (pAf), 77with paradoxical embolism, 71with aortic embolism and 50with undetermined embolism after transesophageal echocardiography. The variables adjusted odds ratio (OR) of internal carotid artery (OR: 12.1, p = 0.037), M1(4.2, p = 0.001), inferior M2(7.5, p = 0.0041) and multiple cortical branches (12.6, p < 0.0001) were significantly higher in patients with pAf. Striatocapsular infarction (12.5, p < 0.0001) and posterior inferior cerebellar artery infarcts (3.6, p = 0.018) were significantly associated with paradoxical embolism. Clinical variables adjusted OR of multiple small scattered infarcts (8.3, p < 0.0001) were significantly higher in patients with aortic embolism. The associations of DWI with different PES have their distinctive characteristics and DWI along with clinical variables may help predict PES in patients with ESUS.

The effects of COVID-19 on the vestibular system.

The symptoms and severity of SARS-CoV-2 infection vary greatly across the spectrum, from asymptomatic infection to severe pneumonia with acute respiratory distress syndrome and even death. Dizziness is a frequently reported symptom of SARS-CoV-2 viral infection. However, the extent to which this symptom results from the effect of SARS-CoV-2 on the vestibular system remains unclear. In the present single-center, prospective cohort study, patients with a previous SARS-CoV-2 infection underwent a vestibular assessment consisting of the Dizziness Handicap Inventory to assess dizziness during and after infection, a clinical examination, the video head impulse test, and the subjective visual vertical test. When the subjective visual vertical test result was abnormal, vestibular-evoked myogenic potentials were performed. Vestibular testing results were compared to pre-existing normative data of healthy controls. In addition, we performed a retrospective data analysis of patients admitted to hospital presenting with acute symptoms of dizziness who were also diagnosed with acute SARS-CoV-2 infection. A total of 50 participants have been enrolled. During and after the SARS-CoV-2 infection, women were significantly more likely than men to suffer from dizziness. A significantly reduced semicircular canal or otolith function was not observed in either women or men. Acute SARS-CoV-2 infection was diagnosed in nine patients who presented to the emergency room with acute vestibular syndrome. Six of the patients exhibited acute unilateral peripheral vestibulopathy upon diagnosis. A different patient was diagnosed with vestibular migraine, and two individuals had a posterior inferior cerebellar artery infarct revealed by magnetic resonance imaging. Overall, a persisting structural affection of the vestibular system by SARS-CoV-2 seems to be unlikely and could not be confirmed by vHIT, SVV, and VEMPS in our study. It seems possible but unlikely that SARS-CoV-2 induces acute vestibulopathy. Nevertheless, dizziness is a common symptom in patients with COVID-19, which should be taken and worked through seriously.

The frequency and characteristics of saccadic dysmetria in isolated cerebellar infarction.

To investigate the frequency and pattern of horizontal saccadic dysmetria in unilateral cerebellar infarction and identify the responsible region for horizontal saccadic dysmetria. From the acute stroke registry of Keimyung University Dongsan Medical Center between July 2016 and October 2020, 43 patients with acute unilateral cerebellar infarction were enrolled. Eye movements were recorded during the acute period and the lesion was mapped using MRIcron software for subtraction analysis. Saccadic dysmetria was marked as hypometric when the gain is < 0.85 and hypermetric when > 1.0. Among the 43 participants, 30 patients (69.8%) demonstrated saccadic dysmetria. The age was significantly higher in patients with dysmetria (66.87 ± 12.82 vs. 53.54 ± 14.09, p = 0.004). Type of dysmetria showed a significant difference according to the vascular territory of the lesion. The posterior inferior cerebellar artery (PICA) infarction group presented ipsiversive saccadic dysmetria, while the superior cerebellar artery (SCA) group showed contraversive dysmetria (p < 0.001). In the SCA group, the culmen, fastigium, and dentate were the most frequently damaged regions, while the tonsil and inferior semilunar lobule were in the PICA group. Saccadic dysmetria was observed in a large proportion of cerebellar stroke patients, and the types of saccades were distinctive according to the vascular territory of the lesion.

PICA ischemic stroke

The posterior inferior cerebellar artery (PICA) has a unique anatomical complexity, which is of great clinical importance and is involved in many pathologies, such as aneurysm, ischemic stroke, neurovascular compression syndrome (NVCS), arteriovenous malformation (AVM) and brain tumour (1).&#x0D; PICA has a sinuous and variable trajectory, divided into 5 segments. PICA infarction usually manifests lateral bulbar syndrome and is more likely to cause mass effects. PICA frequently compresses the bulb and cranial nerves, resulting in various neurovascular compression syndromes (NVCS) (2).&#x0D; The ischemic stroke caused by thromboembolism in the PICA segment is accounted for more than 2% of all cases of ischemic stroke (3). Moreover, it tends to be underdiagnosed due to the symptomatology, represented usually by vertigo which mimics a possible peripheral vestibulopathy (4).

Posterior Inferior Cerebellar Artery Infarction, Surgical Intervention and Outcome

Posterior Inferior Cerebellar Artery Infarction, Surgical Intervention and Outcome

Sudden unilateral hearing loss and vertigo due to posterior inferior cerebellar artery territorial hypo perfusion by vertebral artery dissection

Sudden hearing loss and vertigo are the typical presentation of anterior inferior cerebellar artery infarction, but may occur in posterior inferior cerebellar artery (PICA) infarction. However, it is known that it is very rare that hearing loss and vertigo occur due to perfusion deficits without the occurrence of infarction. Here I describe a patient who presented with sudden hearing loss in left ear and vertigo due to PICA territorial hypo perfusion without infarction by vertebral artery (VA) dissection.

Osteogenesis Imperfecta With Cerebral Atherosclerosis: A Family Report

Background: Osteogenesis imperfecta (OI) is a rare hereditary connective tissue disease. It is mainly associated with pathogenic variants in COL1A1 or COL1A2. Patients with OI usually have repeated history of bone fractures. Besides, osteogenesis imperfecta is associated with some cardiovascular complications, such as aortic and mitral valve dysfunction, aneurysm and aortic dissection. But the relationship between these diseases has not been well studied. Case Presentation: A 55-year-old man was admitted to our hospital mainly due to “dizziness for 2 hours”. He had a 4-month history of hypertension and a history of smoking for more than 20 years. He had no history of drinking alcohol. He had hunchback and O-type legs. Besides, the patient and some of his relatives had a history of repeated brittle fractures,which was considered as “osteogenesis imperfecta”. The clinical manifestation of OI in this family varies to a certain extent, from simple tooth disintegration to severe fracture deformity. The most serious patient of his family was unable to walk. CT and MRI revealed multiple systemic arteriosclerosis, including vertebral artery, posterior inferior cerebellar artery, cervical artery, and bilateral cerebellar multiple lacunar cerebral infarction. The blood sample of the patient was tested by whole exome sequencing, and the saliva samples of the patient’s family members were tested by Sanger sequencing. A mutation c.3159 + 2T > A was detected in COL1A2 gene associated with OI, also found in the other affected family members, which had not been reported before. It was a segregating mutation in the family. The clinical severity of the family members was heterogeneous.Discussion: This case is worth learning from the following aspects: 1. A pathogenic heterozygous mutation, c.3159 + 2T > A was detected in COL1A2 gene in the patient with OI, which is not reported in previous cases of OI. 2. The clinical manifestation of OI in this family varies to a certain extent, from simple tooth disintegration to severe fracture deformity. The most serious patient of his family was unable to walk. It presented the clinical heterogeneity of OI. Further basic researh on the mutation site of related gene of OI are needed. 3. We found the possibility of developing cerebral atherosclerosis in patients with OI. Therefore, patients with OI should give up smooking, exercise properly and keep on a low fat diet. They should pay attention to control blood pressure and blood lipid so as to reduce the risk of atherosclerosis. Conclusion: A c.3159 + 2T>A mutation in COL1A2 gene detected by whole exome sequencing was the causing reason of OI, the discovery enriched the gene mutation spectrum of OI. We also found that OI may have relationship with premature atherosclerosis, and the abnormal bones of the cervical spine may lead to vertebrobasilar ischemia.

Clinical Implication of Corrective Saccades in the Video Head Impulse Test for the Diagnosis of Posterior Inferior Cerebellar Artery Infarction.

Objective: In the present study, we characterized the vestibulo-ocular reflex (VOR) gain and properties of corrective saccades (CS) in patients with posterior inferior cerebellar artery (PICA) stroke and determined the best parameter to differentiate PICA stroke from benign peripheral vestibular neuritis (VN). In particular, we studied CS amplitude and asymmetry in video head impulse tests (vHITs) to discriminate these two less-studied disease conditions.Methods: The vHITs were performed within 1 week from symptom onset in patients with PICA stroke (n = 17), patients with VN (n = 17), and healthy subjects (HS, n = 17).Results: PICA stroke patients had bilaterally reduced VOR gains in the horizontal semicircular canal (HC) and the posterior semicircular canal (PC) compared with HSs. When compared with VN patients, PICA stroke patients showed preserved gains in the HC and anterior semicircular canal (AC) bilaterally (i.e., symmetric VOR gain). Similar to VOR gain, smaller but bilaterally symmetric CS in the HC and AC were observed in PICA stroke patients compared with VN patients; the mean amplitude of CS for the ipsilesional HC was reduced (p < 0.001, Mann–Whitney U-test), but the mean amplitude of CS for the contralesional HC was increased (p < 0.03, Mann–Whitney U-test) in PICA stroke compared with VN. The receiver operating characteristic (ROC) curve showed that CS amplitude asymmetry (CSs) and VOR gain asymmetry (Gs) of HC are excellent parameters to distinguish PICA stroke from VN.Conclusion: In the current study, we quantitatively investigated the VOR gain and CS using vHITs for three semicircular canals in PICA stroke and VN patients. In addition to VOR gain, quantitative assessments of CS using vHITs can provide sensitive and objective parameters to distinguish between peripheral and central vestibulopathies.

Clinical Importance of the Posterior Inferior Cerebellar Artery: A Review of the Literature.

The posterior inferior cerebellar artery (PICA), with its unique anatomical complexity, is of great clinical importance and involved in many diseases including aneurysm, ischemic stroke, neurovascular compression syndrome (NVCS), arteriovenous malformation (AVM), and brain tumor. However, a comprehensive systematic review of the importance of the PICA is currently lacking. In this study, we perform a literature review of PICA by searching all the associated papers in the PUBMED database hoping to provide a better understanding of the artery. The PICA has tortuous and variable course and territory, divided into 5 segments. Various aneurysms involving PICA were not uncommon, of which the treatment is challenging. The PICA infarct typically manifests lateral medullary syndrome (LMS) and is more likely to cause mass effects. The PICA frequently compresses the medulla and the cranial nerves resulting in various neurovascular compression syndromes (NVCS). Arteriovenous malformation (AVM) fed by PICA are associated with aneurysm and dissection which have high risk of rupture and worse outcome. PICA injured by head trauma can cause fatal SAH. VA terminating in PICA probably cause Bow hunter's syndrome (BHS). The PICA supplies many brain tumors and can be used in intracerebellar chemotherapy. The PICA can be exposed and injured during surgeries especially in telovelar approach, and it also plays an important role in bypass surgeries, hinting the surgical importance of PICA. In conclusion, PICA is very important in clinical practice.

Measurement of horizontal ocular deviation on magnetic resonance imaging in various disease with acute vertigo.

In our previous study, we found that horizontal ocular deviation (OD) was significantly increased in patients with unilateral vestibular neuritis (VN). This study is aimed to compare the measurements of horizontal OD in various diseases which can present as acute vertigo in the emergency department. We retrospectively reviewed patients who visited the emergency department and underwent brain MRI due to acute vertigo. We compared them to healthy controls who underwent brain MRI for a regular health examination. Among the study participants, 149 patients who were diagnosed with benign paroxysmal positional vertigo (BPPV), unilateral Ménière's disease (MD), vestibular migraine (VM), unilateral vestibular neuritis (VN), or posterior inferior cerebellar artery (PICA) infarction were enrolled. Absolute angles of horizontal OD were larger in the definite MD (19.1 ± 12.7°), possible and probable MD (15.5 ± 11.7°), and VN (22.2 ± 11.7°) groups compared to the control group (4.3 ± 3.7°). Most VN patients (83.3%) had horizontal OD toward the direction of the lesion. About half of the MD patients (46.2%) and half of the patients with PICA infarction (50.0%) had horizontal OD toward the opposite direction of the lesion. Regarding PICA infarction, horizontal OD was observed only in patients who immediately underwent an MRI after developing the PICA territory vestibulocerebellar infarction. Although the exact mechanism of horizontal OD is unclear, this study suggests that horizontal OD reflects a static vestibular imbalance, and that the eyeball is deviated to the weaker of the two vestibular nuclei during neural resting activity. Therefore, horizontal OD could be helpful in assessing for a prior vestibular imbalance.

Authors' Reply to Letter to the Editor: A Case of Posterior Inferior Cerebellar Artery Infarction after Cervical Chiropractic Manipulation (Korean J Neurotrauma 2018;14:159-163).

Authors' Reply to Letter to the Editor: A Case of Posterior Inferior Cerebellar Artery Infarction after Cervical Chiropractic Manipulation (Korean J Neurotrauma 2018;14:159-163).

Letter to the Editor: A Case of Posterior Inferior Cerebellar Artery Infarction after Cervical Chiropractic Manipulation (Korean J Neurotrauma 2018;14:159–163)

Letter to the Editor: A Case of Posterior Inferior Cerebellar Artery Infarction after Cervical Chiropractic Manipulation (<i>Korean J Neurotrauma</i> 2018;14:159–163)

Transposition of posterior inferior cerebellar artery could have caused ischemic complication in microvascular decompression for hemifacial spasm

Abstract Ischemic complications are generally rare complications in microvascular decompression surgery for hemifacial spasm. We report a case of posterior inferior cerebellar artery (PICA) infarction post-microvascular decompression. A 68-year old woman with a 2-year history of right hemifacial spasm underwent microvascular decompression surgery. Preoperative magnetic resonance image (MRI) showed that her PICA ran through closely to the root exit zone of her facial nerve. We treated the PICA with a string of polytetra fluoroethylene. After surgery, the patient complained about vertigo, and her MRI revealed ischemic changes in the medulla. She was eventually discharged without any neurological deficit. We reviewed our intraoperative video and found that certain steps in the detachment of the vessel, and minor changes in vessel position could have induced vascular obstruction and ischemia. Herein, we also discuss the choice of decompression methods and emphasize that the transposition of vessels was too invasive in this case. An appropriate method of decompression should carefully be performed in such cases, and review of surgical videos is beneficial.

Hearing loss in lateral medullary syndrome

AbstractWe report a case of lateral medullary syndrome with hemiparesis and hearing loss. A 69‐year‐old man was diagnosed with right‐sided lateral medullary syndrome and cerebellar vermis infarction with ipsilateral hemiparesis as a result of an upper cervical lesion. On the seventh hospital day, ipsilateral hearing loss suddenly emerged. The results of auditory and vestibular tests, including auditory brainstem responses, suggested a possible lesion in the vestibulocochlear nerve. Hearing loss could be attributed to a non‐anterior inferior cerebellar artery, vertebral artery and/or posterior inferior cerebellar artery infarction. The possibility of comorbidity of hearing loss with lateral medullary syndrome in this case suggests the possible usefulness of further intensive antithrombotic therapy in cases of lateral medullary syndrome with uncommon presentations.

Isolated Posteroinferior Cerebellar Artery Dissection Diagnosed by High-Resolution Vessel Wall MRI

Arterial dissection is an important cause of stroke. We report two cases of isolated posterior inferior cerebellar artery (PICA) dissection diagnosed by high-resolution vessel-wall MRI (HRVW-MRI). One subject complained of abrupt-onset vertigo and headache, and the other subject had headache, vertigo, and Horner syndrome. Conventional MRA showed only focal dilatation of the PICA, but HRVW-MRI revealed intramural hematoma and double-lumen contour in the PICA, suggesting arterial dissection. We suggest that the use of HRVW-MRI should be considered when diagnosing isolated PICA dissection in a PICA infarct with an unknown cause. Key Words: Isolated PICA dissection, High-resolution vessel-wall MRI, Arterial dissection

A Case of Bilateral Medial Posterior Inferior Cerebellar Artery Infarction Associated with Subclavian Steal Syndrome

Subclavian Steal Syndrome (SSS) is the result of reversed ipsilateral vertebral arterial blood flow caused by proximal subclvian artery steno-occlusive disease. A 78-year-old man with a history of hypertension and smoking presented with sudden dizziness, nausea and vomiting; there was no history of recent trauma and arm claudication. Neurologic examination showed no abnormality except for ataxia of both arms. Diffusion Weighted Image (DWI) indicated acute bilateral medial Posterior Inferior Cerebellar Artery (PICA) infarction. Subsequent brain Magnetic Resonance Angiography (MRA) revealed chronic occlusion at the left proximal subclavian artery with decreased left vertebral artery flow and prominent left (PICA) from vertebral artery. Transcranial Doppler (TCD) ultrasonography showed reversal of flow within the left vertebral artery, and reactive hyperemic cuff test of the left arm showed aggravated reverse flow of left vertebral artery following release of blood pressure cuff inflation, which was suggestive of SSS. Although the etiologies of bilateral PICA infarction might be diverse, we experienced a case of acute bilateral medial PICA infarction, which were presumed as hemodynamic insufficiency due to SSS.

Atypical Presentation of a Posterior Inferior Cerebellar Artery Stroke Found by Magnetic Resonance Imaging, on a Woman without Prior Known Comorbid on Implantable Contraception: A Case Report

On average, every 40 seconds, someone in the United States has a stroke. Women have a higher lifetime risk of stroke, with 1 in 5 chances during age 55-75; but they have a lower age-adjusted incidence below this age range. Migraines and hormone-releasing contraception are two relevant risk factors that contribute to the development of a stroke in women. We present a case of a 37-year-old Hispanic woman with an implantable hormonal device (Implanon®) that developed a posterior inferior cerebellar artery infarct (PICA), and during evaluation a history of intermittent migraines was noted, which was not previously diagnosed or treated by a medical provider. Clinically, the patient presented with acute vertigo, severe headache and associated neck pain, nausea, vomiting and gait instability. Brain Magnetic Resonance Imaging (MRI) revealed an acute infarct involving the right PICA territory and neck MR angiography demonstrated absent visualization of the posterior inferior cerebellar arteries bilaterally. Historically hormonal contraception has been linked to increase risk of thromboembolic events, in particular when it was associated with high doses of estrogen. The newer hormonal contraception, which now has lower estradiol levels still, has a trend to increase risk of thromboembolic events, although the results from various studies are not that clear. This rationale makes it seem plausible that the answer relies on progestin’s hemostasis effect. The combination of migraines and hormone-releasing contraception in woman <45 years of age, are not well described. We conclude that, although the hormonal implantable device and migraines individually increases the risk for cardiovascular events, their combined risk may be additive and should be considered in the appropriate clinical setting.

A Case of Sudden Hearing Loss due to Posterior Inferior Cerebellar Artery Infarction

A Case of Sudden Hearing Loss due to Posterior Inferior Cerebellar Artery Infarction

Study on the correlation of vertebral artery dominance, basilar artery curvature and posterior circulation infarction.

Vertebral artery dominance (VAD), which is a common congenital variation of vertebral artery, may be associated with an increased risk of cerebral posterior circulation infarction (PCI). The aims of this study were to investigate the correlation of VAD with incidence and laterality of PCI, and oblige the correlation of VAD and basilar artery (BA) curvature. Incidence of separate territory infarction in posterior circulation and incidence of BA curvature were compared between 78 VAD patients and 68 controls. VA dominance, laterality of BA curvature and separate territory infarction, and their directional relationships were observed in VAD group. The incidence of BA curvature in VAD group was significantly higher than that in controls (P=0.000). 89.7% (35/39) of patients had an opposite directional relationship between dominant VA and BA curvature. The total incidence of PCI in VAD group was significantly higher than that in controls (P=0.001). The incidences of posterior inferior cerebellar artery (PICA) and BA territory infarction were both significantly higher than those in controls [11.5% (9/78) vs. 1.5% (1/68), P=0.016; 20.5% (16/78) vs. 7.4% (5/68), P=0.024]. No differences were found in superior cerebellar artery and posterior cerebral artery territory infarction between two groups. 77.8% (7/9) of PICA infarction were on the opposite side of dominant VA. 75.0% (12/16) of BA infarction were on the side of dominant VA. The incidence of PCI in BA curvature patients was significantly higher than that in BA straight patients. The incidence of BA curvature is higher in VAD patients, and BA usually bends to the opposite side of dominant VA. The incidence of PCI is higher in VAD patients, especially in PICA infarction and BA infarction patients.