Pure Motor Hemiparesis Research Articles

A Drive Interrupted: Stroke of the Anterior Choroidal Artery – A Case Report

The anterior choroidal artery (AChA) is the most distal branch of the internal carotid artery (ICA) The ACHA is significant because it supplies important structures in the brain, including the optic tract, anterior portion of cerebral peduncle, lateral geniculate body, uncus, globus pallidus, posterior and superficial areas of the thalamus, and the retrolenticular and posterior portions of the internal capsule on the same side as the artery. Isolated strokes involving the AChA are rare and can result in HHH Syndrome, consisting of contralateral hemiplegia, hemisensory loss, and homonymous hemianopia. Features which distinguish an AChA infarction from larger arterial pathology are lack of headache and lack of depressed level of consciousness in subacute infarction, and usually lack of aphasia acutely. The etiology remains controversial, with proposed mechanisms including cardioembolic, large-vessel atherosclerosis, dissection of the ICA, small-vessel occlusion, and cryptogenic causes. Herein, the authors report a case of an isolated AChA infarction resulting in a right-sided, pure motor hemiparesis with no sensory or vision loss, highly suggestive of cardioembolic origin, with the evaluation of the patient, and eventual treatment strategy.

Clinico-Radiological Profile and Outcome of Isolated Paramedian Hemipontine Infarcts

Objective: To study the clinico- radiological profile and outcome of isolated paramedian hemipontine infarcts. Materials and Methods: This is a prospective cross- sectional study. 50 consecutive patients admitted between January 2019 and December 2020 with a diagnosis of isolated paramedian hemipontine stroke were included. The locations of the infarcts were classified as follows- caudal; middle; rostral; dorsomedian; caudal and middle; and middle and rostral pons. The clinico- radiological profiles were studied and the outcomes were assessed using NIHSS (National Institutes of Health Stroke Scale) and mRS (modified Rankin score). Data was analysed using SPSS 22 version software. Paired t-test was used as a test of significance to identify the mean differences between the two quantitative variables. Results: Majority of the subjects were 51- 60 years (34%). The most common risk factors were hypertension and type 2 diabetes mellitus. The most common clinical features were hemiparesis and speech disturbances. Pure motor hemiparesis (PMH) is the common syndrome seen in paramedian hemipontine strokes with infarcts located in caudal; middle; caudal and middle; and middle and rostral pons. In ataxic hemiparesis, infarcts were located in dorsomedian pons. In dysarthria clumsy hand syndrome, infarcts were located at rostral pons. 44% of the subjects had left vertebral artery abnormality. There was a statistically significant difference in the mean NIHSS and mRS when compared at admission/ discharge and at 3 months. Conclusion: Isolated paramedian hemipontine stroke syndromes have good topographical correlation with patients usually having a good functional outcome at the end of three months.

Abstract WP238: Efficacy of Dual Antiplatelet Therapy After Lacunar versus Non-Lacunar Syndromes in the POINT Trial

Introduction: About 20% of ischemic strokes are lacunar infarcts, the pathophysiology of which differs from that of other stroke etiological subtypes. The POINT trial demonstrated the efficacy of dual antiplatelet therapy (DAPT) for secondary stroke prevention in patients with minor ischemic stroke and high-risk TIA, but it remains unknown whether this benefit differed in lacunar versus non-lacunar strokes. Method: In a secondary analysis of POINT trial data, we compared the efficacy of DAPT in patients with an index lacunar syndrome versus not. A lacunar syndrome was defined based on common classic lacunar syndromes (e.g., pure motor hemiparesis, clumsy-hand dysarthria) and ascertained using subcomponents of the National Institutes of Health Stroke Scale documented at baseline. Our primary efficacy outcome was ischemic stroke and the safety outcome was intracranial hemorrhage. We used survival analysis and tests of interaction to compare the effect of DAPT between the lacunar and non-lacunar subgroups. Result: Among 4,881 patients enrolled in the study, 1,083 (22.1%) were classified as having an index lacunar syndrome. The effect of DAPT on the risk of ischemic stroke did not vary significantly after a lacunar syndrome (HR, 0.76; 95% CI, 0.52-1.09) versus after a non-lacunar syndrome (HR, 0.69; 95% CI, 0.50-0.95) (P value for interaction, 0.70). Similarly, the effect of DAPT on the risk of intracranial hemorrhage did not vary significantly after a lacunar syndrome (HR, 2.82; 95% CI, 0.29-27.1) versus after a non-lacunar syndrome (HR, 2.10; 95% CI, 0.63-6.99) (P for interaction, 0.82). Conclusion: In a post hoc secondary analysis of the POINT trial, we found no evidence of a lesser benefit of DAPT after a minor ischemic stroke or TIA in patients presenting with a lacunar syndrome compared to other stroke subtypes.

CLINICAL CHARACTERISTICS OF LACUNAR ISCHEMIC STROKE PATIENTS

Background: Stroke is the leading causes of death and disability in the world. Ischemic stroke covered 85% of stroke types. Based on the subtypes of ischemic stroke, lacunar ischemic stroke encompassed 20% of them. Knowing the characteristics help physicians to diagnose patients clinically and offer management to treat risk factors. Objective: This study aimed to know the characteristics of lacunar ischemic stroke based on patients risk factors, ischemic location on CT-scan, clinical syndrome, and NIHSS score. Methods: Using retrospective analytical study with cross sectional approach, medical record data from 2019-2022 were collected from RSUP DR. Hasan Sadikin Bandung. Results: From 60 patients, 35% (21) are 55-64 years old. Both sexes are equally distributed. 50 patients (83.3%) have multiple risk factors. Out of 60 patients, 57 (95%) have hypertension, 8 (13.3%) have diabetes mellitus, 44 (73.3%) have dyslipidemia, 6 (10%) have hyperuricemia, and 14 (23.3%) smoke. On admission, out of 60 patients, 34 (56.7%) have mild stroke, 23 (38.3%) have moderate stroke, 2 (3.3%) have moderate to severe stroke, and 1 (1.7%) has severe stroke. 44 (73.3%) out of 60 patients have pure motor hemiparesis. 41 (68.3%) out of 60 patients have basal ganglia ischemic. Conclusion: Lacunar ischemic stroke patients were equally distributed in sex with peak incidence occur between 55-64 years old. Most patients have multiple risk factors, basal ganglia lesion, pure motor hemiparesis, and history of hypertension, dyslipidemia, and smoking. On admission, most patients have mild stroke, followed by moderate stroke.

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 WP198: Microatherosclerosis Is A Common But Often Overlooked Cause Of Ischemic Stroke

Background: Clinicians frequently ascribe lacunar strokes to lipohyalinosis/arteriosclerosis, but classic neurovascular pathology studies lacunar infarcts are more often due to “microatherosclerosis” (small atheromatous plaque within penetrating arteries). The proportion of lacunar infarcts in clinical practice due to microatherosclerosis has not been previously quantified. Methods: The findings in all reported neuropathologic studies were catalogued for the 4 lacunar syndromes of pure motor hemiparesis (PMH), pure sensory stroke (PSS), dysarthria-clumsy hand (DCH), and ataxic hemiparesis (AH). Systematic meta-analyses, per PRISMA guidelines, were performed of large clinical series of consecutive ischemic stroke patients to delineate: 1) the proportion of all ischemic strokes due to lacunar infarcts, and 2) among the lacunar events, the relative frequencies of PMH, PSS, DCH, and AH. Results: Neuropathology showed: PMH caused by microatherosclerosis in 64%, parent artery ostial atherosclerosis in 7%, lipohyalinosis in 14%, and embolism in 14%; PSS caused by lipohyalinosis in 100%; DCH caused by embolism in 100%; and AH caused by microatherosclerosis in 100%. In the systematic review, among 22 large ischemic stroke series enrolling 25,260 patients, frequency of lacunar infarct was 18.8% (±5.1%). Among 5 large series enrolling 838 lacunar infarct patients, subtype frequencies were: PMH 45.5%, PSS 17.7%, DCH 7.4%, and AH 2.9% (with the remainder sensorimotor stroke and less common lacunar syndromes). Quantitative synthesis indicated that, among lacunar strokes, microatherosclerosis is the most common cause (44%), followed by lipohyalinosis (33%), and parent artery athero or embolism (combined 23%). Among all ischemic strokes, microatherosclerosis is the cause in 6%. Conclusion: Microatherosclerotic plaque within a penetrating artery is a common cause of cerebral ischemia, accounting for 6% of all ischemic strokes. This substantial burden of microatherosclerosis is the likely pathophysiologic basis for the benefits of thrombolytic and statin therapy in lacunar ischemic stroke.

Investigation of inpatient convalescent rehabilitation outcomes in branch atheromatous disease

PurposeWe investigated inpatient convalescent rehabilitation outcomes of Branch atheromatous disease (BAD). Subjects and methodsThe subjects were 116 patients with lenticulostriate artery territory - BAD (LSA-BAD) and 29 with paramedian pontine artery territory - BAD (PPA-BAD). For all patients, the National Institutes of Health Stroke Scale (NIHSS), Functional Independence Measure (FIM) scores, and Brunnstrom recovery stages (BRS) of the upper limb, fingers, and lower limb were measured on admission and at discharge. ResultsThere were no significant differences in clinical characteristics on admission between the LSA-BAD and PPA-BAD groups. The neurological severity of PPA-BAD, as measured by the NIHSS, was significantly milder compared with that of LSA-BAD upon admission (p = 0.015) and at discharge (p = 0.001). Patients with LSA-BAD had significantly less improvement in the BRS of the upper limb (p = 0.001), fingers (p < 0.001), and lower limb (p = 0.007) at discharge. Furthermore, they had significantly smaller changes in BRS between admission and discharge for the upper limb (p = 0.033) and fingers (p = 0.014) compared with patients with PPA-BAD. The improvement in BRS for patients with LSA-BAD tended to be limited to two stages; however, both patients with LSA-BAD and PPA-BAD saw sufficient gains in FIM at discharge. ConclusionRehabilitation outcomes following BAD in the convalescent period should be assessed in terms of improvements in pure-motor hemiparesis and activities of daily living. Furthermore, the disturbance patterns in the corticospinal tract by ischemic stroke lesions may be different between LSA-BAD and PPA-BAD.

Effects of Bobath and Neurodevelopmental Treatment in A 3.5 Years Old Child with Lacunar Pure Motor Stroke Following Ventricular Septal Defect Repair

Lacunar pure motor stroke happens when an artery leading to the deep section of the brain, which contains the organs like the thalamus or basal ganglia is obstructed. Small and occurring outside of the cortex, lacunar strokes are a subtype of ischemic stroke. Lacunar strokes mostly affect patient’s memory, judgmental skills and language. On the basis of symptoms, lacunar stroke is categorized as pure motor hemiparesis (45% cases), pure sensory stroke (7% cases) and ataxic hemiparesis (17-18% cases). We reported a case of 3.5 years old male patient with pure motor lacunar stroke following ventricular septal defect repair who was effectively treated with bobath therapy and neurodevelopmental therapy as bobath is a generally accepted theory in the rehabilitation of hemiparetic stroke victims worldwide. On examination, the patient had a total pure motor based right sided hemiparesis. The lower extremity movements were more compromised than upper extremity, strength of mainly antigravity or postural muscles was compromised and lower extremity muscles were scoring 1/5 on Manual Muscle Testing (MMT) and scored 1 on Modified Ashworth Scale (MAS). As such there was no spasticity factor in the upper or lower limb muscles but there was weakness (right sided hemiparesis), so the treatment plan was given and thoroughly explained to the patient’s caretaker. There was no major cognitive and sensory deficit, as lacunar stroke has a better prognosis than other types of stroke, so, the recovery was good within 3 to 4 months by NDT and bobath therapy. Bobath therapy mainly improves the motor function with postural balance and stability.

Magnetic Resonance Imaging (MRI) findings in patients with brain small vessel disease

Background: Cerebral small vessel disease (SVD) affects small perforating arteries, causing both lacunar infarction (LI) and confluent white matter lesions (WML). Small vessel disease or lacunar infarct is one of the major stroke subgroups. Lacunar syndromes may be divided into two groups: the classic group (pure motor hemiplegia, pure sensory stroke, ataxic hemiparesis, dysarthria-clumsy hand syndrome, sensorimotor stroke) and the miscellaneous group, including all other lacunar syndromes. We have evaluated risk factors, clinical syndromes, topography, and laboratory findings of 101 consecutive patients with symptomatic lacunar infarcts diagnosed by magnetic resonance imaging.Methods: We analyzed 101 patients with clinical lacunar infarct syndrome who were referred to the neurology department of Qa’em hospital, Mashhad in the northeast of Iran. We assessed clinical features, sex, age, risk factors, radiologic findings and laboratory data of these patients.Results: The pure motor hemiparesis (53.5%) constituted the most usual lacunar syndrome. Mean age of the patients was 63.7± 8.5%. Diabetes mellitus was seen in 14 (13.9%) and hypercholesterolemia in 41 (40.6%) of patients. There were significant differences among ataxic-hemiparesis syndrome and hypertriglyceridemia and CVA history. There was a significant difference between miscellaneous syndromes and valve disease history. Also, there was significant correlation between WML and smoking. Thirty percent of the lesions were detected by CT scan.Conclusion: Sixty percent of the cases were associated with white matter signal changes. Diabetes mellitus were found in 14% of patients. Hypertriglyceridemia, CVA history and valve disease history were associated with some subgroups, but more investigations should be performed for precise assessment of other risk factors.

Putting pontine anatomy into clinical practice: the 16 syndrome

The anatomical localisation of brainstem syndromes is the domain of the clinical neurologist, though MRI has made an encyclopaedic knowledge of neuroanatomy less crucial. Isolated pontine syndromes comprise ∼20% of...

Clinical study on Yihong Kangnaoshuan capsule in treating lacunar infarction pure motor hemiparesis

With the treatment of lacunar cerebral infarction with pure motor hemiparesis (PMH) attach importance to the treatment effect, application benefit of Yihong Kangnaoshuan capsule in the treatment of further effect. Treatment of PMH is mainly depending on the thorough discussion on the cause, to determine the clinical value of treatment based on the principle of. Through the research of Zhejiang People's Hospital of Fenghua from 2013 March to 2014 September 178 cases of pure motor hemiparesis were the benefit of Yihong Kangnaoshuan capsule and vedrin capsule treatment, compared the indexes of efficacy after treatment and blood rheology. Finally found the benefits of Yihong Kangnaoshuan capsule in the application process with high safety, efficacy and greater proportion. And in favor of blood lipid and blood rheology indicators of stability, the repair of neurological function is more. Therefore, clinicians should be applied benefit of red brain thrombus capsule in the treatment of PMH. But the overall difference between drugs is need to further comparison, in order to ensure clinical curative effect.

Chronic kidney disease and cerebral small vessel disease: a casual or causal cerebrorenal relationship?

Abstract is not required for Editorialis not required for Editorial (This page in not part of the published article.) International Journal of Case Reports and Images, Vol. 6 No. 8, August 2015. ISSN – [0976-3198] Int J Case Rep Images 2015;6(8):526–529. www.ijcasereportsandimages.com Rivera-Zambrano et al. 526 CASE REPORT OPEN ACCESS Chronic kidney disease and cerebral small vessel disease: A casual or causal cerebrorenal relationship? Marx Rivera-Zambrano, Adria Arboix, Maria-Jose Sanchez Recent studies show that individuals with progressive chronic kidney disease have a greater risk of cardiovascular events, hospitalization and death [1]. Chronic kidney disease (CKD) is prevalent in acute stroke patients with rates varying from 20–35% in ischemic stroke and from 20–46% in intracerebral hemorrhage [2, 3]. Previously, a higher four to ten times, prevalence of stroke in dialysis patients have been reported [3]. It can therefore be concluded that CKD is an established and emergent risk factor for cardiovascular disease in general and for cerebrovascular disease in particular. Chronic kidney disease is defined either by a decrease in the estimated glomerular filtration rate (eGFR) below 60 ml/min/1.73 m2 or by the presence of albuminuria as a marker of an increased glomerular permeability [4]. It represents also a poor prognosis factor in patients with acute stroke and its presence has been associated with stroke severity and poor outcomes in ischemic and hemorrhagic stroke. A study reported that patients with CKD had a 49% greater risk of neurological deterioration during hospital stay and in-hospital mortality, and higher degree of disability at discharge according to the modified Rankin scale score of 2 or more than patients without CKD [5]. Greater risk of recurrence of non-cardioembolic stroke in CKD patients has also been reported [3]. This Marx Rivera-Zambrano1, Adria Arboix2, Maria-JoseSanchez3 Affiliations: 1Internal Medicine Department, Hospital Universitari Sagrat Cor. Hospital Universitari Sagrat Cor, University of Barcelona, Barcelona, Catalonia, Spain; 2Cerebrovascular Division, Neurology Department, Hospital Universitari Sagrat Cor, University of Barcelona, Barcelona, Catalonia, Spain; 3Library Department. Hospital UniversitariSagratCor, University of Barcelona, Barcelona, Catalonia, Spain. Corresponding Author: Adria Arboix, Barcelona, Catalonia, Spain, 08029; Tel.: 34 934948940; Fax: 34 934948906; Email: aarboix@hscor.com, Received: 03 June 2015 Published: 01 August 2015 EdiTO iAlS OPEN A CE S worse neurological prognosis may be caused by the presence in these patients of proteinuria and albuminuria, and both conditions are significantly associated with high levels of inflammatory cytokines and oxidative stress, inflammation and conditions promoting coagulation, potentially causing excessive vascular damage at stroke onset. These factors are also associated with accelerated atherosclerosis and endothelial dysfunction. Albuminuria is also predictive of hemorrhagic transformation of stroke [2]. We must also point out that CKD patients have both high thromboembolic and high bleeding risks and this has implications for deciding the optimal therapeutic strategy for primary or secondary prevention in these clinical conditions. Thus, non-vitamin K antagonist oral anticoagulants (novel oral anticoagulants) seem to be safer and more effective for patients with nonvalvular atrial fibrillation than warfarin, but cannot be given to patients with advanced CKD because the activity of these drugs is greatly affected by renal function [2, 6]. Intravenous thrombolysis is not contraindicated for patients with CKD but experts have limited experience with this treatment in these patients [6]. It is worth mentioning that kidney impairment is strongly associated with cerebral small vessel diseases (SVDs), which occur as asymptomatic lacunar infarcts (Figure 1) often resulting in classical lacunar syndromes (pure motor hemiparesis, pure sensory syndrome, sensorimotor stroke, ataxic hemiparesis or dysarthriaclumsy hand) or, less frequently, in atypical lacunar syndromes [7,8]. They also result in leukoaraiosis or white matter hyperintensities, silent lacunes, prominent or enlarged perivascular spaces and cerebral microbleeds [9]. One study reported that the volume of white matter lesions increased when eGFR decreased [10], and another showed that proteinuria had strong relation with both the presence and number of microbleeds [11]. This special relationship between CKD and cerebral SVDs is still unclear and warrant further investigation but is probably due to the fact that the vasoregulation of the microvasculature of the two organs (kidney and

Apical Left Ventricular Akinesis in Middle-Aged Endurance Athlete: A Clinical Dilemma

The author reports on the history of a middle-aged male athlete who had sudden acute left pure motor hemiparesis due to a ischemic stroke 7 days after prolonged and strenuous exercise with severe physical fatigue. No chest pain or fever had been reported at that time, only a general feeling of weakness. In hospital all the examinations carried out led to the exclusion of paradoxical embolism via Patent Foramen Ovale. No other investigation was carried out and no anomalies were detected, therefore the patient was discharged with a diagnosis of cryptogenic stroke and neurologic follow up. Two years later the athlete underwent further investigations such as echocardiographic examination which showed a clear left ventricular apical akinesis. On suspicion, therefore, of coronary artery disease a coronary angiography was performed for suspected critical narrowing of the left coronary descending artery branch. However, the coronary angiogram showed patent coronary artery. Assuming that the left ventricular apical akinesia was probably the genesis of ischemic stroke for the formation ofapical thrombus that has migrated into the cerebral circulation occluding the anterior cerebral artery, other examinationswere performed to visualize the cardiovascular findings of the damaged left ventricle apical A cardiac CMR showed a akinetic and thinned left ventricular apex. The LGE showed an aspect of LV apical transmural fibrosis most probably to be attributed to an inflammatory event, that is, to an extended myocarditis, even if the morphological and functional pattern of CMR appears suggestive for an ischemic event. A contemporary coronary computed tomography showed patent coronary arteries as well as profound myocardial bridging at the middle segment of the anterior interventricular artery. The dilemma is thus: the athlete had had extensive myocarditis that had affected the function of the LV apex or he had had a heart attack caused by underlying but hemodynamically significant myocardial bridge?

The Mechanism of Ipsilateral Ataxia in Lacunar Hemiparesis: SPECT Perfusion Imaging

Background and Purpose: Although ataxic hemiparesis is a common lacunar syndrome, the precise mechanism underlying hemiataxia is not clear. We attempted to identify ataxia-related, cerebral blood flow changes in patients presenting with ataxic hemiparesis after acute capsular infarct. Methods: We used 99mTc-ECD brain perfusion single-photon emission computed tomography to evaluate regional cerebral blood flow in 12 patients with ataxic hemiparesis caused by capsular infarct, and we compared the regional blood flow of these patients with that of 11 patients with pure motor hemiparesis caused by similar lesions. Results: The ipsilateral red nucleus blood flow was significantly decreased in the ataxic hemiparesis patients, whereas the ipsilateral red nucleus blood flow was increased in the pure motor hemiparesis patients. Crossed cerebellar diaschisis (decreased contralateral cerebellar blood flow) was seen in ataxic hemiparesis patients; similarly, it was seen in pure motor hemiparesis patients. Conclusions: Our findings suggest that ataxia in hemiparetic patients with capsular infarct can be caused by ipsilateral red nucleus dysfunction secondary to cortico-rubral pathway disruption at the internal capsule. i 2014 S. Karger AG, Basel

S40: Intraoperative neurophysiological monitoring in pediatric neurosurgery: a focus on the sacral system

s of Speakers / Clinical Neurophysiology 125, Supplement 1 (2014) S1–S339 S9 anodal direct cortical stimulation, activates the corticospinal tract close to the axon hillock at the border between the grey and the white matter. DCS remains the most focal stimulation possible and thus is favorable used for tumor removal within the vicinity of the motor cortex. MEPs became focus of neurooncological strategies for optimized glioma resection. Combining DCS-MEPs and monopolar cortical/subcortical stimulation mapping techniques in supratentorial tumor surgery as well as combination with intraoperative imaging could achieve supramarginal resection. The proposed subcortical stimulation motor threshold of 2 mA for safe resection has to be confirmed with regard to tumor type and precise location of stimulation. As been shown in cerebral aneurysm surgery, the ability to detect pure motor hemiparesis in carotid endarterectomy was more recently shown in a multicenter study. In spine surgery, presence or disappearance (“all-or-nothing” principle) of MEP amplitude criteria is commonly accepted: the presence of any MEPs is related to unaffected motor function or transient paresis, with the exception of radiculopathy. In cervical and thoracic intramedullary spinal cord surgery, the additional implementation of the D-wave helps to distinguish between permanent and transient motor deficit: D-wave preservation is always followed by a recovery of motor function. The latter seems to be applicable in supratentorial surgeries alike. In summary, MEPs are specific and sensitive for the assessment of the motor cortex and the corticospinal tract. In supratentorial tumor surgery MEPs are increasingly becoming a tool for “functional” guided resection strategies. S40 Intraoperative neurophysiological monitoring in pediatric neurosurgery: a focus on the sacral system F. Sala1, G. Squintani2, V. Tramontano2, C. Arcaro1 1Institute of Neurosurgery, Verona, Italy; 2Division of Neurology, Neurosciences, Verona, Italy Introduction: Intraoperative neurophysiologic monitoring (IOM) is nowadays extensively used in Pediatric Neurosurgery and tethered cord surgery is one of the most useful application. Our goal is to describe and discuss the standard IOM techniques used during tethered cord surgery, in the light of our clinical experience over the past ten years. Material and methods: Neurophysiological mapping of the conus-cauda is performed through direct stimulation of these structures and bilateral recording from segmental target muscles. While mapping identify ambiguous neural structures, their functional integrity during surgery can be assessed by monitoring techniques only, such as somatosensory evoked potentials (SEPs), transcranial motor evoked potentials (MEPs) from limb muscles and anal sphincters, and the bulbocavernosus reflex (BCR). Results: Between 2002 and 2012, we performed 48 surgical procedures in 47 patients with a tethered cord secondary to a variety of spinal dysraphisms. The monitorability rate was 84% for SEPs, 97% for limb muscle MEPs, 74% for the anal sphincter MEPs, and 59% for the BCR. In all patients but one SEP, MEP and BCR remained stable during surgery. Post-operatively two out of 47 patients presented a significant – though transient – neurological worsening. In six patients an unexpected muscle response was evoked by stimulating tissue macroscopically considered as not functional. Conclusions: Mapping techniques allow to identify and spare functional neural tissue and, vice-versa, to cut non-functional structures that may contribute to cord tethering. Monitoring techniques, MEP and BCR in particular, improve the reliability of intraoperative neurophysiology. IOM minimizes neurological morbidity in tethered cord surgery. S41 Neurophysiology of congenital mirror movements

Pure motor stroke as the most frequent lacunar syndrome: A clinical update

Pure motor stroke (PMS), also known as pure motor hemiparesis, is the most common of any lacunar form (between one half and two thirds of cases, depending on the series). In an acute stroke registry, 733 patients presented a lacunar infarct and PMS accounted for 12.7% (n = 342) of all first-ever stroke patients and for 48% of all lacunar syndromes. The posterior limb of the internal capsule, corona radiata, and pons are the most frequent brain topographies. Infarcts in the mesencephalus or medullary pyramid have been exceptionally reported. This present update is focused on the clinical evidence and mechanisms underlying the relationship between PMS and different stroke etiologies.

High Glycated Hemoglobin Levels and Intracranial Artery Stenosis Are Predictive Factors for Early Motor Worsening Events in Patients with Penetrating Artery Infarction

Background: The purpose of this study was to identify typical clinical characteristics to predict early motor worsening (EMW) of patients with penetrating artery infarction. Methods: We reviewed 65 consecutive patients with pure motor hemiparesis, sensorimotor stroke, and ataxic hemiparesis. EMW was defined as deterioration by ≥1 point on the National Institutes of Health Stroke Scale for motor function within 5 days of admission. Results: EMW was observed in 22 patients (34%). HbA1c levels were higher in patients with EMW than in those without EMW (7.9 ± 2.6 vs. 6.3 ± 1.6%; p < 0.01). The percentage of EMW patients with intracranial artery stenosis (ICAS) was greater than that of non-EMW patients with ICAS (13/22 patients, 59% vs. 8/43 patients, 19%; p < 0.01). Multivariate logistic regression analysis indicated that HbA1c levels ≥7.0% (OR 3.0, 95% CI 1.5–6.8; p < 0.005) or ICAS (OR 2.3, 95% CI 1.2–4.8; p < 0.05) increased the risk of EMW, and the combination of these factors increased the risk in an additive manner (OR 7.6, 95% CI 2.5–40; p < 0.005). Conclusion: HbA1c levels ≥7.0% and/or ICAS in patients with penetrating artery infarction are associated with EMW.

Ateromatosis compleja del cayado aórtico: estudio de 71 pacientes con infartos lacunares

Background and objectivesTo characterize the frequency and the clinical factors of complex aortic atheroma plaques (CAA) in patients with a first-ever lacunar infarct (LI). Patients and methodsSample of 71 consecutive patients with a first LI (9 of uncertain etiology) included in a stroke registry over a period of 4 years, studied by neuroimaging and suprasternal transthoracic echocardiography with harmonic imaging technology. We analyze the risk factors, clinical data and prognosis. ResultsEchocardiography was abnormal in 20 patients (28.2%). Seven patients (9.9%) had simple aortic plaques and 13 (18.3%) had CAA. There were 10 women and 3 men of 79 (range 57-91) years of median age. Pure motor hemiparesis was the most common syndrome present in 5 cases (39%). Hypertension (69%), previous transient ischemic attack (39%) and diabetes (31%) were the main risk factors. Only 3 patients with CAA (4.2% of the total and 33% of LI of uncertain etiology) had no risk factors. Silent infarcts were present in 7 cases (53.8%) (6 LI and one non-LI). No patient died during hospitalization. ConclusionsThe presence of complex aortic atheroma plaques was observed in 18.3% of first-LI patients, with a predominance of females. High risk criteria of aortic embolism was present in 4.2% of LI. CAA should be ruled out in essential LI patients.

A monofocal pontine lesion

The patient was admitted for confusion and a resultant tracheal laceration sustained after her fall which was complicated with subcutaneous emphysema and infection. Diagnostic studies revealed normal serum electrolytes, cerebrospinal fluid study, vitamin B12 level, and tests for rheumatological diseases. Chronic alcoholism was felt to be the cause of the central pontine myelinolysis (CPM). The patient improved significantly with antibiotics and surgical tracheal repair and was discharged with minimal memory residual deficits. Repeat MRI of the brain more than 6 months later showed decreased but persistent hyperintensity in the midpons (Fig. 1). CPM is most commonly associated with: alcoholism, 39.4% of patients; rapid reversal of hyponatremia, 21.5%; and liver transplantation, 17.5%. Prognosis for CPM is reported to be invariably fatal but patients with complete recovery with mild impairment have been seen. Three subtypes of these brain demyelinating diseases are known: (i) CPM, confined to the pons; (ii) extrapontine myelinolysis (EPM); and (iii) osmotic demyelinating syndrome (ODS), in which CPM and EPM are both present. Adult pontine gliomas are rare tumors that usually present clinically with gait disturbance, headaches, weakness of limbs, and cranial nerve involvement. MRI findings include a non-enhancing diffusely infiltrative mass, enhancing localized mass, and isolated tectal tumor. The absence of these findings in our patient made the diagnosis of a pontine glioma unlikely. Pontine infarctions usually present with findings that may include ipsilateral peripheral cranial nerve palsies, contralateral movement disorders, sensory disturbances, and pure motor hemiparesis or hemiplegia. MRI findings typically include a well-demarcated hyperintensity in the pons on T2-weighted MRI with a corresponding hypointensity on T1-weighted MRI. Multiple sclerosis is a chronic, persistent inflammatory–demyelinating disease of the central nervous system that typically presents as an acute clinically isolated syndrome attributable to a monofocal or multifocal demyelinating lesion,

A monofocal pontine lesion

The patient was admitted for confusion and a resultant tracheal laceration sustained after her fall which was complicated with subcutaneous emphysema and infection. Diagnostic studies revealed normal serum electrolytes, cerebrospinal fluid study, vitamin B12 level, and tests for rheumatological diseases. Chronic alcoholism was felt to be the cause of the central pontine myelinolysis (CPM). The patient improved significantly with antibiotics and surgical tracheal repair and was discharged with minimal memory residual deficits. Repeat MRI of the brain more than 6 months later showed decreased but persistent hyperintensity in the midpons (Fig. 1). CPM is most commonly associated with: alcoholism, 39.4% of patients; rapid reversal of hyponatremia, 21.5%; and liver transplantation, 17.5%. Prognosis for CPM is reported to be invariably fatal but patients with complete recovery with mild impairment have been seen. Three subtypes of these brain demyelinating diseases are known: (i) CPM, confined to the pons; (ii) extrapontine myelinolysis (EPM); and (iii) osmotic demyelinating syndrome (ODS), in which CPM and EPM are both present. Adult pontine gliomas are rare tumors that usually present clinically with gait disturbance, headaches, weakness of limbs, and cranial nerve involvement. MRI findings include a non-enhancing diffusely infiltrative mass, enhancing localized mass, and isolated tectal tumor. The absence of these findings in our patient made the diagnosis of a pontine glioma unlikely. Pontine infarctions usually present with findings that may include ipsilateral peripheral cranial nerve palsies, contralateral movement disorders, sensory disturbances, and pure motor hemiparesis or hemiplegia. MRI findings typically include a well-demarcated hyperintensity in the pons on T2-weighted MRI with a corresponding hypointensity on T1-weighted MRI. Multiple sclerosis is a chronic, persistent inflammatory–demyelinating disease of the central nervous system that typically presents as an acute clinically isolated syndrome attributable to a monofocal or multifocal demyelinating lesion,