Motor cortex stimulation for the treatment of trigeminal neuralgia after brainstem infarction: A case report. / 运动皮层电刺激治疗脑干梗死后三叉神经痛1例.

Secondary trigeminal neuralgia after brainstem infarction is rare and rarely reported. A patient with secondary trigeminal neuralgia after brainstem infarction was admitted to the Department of Neurosurgery, Xiangya Hospital, Central South University. The patient was a 44 years old male who underwent motor cortex stimulation treatment after admission. The effect was satisfactory in the first week after surgery, but the effect was not satisfactory after one week. This disease is relatively rare and the choice of clinical treatment still requires long-term observation.

A radiomics feature-based machine learning models to detect brainstem infarction (RMEBI) may enable early diagnosis in non-contrast enhanced CT.

OBJECTIVES: Magnetic resonance imaging has high sensitivity in detecting early brainstem infarction (EBI). However, MRI is not practical for all patients who present with possible stroke and would lead to delayed treatment. The detection rate of EBI on non-contrast computed tomography (NCCT) is currently very low. Thus, we aimed to develop and validate the radiomics feature-based machine learning models to detect EBI (RMEBIs) on NCCT. METHODS: In this retrospective observational study, 355 participants from a multicentre multimodal database established by Huashan Hospital were randomly divided into two data sets: a training cohort (70%) and an internal validation cohort (30%). Fifty-seven participants from the Second Affiliated Hospital of Xuzhou Medical University were included as the external validation cohort. Brainstems were segmented by a radiologist committee on NCCT and 1781 radiomics features were automatically computed. After selecting the relevant features, 7 machine learning models were assessed in the training cohort to predict early brainstem infarction. Accuracy, sensitivity, specificity, positive predictive value, negative predictive value, F1-score, and the area under the receiver operating characteristic curve (AUC) were used to evaluate the performance of the prediction models. RESULTS: The multilayer perceptron (MLP) RMEBI showed the best performance (AUC: 0.99 [95% CI: 0.96-1.00]) in the internal validation cohort. The AUC value in external validation cohort was 0.91 (95% CI: 0.82-0.98). CONCLUSIONS: RMEBIs have the potential in routine clinical practice to enable accurate computer-assisted diagnoses of early brainstem infarction in patients with NCCT, which may have important clinical value in reducing therapeutic decision-making time. KEY POINTS: • RMEBIs have the potential to enable accurate diagnoses of early brainstem infarction in patients with NCCT. • RMEBIs are suitable for various multidetector CT scanners. • The patient treatment decision-making time is shortened.

A New Neurological Screening Approach for Diagnosing Brainstem Infarction Using the Calling Method and Familiar Voices.

This report proposes a new approach to assess dysarthria in patients with brainstem infarction by involving familiar individuals. Collaboration provides valuable insights compared to subjective traditional methods. A man in his 70s presented with resolved positional vertigo. Standard neurological tests showed no abnormalities, and inquiries with the patient's friend did not reveal voice changes. While inquiring about voice changes with family, friends, and acquaintances is a common practice in clinical settings, our approach involved the patient calling out to his friend from a distance. Despite the physician detecting no abnormalities, the friend noticed a lower voice. Subsequent magnetic resonance imaging (MRI) confirmed brainstem infarction. Early and subtle symptoms of brainstem infarction pose a detection challenge and can lead to serious outcomes if overlooked. This report provides the first evidence that distance calling can detect subtle voice changes associated with brainstem infarction potentially overlooked by conventional neurological examinations, including inquiries with individuals familiar with the patient's voice. Detecting brainstem infarction in emergency department cases is often missed, but conducting MRIs on every patient is not feasible. This simple method may identify patients overlooked by conventional screening who should undergo neuroimaging such as MRI. Further research is needed, and involving non-professionals in assessments could significantly advance the diagnostic process.

Predicting functional outcome in patients with acute brainstem infarction using deep neuroimaging features.

BACKGROUND AND PURPOSE: Acute brainstem infarctions can lead to serious functional impairments. We aimed to predict functional outcomes in patients with acute brainstem infarction using deep neuroimaging features extracted by convolutional neural networks (CNNs). METHODS: This nationwide multicenter stroke registry study included 1482 patients with acute brainstem infarction. We applied CNNs to automatically extract deep neuroimaging features from diffusion-weighted imaging. Deep learning models based on clinical features, laboratory features, conventional imaging features (infarct volume, number of infarctions), and deep neuroimaging features were trained to predict functional outcomes at 3 months poststroke. Unfavorable outcome was defined as modified Rankin Scale score of 3 or higher at 3 months. The models were evaluated by comparing the area under the receiver operating characteristic curve (AUC). RESULTS: A model based solely on 14 deep neuroimaging features from CNNs achieved an extremely high AUC of 0.975 (95% confidence interval [CI] = 0.934-0.997) and significantly outperformed the model combining clinical, laboratory, and conventional imaging features (0.772, 95% CI = 0.691-0.847, p < 0.001) in prediction of functional outcomes. The deep neuroimaging model also demonstrated significant improvement over traditional prognostic scores. In an interpretability analysis, the deep neuroimaging features displayed a significant correlation with age, National Institutes of Health Stroke Scale score, infarct volume, and inflammation factors. CONCLUSIONS: Deep learning models can successfully extract objective neuroimaging features from the routine radiological data in an automatic manner and aid in predicting the functional outcomes in patients with brainstem infarction at 3 months with very high accuracy.

Isolated basilar artery dissection following blunt trauma challenging the Glasgow coma score: A case report.

Blunt cerebrovascular injury is a very rare complication of blunt trauma and a diagnostic challenge. A 14 year old male fell 10 m sustaining multi system trauma. The atypical Glasgow Coma Score was six with a fully preserved eye component. Initial whole-body CT scanning demonstrated multiple injuries but no obvious brain injury. Trauma management involved non-operative resuscitation and was successful, however profound coma occurred and brain stem reflexes disappeared on day two. Repeat brain CT scan demonstrated multiple cerebral and cerebellar ischemic lesions and no opacification of the vertebral or basilar arteries. Secondary analysis of the first CT scan demonstrated a small focal basilar artery dissection not initially reported. Our case report highlights an unusual cause of coma after traumatic brain injury where the clinical scenario mimics locked in syndrome. In such circumstances cerebrovascular injury, and in particular traumatic basilar artery dissection, must be actively excluded.

Giant Vertebrobasilar Fusiform Aneurysm Mass Effect Heralds Rapid in Situ Thrombosis and Ischemic Stroke in the Setting of Ulcerative Colitis.

Here we describe a case of brainstem infarction secondary to rapid thrombus formation in a giant vertebrobasilar fusiform aneurysm (GVBFA) that was preceded clinically by several months of headaches and dizziness initially attributable to mass effect. Less than a month after initial identification of the aneurysm, a large partially-occluding thrombus formed leading to infarction of the brainstem. Interestingly, this patient also had ulcerative colitis, which has been associated with acquired hypercoagulability. Balancing risk versus benefit in the management of GVBFA to prevent morbidity and mortality is very challenging; thus more information is needed to better stratify treatment options for patients, particularly those that may have an accelerating clinical course or co-morbidities that increase clotting risk.

Non-Paralytic Pontine Exotropia as a Predominant Sign of Brainstem Infarction - A Case Report.

The association of internuclear ophthalmoplegia (INO) with exotropia in the contralateral eye is a rare finding, known as non-paralytic pontine exotropia (NPPE). We report a case of an 80-year-old woman with acute onset of diplopia on admission who presented with left eye exotropia with left-beating nystagmus whilst fixating with the right eye and inability to adduct the right eye on left gaze. Brain magnetic resonance imaging showed two small areas of vertebrobasilar territory ischaemic stroke, one beneath the inferior portion of the aqueduct and another in the right occipital lobe. Our case highlights an interesting clinical manifestation of brainstem infarction that, along with ocular motility examination, allowed us to review its pathophysiology, including the influence of the contralateral paramedian pontine reticular formation stimulation in the mechanism of contralateral exotropia in NPPE. The fast clinical resolution of these cases can explain the scarcity of NPPE reports.

Case report: Wallenberg's syndrome, a possible cause of symptomatic epicrania fugax.

Background Epicrania fugax has been described as a primary headache. Nevertheless, a symptomatic form was recently found in a patient with a skull base meningioma abutting the trigeminal nerve. Here we report on a patient with facial pain with the features of epicrania fugax occurring after Wallenberg's syndrome. Case report A 53-year-old man suffered a right-sided dorsolateral medullary ischaemic stroke. Nine months later, he presented with brief electric shock-like paroxysms of pain stemming from the right eye and radiating to the ipsilateral forehead, the temple or the cheek in a zigzag trajectory. Some episodes were accompanied by ipsilateral conjunctival injection and eyelid oedema. Treatment with eslicarbazepine abolished the pain. Conclusion A pain with the features of epicrania fugax may be associated with medullary lesions. This finding suggests that the central trigeminal pathways and/or the spinal trigeminal nucleus may play an important role in the pathophysiology of this type of pain.

Thrombectomy in acute basilar artery dissection: A case report.

A 34-year-old patient was admitted with unclear coma and stretch synergisms. CT-imaging was strongly suspicious of basilar artery dissection, this was confirmed on subsequent DSA. The patient was lysed and a complex thrombectomy was performed. Despite sufficient recanalization, the patient unfortunately died shortly after. To the best of our knowledge, this is the first description of an acute basilar artery dissection treated by thrombectomy.

New-onset tachycardia-bradycardia syndrome following acute non-medullary brainstem infarction.

Tachycardia-bradycardia syndrome (TBS) is a variant of sick sinus syndrome (SSS) characterized by alternating tachycardia and bradycardia. A few cases of SSS secondary to structural lesions in the medulla have been reported, but there has never been a reported case of the rare sign akin to TBS following acute non-medullary brainstem infarction. Furthermore, new-onset cardiac arrhythmias in stroke often presented in one continuous pattern - either as bradycardia or tachycardia, but instances of an alternating fashion have been rarely reported. We present the case of a 46-year-old female who developed severe dizziness with vomiting, diplopia, and slurred speech, which gradually worsened to quadriplegia, severe hypophonia, and dysphagia. Brain magnetic resonance imaging (MRI) demonstrated acute midbrain and pontine infarction. Except for neurological symptoms, the patient experienced unexpected TBS with the symptoms of excessive sweating, palpitations, and irritability without any other predisposing factors. The frequency of the episodes gradually declined until it spontaneously disappeared the 5th day after admission. Given the unpredictable nature of the tachycardia and bradycardia, it was challenging to manage the arrythmias with medications. A pacemaker was recommended, but financial reasons led the patient to reject this option. Two weeks after antithrombotic therapy and rehabilitation, she was discharged with residual symptoms of diplopia, moderate dysarthria, mild quadriplegia, and no cardiac symptoms. Our case highlighted the occurrence of TBS as a new-onset arrhythmia that can manifest during the acute phase of non-medullary brainstem infarcts. Further research into brainstem lesions contributing to TBS is warranted us to elucidate the underlying mechanisms.

A Case of Pontine Infarction due to Subclavian Steal Phenomenon Enhanced by an Arteriovenous Shunt for Hemodialysis.

We present a case of pontine infarction caused by subclavian steal phenomenon (SSP) due to subclavian artery stenosis (SAS) and an arteriovenous shunt in the forearm in a 74-year-old man with hemodialysis and stenting for SAS with improvement of SSP. He developed dysarthria during dialysis. He was admitted to our hospital and diagnosed with a pontine infarction. As the basilar artery appeared to be occluded on magnetic resonance angiography, an emergency diagnostic angiography was performed. Aortagram showed severe stenosis of the left subclavian artery. Right vertebral artery (VA) angiogram revealed retrograde arterial blood flow from the right VA to the left VA via the VA union, which suggested SSP. In addition, the steal was augmented by an ipsilateral hemodialysis arteriovenous shunt. Percutaneous subclavian artery stenting was performed 12 days later, and there was no recurrence of symptoms in the follow-up period. To our knowledge, this study is the first to report a patient with SSP who developed a pontine infarction due to SAS and an arteriovenous shunt during hemodialysis and who underwent subclavian artery stenting and had a good outcome.

Bilateral medial medullary infarction: a systematic review.

Bilateral infarction of the medial medulla (MMI) is rare. Limited information is available on clinical characteristics, etiology, and prognosis. High-resolution neuroimaging has a major role in elucidating the underlying stroke mechanism. The aim of this systematic review was to analyze the clinical presentations, stroke mechanisms, and outcomes in patients with bilateral MMI. We performed a systematic review of the literature from 1992-2011 that reported on clinical presentations, stroke mechanism, and/or outcomes in patients with magnetic resonance imaging-proven bilateral MMI. Medline, EMBASE, and Web of Science Scholars Portal were searched without language restriction. Two reviewers independently assessed identified studies to determine eligibility, validity, and quality. The primary outcome was inpatient mortality; a secondary outcome was case fatality at 12 months. We identified 138 articles from Medline, EMBASE, and Scholars Portal including the MeSH terms "brainstem infarction," "medulla," and "bilateral." Twenty-nine articles met our inclusion criteria, including a total of 38 cases with bilateral MMI, and included in our study. These 38 patients had a mean age of 62.2 years and were predominately male (74.2%). The most common clinical presentations were motor weakness in 78.4%, dysarthria in 48.6%, and hypoglossal palsy in 40.5%. The most common vascular pathology was vertebral artery atherosclerosis, in 38.5%. The clinical outcome was poor (mortality, 23.8%; dependency, 61.9%). Bilateral medial medullary infarction is a rare stroke syndrome. Clinical presentations were mostly rostral medullary lesions. Large-artery atherosclerosis and branch disease were the most common stroke mechanisms. The clinical outcome was usually poor.

A Case of Sudden Cardiac Arrest After Brainstem Infarction.

Research on the causes of sudden cardiac arrest (CA) after ischemic stroke, especially disruption of the autonomic nervous system's central control, has recently focused more on the widespread cortical and subcortical network than on autonomic circuits at the spinal and brainstem level. However, no clinical case of sudden CA requiring cardiopulmonary resuscitation (CPR) after brainstem infarction has been reported. We report a case of a 78-year-old woman who died suddenly from a brainstem infarction. Her husband heard a falling sound and found her unresponsive and lying with agonal breathing. The initial cardiac rhythm was pulseless electrical activity confirmed by emergency medical technicians. Recovery of spontaneous circulation was achieved after CPR. Basilar artery occlusion was shown on computed tomography, but no other findings that could have caused CA were found. Targeted temperature management was initiated, but she died on hospital day 22. Brainstem infarction may cause sudden CA; therefore, definitive treatment may achieve better outcomes.

Intraoperative venous congestion and brainstem venous hemorrhagic infarction during retrosigmoid for acoustic neuroma.

Venous hemorrhagic infarction is rare but can occur during acoustic neuroma resection [1-5]. We present the case of a 27-year-old male with 1.5 years of progressive headaches, tinnitus, imbalance and hearing loss. Imaging revealed a left Koos 4 acoustic neuroma. The patient underwent a retrosigmoid approach for resection. During surgery, a vein of significant size within the capsule of the tumor was encountered and was necessary to take to proceed with resection. After coagulation of the vein, intraoperative venous congestion with cerebellar edema and hemorrhagic infarction ensued, requiring resection of a portion of the cerebellum. Given the hemorrhagic nature of the tumor, continuing tumor resection was necessary to prevent postoperative hemorrhage. This was carried out until hemostasis was achieved. 85 % resection was achieved, leaving a residual against the brainstem and cisternal course of the facial nerve. Postoperatively, the patient required 5 weeks hospitalization followed by 1 month of rehabilitation. At discharge to rehabilitation, patient had trach, PEG, left House-Brackmann 5 facial weakness, left sided deafness, and right upper extremity hemiparesis (1/5). At 7 months follow up, he continued to have left House-Brackmann 5 facial weakness and left sided deafness but trach and PEG had been removed and strength had improved to 5/5. We demonstrate in this video the unfortunate and rare occurrence of intraoperative venous hemorrhagic infarction during acoustic neuroma resection - particularly for large tumors in young patients - and discuss its etiology and surgical steps that are necessary to partially remedy its devastating impact on the patient. The patient consented to the procedure and participating in this surgical video.

Immediate effects of electroacupuncture in oculomotor nerve palsy following brainstem infarction: A case report.

INTRODUCTION: Research has demonstrated that electroacupuncture (EA) stimulation of paralyzed muscles significantly improves nerve regeneration and functional recovery. DESCRIPTION: An 81-year-old man with no history of diabetes mellitus or hypertension presented with a history of brainstem infarction. Initially, the patient had medial rectus palsy in the left eye and diplopia to the right in both eyes, which almost returned to normal after six sessions of EA. METHODS: The CARE guidelines informed the case study report. The patient was diagnosed with oculomotor nerve palsy (ONP) and photographed to document ONP recovery after treatment. The selected acupuncture points and surgical methods are listed in the table. DISCUSSION: Pharmacological treatment of oculomotor palsy is not ideal, and its long-term use has side effects. Although acupuncture is a promising treatment for ONP, existing treatments involve many acupuncture points and long cycles, resulting in poor patient compliance. We chose an innovative modality, electrical stimulation of paralyzed muscles, which may be an effective and safe complementary alternative therapy for ONP.

Pain Mimicking Trigeminal Neuralgia in Patients with Acute Ischemic Stroke of the Brainstem.

Background and Purpose: Cases of pain mimicking trigeminal neuralgia (TN) induced by ischemic stroke in the brainstem have been sparsely reported. The study was to determine the characteristics of symptomatic TN in patients with acute ischemic stroke in the medulla oblongata and pons, and to determine the location of the ischemic lesion associated with the pain. Patients and Methods: A total of 6/21 (28.5%) patients with medullary ischemic stroke and 3/34 (8.8%) patients with pontine ischemic stroke who experienced pain mimicking TN between 1 week before and 2 weeks after the stroke onset were enrolled in the study. All patients accepted neuroimaging examinations to determine the location of the ischemic lesion and the etiology of ischemic stroke. The characteristics of pain were recorded and analyzed. Results: Ischemic lesions of patients who experienced pain mimicking TN were located in the lateral medulla oblongata (n=6), nerve root entry zoo (n=2), and areas involved with the spinal trigeminal tract (n=1) in the pons. Half of the instances of pain induced by medullary ischemic stroke occurred prior to the stroke onset. The branch of V1 was exclusively involved in patients with lateral medullary infarction and the branches of V2 and V3 were typically involved in patients with pontine infarction. The pain was relieved spontaneously (n=4, 44.4%) or was controlled with drugs for neuropathic pain treatment (n=5, 55.5%). Conclusion: Half of the instances of pain induced by medullary ischemic stroke occurred prior to the stroke onset. Pain mimicking TN might be a premonitory symptom of the medullary ischemic stroke. Pain mimicking TN induced by brainstem infarction has a good prognosis.

Convulsive-like movements as the first symptom of basilar artery occlusive brainstem infarction: A case report.

BACKGROUND: Convulsive-like movements are rare in basilar artery occlusive cerebral infarction (BAOCI). These manifestations may easily be mistaken for epileptic seizures caused by compromised anterior circulation or by cortical lesions. Delayed diagnosis of this condition affects its subsequent treatment and prognosis. Therefore, it is critical to recognize this type of phenomenon in the early stage. CASE SUMMARY: A 55-year-old male patient presented with unconsciousness, rigidity, and a paroxysmal twitch in both lower limbs. These conditions lasted for nearly 2 h and resembled status epilepticus. After the initial conditions subsided, hemiplegia occurred and then subsided rapidly. The family refused thrombolytic therapy because the symptoms were similar to Todd paralysis after epilepsy. However, magnetic resonance imaging showed left pontine infarction. No abnormality was observed in a video electroencephalogram during the interictal period. Digital subtraction angiography revealed that the basilar artery was occluded and that the posterior communicating arteries were patent. Fortunately, the patient received a good prognosis after antiplatelet therapy, lipid regulation, balloon dilatation of the basilar artery, and rehabilitation. CONCLUSION: Convulsive-like movements may be an early sign of basilar artery occlusive brainstem infarction. It is important to identify this phenomenon in a timely manner.

Locked-in Syndrome Due to Meningovascular Syphilis: A Case Report and Literature Review.

We herein report a 46-year-old man presenting with locked-in syndrome secondary to meningovascular syphilis. Brain magnetic resonance imaging (MRI) demonstrated multiple acute infarctions in the left ventromedial pons, right basis pontis, and left basal ganglia. His locked-in syndrome was hypothesized to have been caused by thrombosis of the small paramedian branches of the basilar artery due to syphilitic arteritis. This is a unique case of bilateral ventromedial pontine infarction caused by meningovascular syphilis that presented as locked-in syndrome. Meningovascular syphilis should be included in the differential diagnosis of uncommon stroke, particularly in young men.

Limb-shaking transient ischemic attack in posterior circulation ischemia: a case report.

Limb-shaking transient ischemic attack (LS-TIA) is a rare clinical manifestation of steno-occlusive carotid lesions. Reports of LS-TIA caused by posterior circulation ischemia are rare. Here, the case of a 56-year-old male patient with a history of epilepsy, who presented with dizziness, nausea and vomiting, is reported. Initial brain magnetic resonance imaging (MRI) indicated no signs of acute ischemia, and the patient's symptoms had not relieved despite drug administration to treat dizziness. During a vestibular function test on the next day, he developed sudden left-limb shaking without disturbance of consciousness or facial twitching. Considering a seizure, an anti-epileptic drug was administered, but no improvement was observed. Eight hours later, the patient experienced left-limb paralysis, and re-examination of the MRI indicated brainstem infarction. The patient recovered well with antiplatelet and antiatherosclerotic therapy. While LS-TIA is a rare manifestation of TIA of the carotid arterial system, posterior circulation ischemia may also manifest as LS-TIA. If a patient presents with limb shaking due to postural changes despite a history of epilepsy, LS-TIA should be highly suspected.

Basilar Artery Dolichosis Increases the Risk of Long-Term Recurrence in Patients With Pontine Infarction: A Prospective Cohort Study.

Background and Purpose: Patients with basilar artery (BA) dolichosis are at high risk of acute pontine infarction (API), but the association between BA dolichosis and long-term stroke recurrence has received little attention. We aimed to identify the effect of BA dolichosis on the risk of long-term brainstem infarction recurrence in patients with API. Methods: In this prospective cohort study, we enrolled 113 patients with API admitted to our department. BA dolichosis was diagnosed by a BA curve length >29.5 mm or bending length (BL) >10 mm on magnetic resonance angiography. The primary outcome was the occurrence of diffusion-weighted imaging (DWI)-confirmed brainstem infarction. The Cox proportional hazard model was used to detect possible predictors of brainstem infarction recurrence. Results: Among 113 patients with API, 39 (34.5%) patients had BA dolichosis, and DWI-confirmed brainstem infarction recurred in 15 (13.3%) patients with a mean follow-up time of 31.2 months; the estimated 5-year incidence of brainstem infarction recurrence was 23.1% in patients with BA dolichosis, which was significantly higher than the incidence of 8.1% in patients without BA dolichosis. Cox proportional hazard analysis showed that age ≥65 years (hazard ratio (HR) = 3.341, 95% confidence interval (CI): 1.079-10.348, P = 0.036) and BA dolichosis (HR = 3.048, 95% CI: 1.069-8.693, P = 0.037) were significantly associated with a higher risk of brainstem infarction recurrence. In a subgroup analysis stratified by age, the patients aged ≥65 years with BA dolichosis had a higher risk of brainstem infarction recurrence (HR = 7.319, 95% CI: 1.525-35.123, P = 0.013). Conclusions: This study indicates that BA dolichosis may increase the risk of long-term brainstem infarction recurrence in patients with API, especially in elderly patients, and therefore warrants more attention in clinical practice.