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.

Bilateral medial medullary stroke: A rare stroke syndrome masquerading as myasthenia crisis in a young diabetic lady.

Bilateral medial medullary stroke is a rare stroke syndrome. The clinical presentation of bilateral medial medullary stroke is heterogenous and often overlaps with other non-stroke neurology emergencies such as Guillain-Barrésyndrome, myasthenic crisis and acute vestibular syndrome, leading to misdiagnosis. We wish to present a case of a young lady with type 1 diabetes mellitus, who had presented with subacute neuromuscular weakness which was erroneously treated as myasthenic crisis. Her case was subsequently diagnosed as bilateral medial medullary stroke, following evolving clinical signs and magnetic resonance imaging (MRI) findings of a heart-shaped abnormality at the rostral medulla. This rare stroke syndrome represented a diagnostic challenge which necessitated a strong clinical suspicion and an urgent MRI scan of the brain for prompt diagnosis to enable appropriate treatment initiation.

Brainstem stroke presenting as isolated bilateral ptosis.

Pure midbrain infarctions not involving surrounding structures are an uncommon clinical phenomenon. A midbrain infarction that results in isolated bilateral ptosis as the only neurological deficit is much rarer and an easy diagnosis to miss; therefore, potentially leading to further downstream complications. We describe the case of an elderly patient who presented with isolated bilateral ptosis, initially thought to be consequent to myasthenia gravis but subsequently identified to have a perforator infarct in the midbrain, resulting in his symptoms.

Weber syndrome secondary to brain stem tuberculoma.

This case report describes a rare presentation of presumed brain stem tuberculoma in a 28-year-old male who presented with acute onset of third cranial nerve palsy with contralateral hemiparesis (Weber syndrome) and upgaze palsy. Isolated midbrain tuberculoma is rare, presenting with varied clinical manifestations and radiological findings posing as a diagnostic dilemma. Weber syndrome is commonly caused by midbrain infarct secondary to occlusion of branches of the posterior cerebral artery and rarely from a tuberculoma. The patient is a case of disseminated tuberculosis with granuloma in midbrain causing pressure effect, thereby presenting with features consistent with Weber syndrome and upgaze palsy. The patient had good recovery with antitubercular treatment and systemic steroids.

Minocycline-induced polyarteritis nodosa-like vasculitis presenting as brainstem stroke.

Minocycline use has been associated with the development of autoimmune disorders, including drug-induced vasculitis. Previously published reports suggest that clinical manifestations are limited to cutaneous, constitutional, or musculoskeletal symptoms. To our knowledge there has been only one reported patient with ischemic stroke in the setting of minocycline-induced vasculitis. We describe a 26-year-old woman, with no vascular risk factors, who had an ischemic pontine stroke in the setting of biopsy-proven minocycline-induced polyarteritis nodosa-like vasculitis. Discontinuation of minocycline resulted in resolution of the vasculitis, and she has not had any recurrent ischemic events. This report shows that ischemic strokes may occur as a result of minocycline-induced vasculitis. While this is likely a rare association, recognition is important given the widespread use of minocycline and the potential for devastating consequences in a young population. Consequently, drug-induced vasculitis should be considered in patients with an ischemic stroke taking minocycline.

Relationship Between the Hypersensitive c-Reactive Protein (hs-CRP) Level and the Prognosis of Acute Brainstem Infarction.

The objective of this study is to explore the relationship between the hypersensitive c-reactive protein (hs-CRP) level and the prognosis of acute brainstem infarction. Serum levels of hs-CRP were measured in 68 patients with acute brainstem infarction 72 h after disease onset. The hs-CRP levels in the U.S. National Institutes of Health Stroke Scale (NIHSS) score group and in the modified RANKIN scale (mRS) score group were compared. The independent risk factors of brainstem infarction were analyzed using Logistic binary regression. The hs-CRP level was significantly higher in the group with NIHSS >5 compared with the one with NIHSS ≤ 5 (P = 0.004). In the group with mRS > 2, the age, smoking history, and blood glucose level were significantly higher than those in the group with mRS ≤ 2 (P < 0.05), whereas the hs-CRP level was significantly higher (P = 0.001). Age and hs-CRP level were the independent prognostic factors of the brainstem infarction. The serum hs-CRP level is closely related with the severity and prognosis of brainstem infarction, and is an independent risk factor of acute brainstem infarction.

Late-onset radiation-induced vasculopathy and stroke in a child with medulloblastoma.

We report a case of a 15-year-old boy who presented to our institution with left-sided weakness and slurred speech. He had a history of medulloblastoma diagnosed at 3 years of age, status postsurgical resection and craniospinal radiation. Magnetic resonance imaging (MRI) of brain revealed a right paramedian pontine infarction, suspected secondary to late-onset radiation-induced vasculopathy of the vertebrobasilar system. Radiation to the brain is associated with increased incidence of ischemic stroke. Clinicians should have a high index of suspicion for stroke when these patients present with new neurologic symptoms.

[Chronic tuberculous meningitis presenting recurrent brainstem infarction without features of meningitis].

A 44-year-old woman with a history of transient right hemiparesis presented with personality change. One year later, she was admitted with ophthalmoparesis, dysarthria and regression phenomenon. MRI indicated acute infarction of the paramedian region of the midbrain and a nodular lesion in the interpeduncular fossa with contrast enhancement. Two years later, the patient was admitted with sudden onset of right hemiplegia. MRI showed acute infarction in the left side of the pons, diffuse brain atrophy, and abnormal contrast enhancement in the nodular lesion of interpeduncular fossa and leptomeninges of the ventral pons. MR angiography revealed that cerebral main tracts were intact, and cerebrospinal fluid analysis revealed mild pleocytosis and slightly elevated protein levels. Cervical lymph node biopsy demonstrated caseating granuloma with acid-fast bacilli. The patient was diagnosed with chronic tuberculous meningitis, even though tuberculous bacilli were not detected on polymerase chain reaction (PCR) or in culture. Antituberculous medication resulted in radiological resolution and neurological improvement. Although the patient had mild headache and pyrexia at the first admission, no signs of meningeal irritation were confirmed throughout the clinical course. We suspect that a paucity of tuberculous bacilli released from the tuberculous foci in the meninges to the subarachnoid space caused prolonged clinical course and lack of meningeal irritation signs.

Lateral medullary stroke in patient with granulomatous polyangiitis.

Granulomatous polyangiitis (GPA), also known as Wegener granulomatosis, is a systemic antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis that infrequently affects the central nervous system. We report a 41-year-old man with lateral medullary infarction who developed rapidly progressive renal failure. He was diagnosed with GPA based on positive serum c-ANCA and antiproteinase 3 antibodies and demonstration of pauci-immune crescentic glomerulonephritis on kidney biopsy. He was treated with Coumadin, pulse steroids, cyclophosphamide, and plasmapheresis. He had resolution of his neurologic deficits and improvement in renal function. This case report highlights the importance to consider GPA vasculitis in the differential diagnosis of stroke in patients with development of acute kidney injury.

Brain stem infarction associated with familial Mediterranean fever and central nervous system vasculitis.

Familial Mediterranean fever (FMF) is an autoinflammatory autosomal recessive disease caused by mutations of the Mediterranean fever (MEFV) gene on chromosome 16p. Clinically, it is characterized by recurrent episodes of fever and painful polyserositis. An association of FMF with systemic vasculitis, namely Henoch-Schönlein purpura, polyarteritis nodosa and Behçet's disease has been described. Neurological manifestations of FMF occur rarely and include demyelinating (MS-like) lesions, posterior reversible encephalopathy syndrome, and pseudotumour cerebri. Hitherto hardly known, we herein present a young patient with a genetically proven FMF who suffered a brain stem infarction during a typical FMF attack. After a careful diagnostic workup including cerebrospinal fluid analysis, intra-arterial angiography and leptomeningeal biopsy, a FMF-associated central nervous system vasculitis was identified as the cause of stroke. The pathophysiological background and potential therapeutic strategies are discussed.

Brachium pontis stroke revealing neurofibromatosis type-2.

NF2 is an autosomal dominant disorder with neuroectodermal dysplasia. Most patients present with characteristic clinical tumors during or beyond the adolescent age group. The diagnosis is mainly clinical. Vasculopathy is rarely associated with NF2. Vascular complication as the presenting symptom in NF-2 is unknown. We report a case of a 2-year-old child with no prior family history of neurofibromatosis presenting with ataxia and brain-stem stroke.

Bruns-Cushing nystagmus due to hypertensive unilateral paramedian pontine base infarction.

Bruns-Cushing nystagmus is unusually rare and is known to be related with cerebellopontine angle tumor. A 32-year-old male patient came to our emergency department 3 times because of dizziness, right upper limb ataxia, hypertension, and Bruns-Cushing nystagmus. Magnetic resonance imaging demonstrated left paramedian pontine infarction. In conclusion, Bruns-Cushing nystagmus not only indicates a cerebellopontine angle tumor but may also be associated with pontine infarction.

Development of transdural anastomosis after craniotomy in a patient with atherothrombotic carotid occlusion.

Development of transdural anastomosis is extremely rare in the patients with atherosclerotic cerebrovascular disease. We report a rare case of development of transdural anastomosis after craniotomy in the patient with atherothrombotic carotid occlusion.

Multiple brainstem infarctions in a boy caused by angiitis of the basilar artery.

A 13-year-old boy was admitted to our hospital with altered states of consciousness coupled with a headache and nausea. Upon admission, the patient was afebrile and comatose with a decorticated posture and was subsequently intubated. All routine laboratory tests and cerebrospinal fluid analyses were normal. Brain T2-weighted MRI (figure 1A) revealed multiple hyperintense signals in the brainstem and cerebellum. A single gadolinium-enhanced lesion was observed in the left occipital lobe. These observations were indicative of acute disseminated encephalomyelitis (ADEM) and we subsequently started methylprednisolone pulse therapy. In the follow-up MRI study, the lesions were necrotic, suggesting changes after a stroke rather than ADEM. The MR angiography (figure 1B) and the conventional cerebral angiography (figure 1C,D) performed on days 25 and 28, respectively, revealed segmental stenoses ("beading") of the basilar artery and the left middle cerebral artery and the near occlusions of both posterior cerebral arteries with thrombus adjacent to the basilar artery bifurcation. No angiographic abnormalities were observed in the extracranial carotid and renal arteries. We diagnosed the lesions as angiitic infarctions and started plasma exchange and antiplatelet therapy.

Medial medullary infarction identified by diffusion-weighted magnetic resonance imaging.

OBJECTIVE: To elucidate the frequency and clinical profiles of patients with medial medullary infarction (MMI) identified by diffusion-weighted MRI (DWI). METHODS: We assessed the frequency, radiological findings, etiology and clinical features of MMI detected by DWI from our single-center registry of acute ischemic patients. RESULTS: Thirty patients (1.5% of 2,014 with ischemic stroke) had MMI, including isolated unilateral MMI in 26 patients. Lesions were located by DWI in the rostral medulla of 25 patients (83%). Culprit infarcts that were undetectable by DWI in 6 (38%) of 16 patients who were assessed within 24 h after onset were later confirmed as MMI. The major etiological mechanism was small artery occlusion (SAO; 19 patients) and the median initial National Institutes of Health Stroke Scale score was 4 (interquartile range: 3-4.75). The most frequent symptom was contralateral hemiparesis (27 patients). None of the patients fulfilled the classical Dejerine Triad. Twenty-two patients (73%) had a modified Rankin Scale score of ≤2 at 3 months. A patient developed transient ischemic attack within 3 months; none developed recurrent stroke. CONCLUSIONS: Rostral medullary infarction with mild neurological deficits resulting from SAO is relatively frequent. Because emergency DWI within 24 h could not detect MMI in one third of the patients, this type of infarction could be misdiagnosed as capsular/pontine lacunae or other neurological disorders.

Claude's syndrome associated with neurocysticercosis.

Claude's syndrome is a distinctive brainstem syndrome characterized by ipsilateral third cranial nerve palsy with contralateral hemiataxia and is due to an intrinsic or extrinsic lesion in the midbrain. We report a case of Claude's syndrome caused by neurocysticercosis infection. A 68 year-old Asian man was admitted to our hospital because of ataxia, left ptosis, and diplopia. Brain magnetic resonance imaging (MRI) showed a cystic lesion in the midbrain, which was surrounded by ring enhancement and peripheral edema. Neurocysticercosis infection was diagnosed by the cerebral spinal fluid study. The patient was treated with albendazole and steroids. A follow-up brain MRI three months later demonstrated the disappearance of a surrounding brain edema and rim enhancement. The most common cause of Claude's syndrome is cerebrovascular disease and malignancy. However, there is no report caused by neurocysticercosis infection. Therefore, if we encounter Claude's syndrome, we should consider neurocysticercosis infection as one of the etiologic factors.

Clinical approach to brainstem lesions.

The brainstem consists of the midbrain, pons, and medulla. The cerebellum is attached to the dorsal surface of the pons and upper medulla. The brainstem contains 9 of the 12 cranial nerves and is crossed by ascending, descending, and cerebellar pathways and their nuclei as well as the reticular formation. Numerous and rare crossed brainstem syndromes have been described in recent years, many of them without clinical significance. The aim of this article is to provide a brief clinical description of some conditions affecting the brainstem.

Magnetic resonance techniques for the brainstem.

Imaging of the brainstem is a real challenge from the technical point of view, because it is a very complex structure. There are gray matter nuclei with vital functions mixed to white matter tracts with very important connections, as the Cortico-Spinal Tract (CST). On the other hand, the situation of the brainstem, near bony structures and surrounded by vessels adds even more difficulties due to the lower homogeneity of the field and the flow effect of both the vessels and the CSF. Structural imaging with 3-D sequences, either in T1 or T2 has been a major advance in the diagnosis of small lesions of the brainstem. Advanced techniques such as Spectroscopy, Diffusion and Perfusion sequences add important information that can reliably handle many lesions in which biopsy is a very high risk. Therefore, proper management of imaging techniques is particularly important in lesions of the brainstem.