Bilateral, vertical supranuclear gaze palsy following unilateral midbrain infarct.

A 60-year-old man recently admitted for bipedal oedema, endocarditis and a persistently positive COVID-19 swab with a history of anticoagulation on rivaroxaban for atrial fibrillation, transitional cell carcinoma, cerebral amyloid angiopathy, diabetes and hypertension presented with sudden onset diplopia and vertical gaze palsy. Vestibulo-ocular reflex was preserved. Simultaneously, he developed a scotoma and sudden visual loss, and was found to have a right branch retinal artery occlusion. MRI head demonstrated a unilateral midbrain infarct. This case demonstrates a rare unilateral cause of bilateral supranuclear palsy which spares the posterior commisure. The case also raises a question about the contribution of COVID-19 to the procoagulant status of the patient which already includes atrial fibrillation and endocarditis, and presents a complex treatment dilemma regarding anticoagulation.

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.

Pattern of voiding dysfunction after acute brainstem infarction.

BACKGROUND: The purpose of this study is to compare the patterns of voiding dysfunction according to the locations of brainstem lesions. METHODS: Between November 2008 and December 2011, a total of 30 patients participated in this study. All 30 subjects, consisting of 16 men and 14 women, aged between 41 and 82 years (mean age, 63.0±11.0 years) underwent a urodynamic study within 7 days after the onset of a stroke. RESULTS: Twenty-one (70%) patients had a pontine lesion and 9 (30%) had a medullary lesion. Fourteen of these patients (46.7%) had bladder storage disorder, 7 patients (23.3%) had bladder emptying disorder, and 9 patients (30%) had a normal report. Five of the patients who had a medullary lesion (55.6%) had bladder emptying disorder, whereas only 2 patients who had a pontine lesion (9.5%) had bladder emptying disorder. Thirteen patients who had a pontine lesion (61.9%) showed bladder storage disorder. DISCUSSION: The descending pathway from the midbrain tegmentum is inhibitory, and the pathway from the pontine tegmentum is stimulatory. Because of their location pontine lesions could disrupt the descending fibers of the midbrain tegmentum and medullary lesions could disrupt the descending fibers of the pontine tegmentum.

Ocular vestibular evoked myogenic potentials induced by air-conducted sound in patients with acute brainstem lesions.

OBJECTIVE: The ocular vestibular-evoked myogenic potential (oVEMP), a recently documented otolith-ocular reflex, is considered to reflect the central projections of the primary otolithic afferent fibers to the oculomotor nuclei. The aim of our study is to define air-conducted sound oVEMP abnormality in patients with acute brainstem lesions and to determine the brainstem structures involved in the generation of oVEMPs. METHODS: In response to air-conducted tone burst sounds (ACS), oVEMP was measured in 52 patients with acute brainstem lesions. Individualized brainstem lesions were analyzed by means of MRI-based voxel-wise lesion-behavior mapping, and the probabilistic lesion maps were constructed. RESULTS: More than half (n=28, 53.8%) of the patients with acute brainstem lesions showed abnormal oVEMP in response to ACS. The majority of patients with abnormal oVEMPs had lesions in the dorsomedial brainstem that contains the medial longitudinal fasciculus (MLF), the crossed ventral tegmental tract (CVTT), and the oculomotor nuclei and nerves. CONCLUSION: MLF, CVTT, and the oculomotor nuclei and nerves appear to be responsible for otolith-ocular responses in the brainstem. SIGNIFICANCE: Complemented to cervical VEMP for the uncrossed otolith-spinal function, oVEMP to ACS may be applied to evaluate the crossed otolith-ocular function in central vestibulopathies.

Occurrence and clinicotopographical correlates of brainstem infarction in patients with diabetes mellitus.

BACKGROUND: The goal of the study was to clarify the association between diabetes mellitus (DM) and brainstem infarctions (BSIs) and to investigate the clinicotopographic characteristics of BSIs in patients with diabetes. METHODS: Data were retrospectively reviewed for 1026 consecutive patients admitted to our hospital because of acute cerebral infarctions from January 2004 to August 2010. Acute symptomatic BSIs were explored on radiologic images and classified into multiple infarctions with BSIs, multifocal BSIs, and monofocal BSIs. Isolated BSIs were further classified based on the vertical distribution into midbrain, pontine, and medullary infarctions, and on the horizontal distribution into anterior-dominant, posterior-dominant, and anterior/posterior BSIs. Neurologic symptoms of BSIs and clinical background were compared between DM and non-DM patients. RESULTS: The prevalence of BSIs was 2.6-fold higher (P < .0001) in DM patients. Logistic regression analysis including age, sex, smoking, previous stroke, atrial fibrillation, other cardiac diseases, hypertension, hyperlipidemia, and DM showed that DM was independently associated with BSIs (odds ratio [OR] 2.814; 95% confidence interval [CI] 1.936-4.090; P < .0001). Compared with non-DM patients, DM patients showed more frequent monofocal BSIs (P < .0001) and multifocal BSIs (P = .0296). Monofocal BSIs (n = 114) more frequently involved the pons (P < .0001) and medulla (P = .0212). Anterior-dominant BSIs (P < .0001) were more common in DM patients than in non-DM patients. Symptoms of BSIs included more frequent motor paresis (P = .0180) and less frequent diplopia (P = .0298) in DM patients than in non-DM patients. CONCLUSIONS: DM is important in the development of BSIs, and the associated clinical characteristics include more frequent motor paresis and less frequent diplopia.

Unilateral headache associated with a pontine infarction.

Brain stem structures are implicated in the generation of migraine and other types of headache. The patient described herein had chronic left hemicranial headaches associated with a left pontine infarction.

Brain stem cavernous malformations.

We retrospectively reviewed the clinical experience of 30 patients with brain stem cavernous malformations (BSCM) treated operatively and non-operatively at our hospital between 1983 and 2005 to elucidate the natural history of BSCM and the factors that affect surgical outcome. Inpatient charts, imaging studies, operative records, and follow-up results were evaluated. The average follow up was 48.5 months. Twenty-two patients (73.3%) received surgical extirpation and of these 86.4% improved or stabilized and 13.6% deteriorated with permanent or severe morbidity. There was no mortality. Size, preoperative status, and surgical timing were factors related to surgical outcome. In the non-operative group, 50% of the patients were the same or better, 25% deteriorated, and 25% died. With appropriate patient selection, resection of BSCM can be achieved with acceptable morbidity compared with the ominous natural history of these lesions.

Rupture of a vertebral artery dissecting aneurysm developing immediately after trapping of a dissecting aneurysm on the contralateral vertebral artery: case report.

The development of vertebral artery (VA) dissecting aneurysm after trapping of the contralateral VA is rare, and rupture of angiographically occult VA dissecting aneurysms immediately after trapping is even less common. A 39-year-old man suffered subarachnoid hemorrhage caused by rupture of a left VA dissecting aneurysm. The VA was trapped and the left occipital artery anastomosed to the posterior inferior cerebellar artery. Postoperatively, he suddenly developed apnea and died of rupture of a right VA dissecting aneurysm. Histological examination of the bilateral VAs and the basilar artery disclosed a hematoma between the media and the adventitia. This case further confirms the need for careful preoperative imaging study of the dissection and all segments of the dissected vessel in patients requiring trapping of a VA dissecting aneurysm, as well as preservation of VA anterograde flow.

Experimental model of brainstem stroke in rabbits via endovascular occlusion of the basilar artery.

BACKGROUND: Basilar artery thrombosis remains a significant clinical problem, and no reproducible animal model has been established to study the stroke within the vertebrobasilar distribution. We report a study designed to pilot test a novel model of brainstem stroke in rabbits, created by selective endovascular occlusion of the basilar artery. METHODS: Basilar artery occlusion was induced in 8 New Zealand white rabbits by injection of the autologous clot through the microcatheter positioned within the distal vertebral artery. Animals were divided into subgroups (I and II) based on the length of produced ischemia (3 and 6 hours, respectively). Magnetic resonance (MR) imaging of the brain and MR angiography of the intracranial vessels were performed before the procedure, and at 3 hours after induced ischemia for groups I and II, with continued imaging up to 6 hours for group II, with diffusion-weighted images acquired approximately every 30 minutes. Animals were killed at the end of the 3-hour (group I) or 6-hour (group II) ischemia time. RESULTS: Brainstem stroke was successfully induced in all animals, with pathological changes documented in all cases. The earliest changes of ischemia on MR diffusion-weighted images were identified at only 4.5 hours of basilar artery occlusion. CONCLUSION: These results suggest that a reproducible model of brainstem stroke can be induced in rabbits using selective endovascular occlusion of the basilar artery. The availability of such a model, integrated with state-of-the-art imaging techniques, holds promise for preclinical investigations of emergent therapeutic approaches in stroke.

Typical trigeminal neuralgia associated with brainstem white matter lesions on MRI in patients without criteria of multiple sclerosis.

INTRODUCTION: Although compression of the trigeminal nerve by a vascular loop is thought to be the most common cause of trigeminal neuralgia (TN), other aetiologies, such as multiple sclerosis or brainstem infarction may be associated with this disorder. MRI may detect lesions different from vascular loop compression of the trigeminal nerve that may be related to TN. PATIENTS AND METHODS: The pre-operative MRIs of 68 patients without the diagnosis of multiple sclerosis who were operated for typical TN between 1998 and 2003 were retrospectively reviewed Four of these showed hyperintense lesions in the pons on T2 MRI sequences. No patient had prior surgery. These four patients underwent different operations for the control of pain but in two of them only ablative procedures were effective DISCUSSION: Although it is uncertain whether the occurrence of TN in our patients may be attributed to the brainstem abnormalities seen on MRI, the presence of these lesions appears to be the most convincing explanation for the occurrence of pain. We believe that, in the presence of such imaging changes, a destructive procedure should be regarded as the elective surgical treatment in patients presenting with typical TN with or without apparent vascular loop compression of the trigeminal root.

Use of intravenous tissue plasminogen activator in a 16-year-old patient with basilar occlusion.

Intravenous tissue plasminogen activator (t-PA) is currently approved by the US Food and Drug Administration (FDA) for the treatment of ischemic stroke in patients > 18 years of age who present within 3 hours of stroke onset and meet certain criteria. We report a case of a 16-year-old, previously healthy female who presented with a basilar artery occlusion and pontine ischemic stroke. She was treated with intravenous t-PA approximately 4 hours after the onset of symptoms. The patient demonstrated a remarkable recovery 6 hours after onset of her symptoms and had minimal deficits on discharge from the hospital 1 week later. She was found to have a lupus anticoagulant and was heterozygous for the prothrombin gene G2010A mutation. These were likely contributing causes for her stroke. She was also homozygous for plasminogen activator inhibitor 1 (PAI-1) 4G/4G, which at present is a controversial stroke risk factor.

Simultaneous posterior ischemic optic neuropathy, cerebral border zone infarction, and spinal cord infarction after correction of malignant hypertension.

A 31-year-old woman developed bilateral posterior ischemic optic neuropathy and infarctions of the cerebral arterial border zones and spinal cord after correction of malignant hypertension. Although a few reports have described patients with neurologic abnormalities after treatment of malignant hypertension, full clinical and neuroimaging documentation of this combination of findings has not occurred. This case report suggests that the relative hypotension of autoregulatory failure induced by treatment of malignant hypertension may give rise to these neurologic complications.

Brainstem distortion from postoperative cerebellar herniation through a dural and bony defect.

We report a patient with a cerebellar encephalocele following excision of a cerebellar metastasis. This is a life-threatening condition that may be prevented with adequate dural and bony closure.

Dissection of the posterior inferior cerebellar artery in a young adult with cerebellar infarct.

The posterior inferior cerebellar artery (PICA) is frequently involved in dissection of the vertebral artery (VA); however, isolated PICA dissection has rarely been reported. A 37-year-old man experienced acute and progressive drowsiness, vertigo, occipital headache, vomiting, and ataxia. There was no precedent trauma or chiropractic manipulation. Neurologically, he had dysmetria of the left extremities. His NIHSS score was 3. Brain magnetic resonance imaging showed an acute cerebellar infarct in the left PICA territory. Magnetic resonance angiography showed a faint signal adjacent to the junction of the left VA and PICA, suggesting a vascular shadow. Catheter angiography showed focal stenosis with a post-stenotic fusiform aneurysmal dilatation of the left proximal PICA that was highly suggestive of dissection with pseudoaneurysm formation. He was treated with clopidogrel and was free of neurological symptoms 3 months after the stroke event. Isolated PICA dissection may be considered in patients with PICA territory infarct or subarachnoid hemorrhage. Treatment depends on the manifestations; ruptured dissecting aneurysms are often treated with surgery or embolization, and infarcts are usually treated with antithrombotic agents.

Uveitis associated with Primary Angiitis of the Central Nervous System.

BACKGROUND: In Primary Angiitis of the Central Nervous System (PACNS), disease is typically limited to the brain and spinal cord although other organs may be affected. Uveitis is occasionally seen in systemic vasculitides but is not a recognized manifestation of PACNS. We describe two patients who developed PACNS following the onset of uveitis. CASE DESCRIPTIONS: Case 1--a 47-year-old male suffered multiple TIAs and left pontine stroke shortly after two episodes of diffuse uveitis. A cerbral angiogram demonstrated multiple caliber changes within several intracranial vessels. Cyclophosphamide was added after his stroke occurred during pulse methylprednisolone therapy. Case 2--a 35-year-old male suffered a spinal cord TIA followed by hemispheric and brainstem infarctions two months after an episode of uveitis and Bell's palsy treated with oral prednisone. A cerebral angiogram demonstrated multiple caliber changes within several intracranial vessels. He was successfully treated with oral prednisone and cyclophosphamide. CONCLUSIONS: Uveitis should be considered a recognized feature of PACNS. Combination immunosuppressive therapy with prednisone and cyclophosphamide may be necessary for successful treatment.

Brainstem hypoperfusion in severe symptomatic vasospasm following aneurysmal subarachnoid hemorrhage: role of basilar artery vasospasm.

BACKGROUND: The hemodynamic effects of vertebrobasilar vasospasm are ill defined. The purpose of this study was to determine the effects of basilar artery (BA) vasospasm on brainstem (BS) perfusion. METHODS: Forty-five patients with delayed ischemic neurological deficits (DIND) following aneurysmal subarachnoid hemorrhage (SAH) underwent cerebral angiography prior to decision-making concerning endovascular treatment. BA diameter was compared with baseline angiogram. Regional brainstem (BS) cerebral blood flow (CBF) was qualitatively estimated by (99m)Tc ethyl cysteinate dimer single photon emission computed tomography (ECD-SPECT). FINDINGS: Delayed BS hypoperfusion was found in 22 (48.9%) of 45 patients and BA narrowing of more than 20% was found in 23 (51.1%). Seventeen of 23 (73.9%) patients with BA narrowing of more than 20% experienced BS hypoperfusion compared to 6 of 22 (27.3%) patients with minimal or no narrowing (p = 0.0072). Patients with severe and moderate BS hypoperfusion had higher degree of BA narrowing compared to patients with normal BS perfusion and mild BS hypoperfusion (p < 0.001). The three-month outcome of patients n-22) with BS hypoperfusion was significantly worse compared to patients (n-23) with unimpaired (p = 0.0377, odd ratio for poor outcome 4, 1.15-13.9 95% confidence interval). INTERPRETATION: These findings suggest that the incidence of BA vasospasm in patients with severe symptomatic vasospasm is high and patients with significant BA vasospasm are at higher risk to experience BS ischemia. Further studies should be done to evaluate the effects of endovascular therapy on BS perfusion and the impact of BS ischemia on morbidity and mortality of patients with severe symptomatic vasospasm.