Basilar Artery Tortuosity May Be Associated with Early Neurological Deterioration in Patients with Pontine Infarction.

BACKGROUND: Early neurological deterioration (END) occurs in patients with pontine infarction that is adversely associated with a long-term functional outcome. As basilar artery (BA) tortuosity may alter hemodynamics, we investigated whether factors including BA tortuosity are associated with END and poor outcome at 3 months. METHODS: We reviewed patients with acute (<7 days from stroke onset) unilateral pontine infarction mainly involving the pontine base and/or tegmental regions from January 2017 through April 2021. END was defined as increase of ≥2 in total National Institutes of Health Stroke Scale (NIHSS) score or ≥1 in motor NIHSS score within first 72 h. A poor clinical outcome was defined as modified Rankin Scale (mRS) 3-6 at 3 months. The BA tortuosity index (TI) was measured: ([actual/straight length -1] x 100). To assess interobserver agreement, TI measurements were obtained by 2 independent raters. RESULTS: The study included 245 patients; END occurred in 72 (29.3%) and 35 (14.2%) showed poor outcome at 3 months. Old age (odds ratio [OR] = 1.03, 95% confidence interval [CI] 1.004-1.062; p = 0.027), previous stroke history (OR = 2.36, 95% CI: 1.176-4.717; p = 0.016), lower initial NIHSS (OR = 0.72, 95% CI: 0.628-0.827; p < 0.001), and high BA TI (OR = 1.17, 95% CI: 1.062-1.295; p = 0.002) were associated with END. On the other hand, old age (OR = 1.04, 95% CI: 1.002-1.073; p = 0.037) and END (OR = 3.03, 95% CI: 1.429-6.403; p = 0.004) were associated with poor outcome at 3 months. CONCLUSIONS: High BA tortuosity may be a factor associated with END in patients with pontine infarction. As END was related to unfavorable clinical outcome, this risk may have to be carefully considered in patients with high BA tortuosity.

Complete functional recovery in a child after endovascular treatment of basilar artery occlusion caused by spontaneous dissection: a case report.

Stroke caused by dissection of arteries of the vertebrobasilar system in children is still poorly investigated in terms of etiology, means of treatment, course of disease, and prognosis. The aim of this report was to describe the unusual course of a spontaneous dissection of the basilar artery (BA) in a child treated with endovascular techniques and to point out that the plasticity of the brain stem can fully compensate for structural damage caused by stroke. We report the case of a 15-year-old boy who suffered a wake-up stroke with BA occlusion caused by spontaneous dissection. A blood clot was aspirated from the false lumen and the true lumen re-opened, but the patient deteriorated a few hours later, and repeated angiography revealed that the intimal flap was detached, occluding the BA again. The lumen of BA was then reconstructed by a stent. Despite a large pons infarction, the patient was completely recovered 11 months after the onset. The case was analyzed with angiograms and magnetic resonance imaging, macroscopic and microscopic pathological analysis, computed tomographic angiography, magnetic resonance-based angiography, and diffusion tensor imaging. This case illustrates that applied endovascular techniques and intensive care measures can alter the course of potentially fatal brain stem infarction. Our multimodal analysis gives new insight into the anatomical basis for the plasticity mechanism of the brain stem.

Anatomic and MRI bases for medullary infarctions with patients' presentation.

OBJECTIVE: There is a low incidence of the medullary infarctions and sparse data about the vascular territories, as well as a correlation among the anatomic, magnetic resonance imaging (MRI) and neurologic signs. MATERIALS AND METHODS: Arteries of the 10 right and left sides of the brain stem were injected with India ink, fixed in formalin and microdissected. The enrolled 34 patients with medullary infarctions underwent a neurologic, MRI and Doppler examination. RESULTS: Four types of the infarctions were distinguished according to the involved vascular territories. The isolated medial medullary infarctions (MMIs) were present in 14.7%. The complete MMIs comprised one bilateral infarction (2.9%), whilst the incomplete and partial MMIs were observed in 5.9% and 8.9%, respectively. The anterolateral infarctions (ALMIs) were very rare (2.9%). The complete and incomplete lateral infarctions (LMIs), noted in 35.3%, comprised 11.8% and 23.6%, respectively, that is, the anterior (5.9%), posterior (8.9%), deep (2.9%), and peripheral (5.9%). Dorsal ischemic lesions (DMIs) occurred in 11.8%, either as a complete (2.9%), or isolated lateral (5.9%) or medial infarctions (2.9%). The remaining ischemic regions belonged to various combined infarctions of the MMI, ALMI, LMI and DMI (35.3%). The infarctions most often affected the upper medulla (47.1%), middle (11.8%), or both (29.5%). Several motor and sensory signs were manifested following infarctions, including vestibular, cerebellar, ocular, sympathetic, respiratory and auditory symptoms. CONCLUSIONS: There was a good correlation among the vascular territories, MRI ischemia features, and neurologic findings regarding the medullary infarctions.

Brainstem Infarctions Caused by a Proximal Marker of the PulseRider Device Obstructing the Origin of a Perforator.

The PulseRider (Cerenovus, Johnson & Johnson Medical Devices, New Brunswick, NJ, USA) is a neck reconstruction device that is used for the treatment of unruptured wide-necked bifurcation aneurysms. Herein, we describe the case of a 51-year-old male patient with a basilar apex aneurysm who was treated with PulseRider but had post-procedural brainstem infarctions caused by one of the proximal markers covering the origin of a perforator. In such cases, repositioning of the PulseRider should be performed to avoid infarctions.

Massive Brainstem and Cerebellum Infarction Due to Traumatic Extracranial Vertebral Artery Dissection in a Motor Traffic Accident: An Autopsy Case Report.

ABSTRACT: Traumatic unilateral vertebral artery (VA) injury can cause focal thrombosis and may block the basilar artery which can further lead to ischemic stroke and massive cerebral infarction and subarachnoid hemorrhage and even rapid death. Here, we present an autopsy case with a traumatic extracranial VA dissection in a motor traffic accident, and the identification of cause of death underwent 2 autopsies. A 62-year-old male pedestrian collided with the right rearview mirror of a car and fell down to the ground. He complained pains in the head and neck. Head computed tomography (CT) showed a right linear temporal bone fracture and a small left temporal subdural hematoma. Neck CT and magnetic resonance imaging (MRI) examination showed left transverse process fracture of the sixth cervical vertebra (C6) and left extracranial VA injury. After 6 days of hospitalization, the left temporal subdural hematoma had been nearly absorbed, and the man was discharged home. On day 15 after the traffic accident, the man suffered sudden unconsciousness accompanied by frequent vomiting at home. The man was taken to hospital, and there were no obvious abnormal findings by head CT examination. However, the man soon fell into a coma state and died 2 days later. The first autopsy was performed 7 days after death and confirmed a left transverse process fracture of C6 and that the deceased died of cerebral infarction and secondary subarachnoid hemorrhage caused by blunt force in the motor traffic accident. In the civil lawsuit, the traffic accident wrecker put forward the objection whether the deceased had fatal diseases. The second autopsy (84 days after the death) findings verified the left extracranial VA injury. Histopathological examination further showed intimal dissection and thrombus formation of the left extracranial VA and secondary basal arterial thromboembolism. Massive infarction of the brainstem and cerebellum was disclosed. Therefore, the deceased died of delayed massive brainstem and cerebellum infarction because of left extracranial VA dissection in the motor traffic accident.

Bilateral MCP Infarct Due to Vertebral Giant Cell Arteritis.

We present the case of an 83-year-old woman with an isolated bilateral middle cerebellar peduncles stroke caused by complete occlusion of the right vertebral artery and focal occlusion of the left vertebral artery due to giant cell arteritis. The diagnosis was achieved by integrating MRI, ultrasound study, laboratory data and subsequent pathology analysis after biopsy of the temporal artery.

Higher Cerebral Small Vessel Disease Burden in Patients with White Matter Recent Small Subcortical Infarcts.

INTRODUCTION: Recent small subcortical infarcts (RSSI) are considered an acute manifestation of cerebral small vessel disease (CSVD). We assessed whether the topography of RSSI was related to CSVD markers on magnetic resonance imaging (MRI). MATERIAL AND METHODS: We screened the local registries of two independent stroke centers in Catalonia and selected patients with a symptomatic RSSI on MRI performed during admission. RSSI location was classified into brainstem, supratentorial subcortical structures (SSS), and centrum semiovale (CSO) regions. Clinical variables, including vascular risk factors, were collected. Radiological markers of CSVD on MRI were evaluated individually and by means of the global CSVD burden score. The associations between each RSSI location and CSVD markers were studied in uni- and multivariate logistic regression analysis. RESULTS: Among 475 patients with RSSI, 152 (32%) had an infarct in the brainstem, 227 (48%) in SSS, and 96 (20%) in CSO region. The median CSVD burden score was 2 (IQR, 1-3). After adjusting for confounding factors, a RSSI in CSO was associated with higher periventricular and deep white matter hyperintensity scores [OR 1.64 (95% CI, 1.16-2.33), and OR 1.44 (95% CI, 1.07-1.93), respectively]. Higher CSVD burden score was positively associated with CSO [OR 1.48 (95% CI, 1.22-1.81)] and inversely associated with SSS [0.85 (95% CI, 0.72-0.99)] location after adjusting for relevant confounders. CONCLUSIONS: CSO RSSI were related to a higher burden of CSVD, particularly to white matter hyperintensities, compared to other RSSI locations. The pathophysiological significance of such findings should be investigated in the future with advanced neuroimaging techniques.

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.

Chronic Small Cortical Cerebellar Infarctions on MRI are Associated with Patent Foramen Ovale in Young Cryptogenic Stroke.

BACKGROUND: In acute infarction patients, small cortical cerebellar infarctions (SCCI) on MRI (assessed on diffusion-weighted imaging, with SCCI often chronic and asymptomatic) are associated with acute cardioembolic infarction. In young cryptogenic stroke patients, patent foramen ovale (PFO) is thought to be a potential source of cardioembolic infarction. We hypothesize that SCCI on MRI would be associated with PFO in young cryptogenic stroke patients. METHODS: A total of 321 consecutive young (≤50 years) stroke patients admitted between January 2015 and July 2019 were screened. Of these patients, 287 patients had diagnostic work-up including early-phase MRI, intra- and extracranial vessel imaging, contrast transoesophageal or contrast transthoracic echocardiography, and ≥24 h ECG-monitoring. We retrospectively analyzed MRI scans of the 112 patients with cryptogenic stroke, including 63 with and 49 without PFO. Between both groups, we compared baseline characteristics (including cardiovascular risk factors and history of stroke), MRI characteristics of acute symptomatic infarction (cortical/subcortical localization, arterial territory, lesion number, and lesion size in case of subcortical infarction), atrial septum aneurysm (ASA) presence, and acute and chronic SCCI and non-SCCI lesions assessed on diffusion-weighted imaging. RESULTS: Groups with and without PFO were comparable in regard to performed vessel imaging and echocardiography modalities, baseline characteristics, and acute infarction characteristics, except for more frequent current smoking (67 vs. 44%, p = 0.022) and multiterritorial infarction (14 vs. 0%, p = 0.0024) and less frequent ASA (10 vs. 48%, p < 0.001) in the group without PFO. Risk of Paradoxal Embolism score was >6 in 76% of patients with PFO. SCCI was more frequent in patients with than without PFO (33 vs. 10%, p = 0.0061; OR 4.4, 95% CI 1.5-12.7), with chronic and asymptomatic SCCI in the vast majority of cases. No difference was observed for non-SCCI lesions. CONCLUSIONS: Chronic SCCI are strongly associated with PFO in young cryptogenic stroke patients. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT04043559.

Intravenous thrombolysis for pure pontine infarcts caused by cardiac myxoma: a case report and literature review.

Purpose: Cardiac myxoma (CM) is a rare but important cause of ischemic stroke, and typically involves the middle cerebral artery and rarely affects the brainstem only. The safety and efficacy of intravenous thrombolysis (IVT) for CM-related acute cerebral embolism are not clear.Methods: We report a case of a 55-year-old woman who suffered a CM-related acute cerebral embolism presented with pure pontine infarcts and achieved a favorable prognosis by IVT with urokinase. We summarized the clinical data of this entity and performed a literature review of 21 previous reports of patients with CM-related acute cerebral embolism who were treated with IVT.Results: In combination with previous reports, we found that the majority of patients (81.8%) obtained improvements in symptoms after IVT, including 63.6% in remarkable clinical improvement. The total rate of IVT-induced intracerebral hemorrhage was 22.7% and all occurred within 36 h, including hemorrhagic infarction type 1 (4.5%) and parenchymal hematoma type 2 (18.2%). Most of the cases had relatively good outcomes and no case died due to IVT.Conclusion: Taken together, our findings support the use of IVT as an effective and safe tool for the ultra-early treatment of CM-related acute phase ischemic stroke.

"Basilar Web" Causing Basilar Branch Infarction.

We present a young patient with no vascular risk factors with a basilar branch infarction secondary to a shelf-like filling defect of the basilar artery. This defect was present and unchanged on repeat imaging and determined to be most consistent with a basilar web. Similar to carotid webs, a basilar web is believed to be an area of focal intimal fibroplasia that increases the risk of brainstem infarction. Focal fibroplasia of the posterior circulation should be considered when evaluating young adults with posterior circulation strokes of otherwise undetermined cause.

Non-alcoholic fatty liver disease is associated with stroke severity and progression of brainstem infarctions.

BACKGROUND AND PURPOSE: Non-alcoholic fatty liver disease (NAFLD) is closely correlated to visceral obesity, dyslipidaemia, insulin resistance and type 2 diabetes mellitus. We sought to assess the association between a specific stroke subgroup, brainstem infarctions (BSIs) and NAFLD. Furthermore, we evaluated whether NAFLD is an independent risk factor in patients with BSIs. METHODS: Non-alcoholic fatty liver disease was assessed in 306 patients with radiologically confirmed BSIs via liver ultrasound. Differences between patients with and without NAFLD were compared. Data associated with stroke severity and progression after admission were collected. RESULTS: Non-alcoholic fatty liver disease was found in 130 (42.5%) patients with acute BSIs; 58 (19.0%) had National Institutes of Health Stroke Scale scores >7 and 57 (18.6%) had progression after admission. Initial National Institutes of Health Stroke Scale scores, incidence of progression and stroke severity, and modified Rankin Scale scores at discharge were significantly higher in patients with NAFLD than in those without NAFLD. NAFLD was associated with stroke severity [Cox regression: hazard ratio (HR), 2.243; 95% confidence interval (CI), 1.254-4.013, P < 0.01]. This risk remained statistically significant after controlling for age, gender, diabetes mellitus and C-reactive protein (HR, 2.327; 95% CI, 1.252-4.324, P < 0.01). In addition, NAFLD was associated with progression (HR, 2.155; 95% CI, 1.201-3.865, P < 0.05) and remained significant after controlling for age, gender, diabetes mellitus, fibrinogen and C-reactive protein (HR, 2.378; 95% CI, 1.260-4.486, P < 0.01). CONCLUSIONS: These results suggest that NAFLD is a potential risk factor when evaluating the severity and progression of acute BSIs. This relationship is independent of classic risk factors and metabolic syndrome features.

Varicella zoster virus reactivation antedating ipsilateral brainstem stroke.

itor Title: Varicella zoster virus reactivation antedating ipsilateral brainstem stroke Authors: Giuliana Galassi1, Maurilio Genovese2, Marisa Meacci3, Marcella Malagoli2 Affiliations: 1Department of Biomedical, Metabolic, Neural Sciences, University Hospital of Modena, Italy, 2Neuroradiology Service, University Hospital of Modena, Italy, 3Department of Laboratory Medicine and Patholgy, Microbiology and Virology Unit, University Hospital of Modena, Italy Corresponding Author: Giuliana Galassi, MD, Department of Biomedical, Metabolic, Neural Sciences, University Hospital of Modena, Via P. Giardini 1455, Modena, Italy, Tel: 39-3497325802, Email: giulianagalassi46@gmail.com Abstract: Varicella zoster virus (VZV) infection and reactivation are associated with a number of neurologic conditions. Unifocal large vessel infarcts may follow zoster in the trigeminal or cervical distribution as a result of transaxonal transport of virus from trigeminal or cervical afferent fibers that innervate vessels. Ophthalmic zoster (HZO) might cause ophthalmoplegic syndromes, with secondary optic neuritis. Mechanisms include local orbital muscle inflammation and, viral spread from the ophthalmic branch of the fifth nerve with associated vasculopathy. A 72-year-old man developed a vesicular rash in the territory of C5-T5-6. Within four weeks, the patient developed headache, dysphagia, left facial and extremity ataxic weakness. Magnetic resonance imaging (MRI) revealed a right pontine infarction. A 66-year-old woman presented with right-sided painfull HZO. One week later she developed complete external ophthalmoplegia and blurred vision. MRI showed ill-defined signal alteration in the retrobulbar tissue. Three weeks later, the patient was admitted because of dysarthria, deviated tongue, left-sided limb weakness, and tactile hypoesthesia. Spinal fluid contained 23 lymphocytes/mm3 and increased protein. The serum contained antibodies to VZV IgG and IgM in both cases. The patients received intravenously acyclovir with improvement. This report confirms unusual occurrence of ipsilateral brainstem stroke after VZV reactivation in immunocompetent subjects.

Etiology of isolated pontine infarctions: a study based on high-resolution MRI and brain small vessel disease scores.

BACKGROUND: In this retrospective study, we investigated the main pathogenesis of the two types of isolated pontine infarction: paramedian pontine infarcts (PPIs) and small deep pontine infarcts (SDPIs). METHODS: Acute ischemic stroke patients, comprising 117 PPI patients and 40 SDPI patients, were enrolled. High-resolution magnetic resonance imaging (HR-MRI) and routine MRI sequences were performed for each patient, and clinical data were collected. The following brain small vessel disease (SVD) features of the MRI scans were each rated (0 or 1) separately: asymptomatic lacunar infarcts, white matter lesions (WMLs), deep and infratentorial cerebral microbleeds (CMBs), and enlarged perivascular spaces in the basal ganglia. The ratings were also summed in an ordinal "SVD score" (range: 0-4). The difference in the SVD score between the PPI and SDPI groups was determined. The presence and location of basilar artery (BA) atherosclerotic plaques (based on HR-MRI) in the two groups was evaluated. RESULTS: There was a significant difference in the total SVD score and three of the four independent SVD features (asymptomatic lacunar infarcts, WMLs, and deep and infratentorial CMBs) between the two groups. The prevalence of BA plaques relevant to the infarcts in the PPI group was significantly higher than that in the SDPI group, whereas the prevalence of plaques irrelevant to the infarcts was similar between the two groups. The degree of BA stenosis was slightly higher in the PPI group than in the SDPI group. Diabetes mellitus was much more prevalent in the PPI group. The National Institute of Health Stroke Scale score was higher in the PPI group, which is in accordance with the larger infarct size in the PPI group. CONCLUSION: BA atherosclerosis may be the major cause of PPI, while SVD may be the main mechanism underlying SDPI. HR-MRI combined with the total SVD score should be helpful to explore the pathogenesis underlying isolated pontine infarctions, especially in cases involving low-grade BA stenosis.

Predictors of Extubation Success in Patients with Posterior Fossa Strokes.

OBJECTIVE: Posterior fossa stroke is unique in its presentation and outcomes, and mechanical ventilation is commonly used in the management of these patients. We aimed to identify predictors of extubation success in patients with posterior fossa stroke, who require mechanical ventilation. DESIGN: We included consecutive adult patients admitted to the neurosciences ICU from January 2003 to December 2012. Extubation failure was defined as re-intubation within 7 days of extubation. A modified Rankin Scale score of 0-3 was considered a good outcome. MEASUREMENTS AND MAIN RESULTS: We identified 150 patients with mean age of 65 ± 15.7 years with posterior fossa strokes; 77 (51 %) were hemorrhagic, and 73 (49 %) were ischemic. The most common reason for intubation was depressed consciousness (54 %). Fifty-two (35 %) were successfully extubated, 18 (12 %) failed extubation, 17 (11 %) patients had tracheostomy without attempted extubation, and 63 (42 %) were transitioned to palliative care prior to extubation. In the logistic regression analysis, controlling for transition to palliative care, Glasgow Coma Score (GCS) score >6 at the time of intubation (p = 0.020), mechanical ventilation for less than 7 days (p = 0.004), and surgical evacuation of a hematoma (p = 0.058) were independently associated with successful extubation. The presence of cough, gag reflex, and absence of pneumonia/atelectasis were not associated with successful extubation. Success of extubation predicted a good outcome at hospital discharge. CONCLUSIONS: In posterior fossa stroke patients with a GCS ≤ 6 at the time of intubation and who remain intubated for more than 1 week, extubation is less likely to be successful, and tracheostomy should be considered.

Brain Stem Infarction Due to Basilar Artery Dissection in a Patient with Moyamoya Disease Four Years after Successful Bilateral Revascularization Surgeries.

Moyamoya disease (MMD) is a rare cerebrovascular disease with an unknown etiology and is characterized by intrinsic fragility in the intracranial vascular walls such as the affected internal elastic lamina and thinning medial layer. The association of MMD with intracranial arterial dissection is extremely rare, whereas that with basilar artery dissection (BAD) has not been reported previously. A 46-year-old woman developed brain stem infarction due to BAD 4 years after successful bilateral superficial temporal artery-middle cerebral artery anastomosis with indirect pial synangiosis for ischemic-onset MMD. She presented with sudden occipitalgia and subsequently developed transient dysarthria and mild hemiparesis. Although a transient ischemic attack was initially suspected, her condition deteriorated in a manner that was consistent with left hemiplegia with severe dysarthria. Magnetic resonance (MR) imaging revealed brain stem infarction, and MR angiography delineated a double-lumen sign in the basilar artery, indicating BAD. She was treated conservatively and brain stem infarction did not expand. One year after the onset of brain stem infarction, her activity of daily living is still dependent (modified Rankin Scale of 4), and there were no morphological changes associated with BAD or recurrent cerebrovascular events during the follow-up period. The association of MMD with BAD is extremely rare. While considering the common underlying pathology such as an affected internal elastic lamina and fragile medial layer, the occurrence of BAD in a patient with MMD in a stable hemodynamic state is apparently unique.

[The clinical, radiological and prognostic factor analysis of medullary infarction].

OBJECTIVE: To investigate the clinical and radiological features of medullary infarction (MI), and to compare the clinical characteristics of lateral medullary infarction (LMI) and medial medullary infarction (MMI). METHODS: Patients diagnosed as acute MI who were treated from January 2009 to December 2014 in Department of Neurology, Peking University Third Hospital, were retrospectively enrolled in the study and data were analyzed including risk factors, clinical features, laboratory findings, radiological characteristics, etiology and outcomes. RESULTS: A total of 62 cases of MI were enrolled with 48 cases of LMI and 14 cases of MMI , including 2 cases of bilateral MMI. The mean onset age of LMI and MMI was 60.2±12.3 and 56.9±14.2, respectively. The frequently affected location of LMI was the middle and upper part of medulla [40 cases (83.3%)]. The common symptoms and signs of LMI were dizzy (38 cases , 79.2%), sensory disturbance (33 cases , 68.8%), dysarthria ( 32 cases , 66.7%), dysphagia (30 cases , 62.5%), diminished pharyngeal reflex (30 cases, 62.5%), Horner's sign (29 cases, 60.4%), ataxia (26 cases, 54.2%) and nausea or vomiting (25 cases, 52.1%). The frequently affected location of MMI was the upper part of medulla (13 cases, 92.9%). The common symptoms and signs of MMI were motor dysfunction (12 cases, 85.7%), sensory disturbances (11 cases, 78.6%), dizzy (10 cases, 71.4%) and dysarthria (10 cases, 71.4%). Infarctions caused by atherosclerosis were found in 35 cases of LMI (72.9%) and 12 cases of MMI (85.7%). Five cases (10.4%) of LMI died in hospital, while 1 case (7.1%) of MMI died in hospital. No lesion was found in 16 cases (25.8%) by MRI-DWI within the first 24 hours of onset. CONCLUSIONS: Our study showes that the mean onset age of LMI is older than that of MMI. The lesion of LMI is frequently located in the upper and middle medulla, whereas the lesion of MMI is mostly in the upper medulla. The prognosis of LMI is worse than that of MMI. Atherosclerosis of the vertebral arteries is the predominant vascular pathology in MI.

[Brain stem infarction, temporal headache, and elevated inflammatory parameters in a 74-year-old man]. / Hirnstamminfarkt, temporaler Kopfschmerz und erhöhte Entzündungsparameter bei einem 74-jährigen Patienten.

We report the case of a 74 year old man with a brain stem infarction, temporal headache and elevated inflammatory parameters. Giant cell arteritis with involvement of the temporal and vertebral arteries was proven by histology, duplex sonography and MRI. Although intensive immunosuppressive therapy was started, the patient developed two brain infarcts within 6 months. Initially, C­reactive protein and erythrocyte sedimentation rate were significantly elevated, but normalized over time. Involvement of the vertebral artery in giant cell arteritis is thought to be rare; steroid refractory courses are very rare. Brain stem infarction might be the consequence.

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.