A Case Report of Severe Headache after Decompression Craniotomy by Cerebellar Infarction Successfully Treated with a Kampo Formulation Goreisan / 日本東洋医学雑誌

We report a case of severe headache associated with cerebellar infarction was successfully treated with Kampo therapy. The patient complained of severe headache and vertigo in spite of standard therapy after the decompression craniectomy. However, his symptoms were relieved immediately by administration of goreisan. The pharmacological effect of Kampo formulation i.e. goreisan is still unknown, but this formulation has been used for headache with edema, vertigo and vomiting. According to the classic textbook, this formulation has a potential to improve water imbalance in the body, including brain edema. This Kampo medicine is seemed to be an alternative to manage such patients.

Cerebellar infarction complicated with acute hydrocephalus

Acute hydrocephalus is a rare manifestation of posterior circulation strokes. Clinical worsening and coma may occur in addition to these symptoms of cerebellar dysfunction. Timely and careful approach will certainly prove to be life saving when deciding for a shunt procedure in a patient developing obstructive hydrocephalus following cerebellar infarct. The case presented here is a reminder for both this rare complication, and the treatment approach. We present a patient with cerebellar infarct and secondary obstructive hydrocephalus. Forty three year old male patient was brought to the emergency room in our hospital with unconsciousness, before that patient with suddenly developing dizziness, loss of balance and vomiting. His neurological examination showed that he was coma. The patient's brain computed tomography scan showed severe third and lateral ventricular dilation suggestive of obstructive hydrocephalus. Following shunt placement and suboccipital decompression, the patient recovered and was able to walk without assistance. Cerebellar infarcts may cause death as a result of pressure increase in the posterior fossa and pressure on the brain stem due to edema. Moreover, the aquaductus or the fourth ventricle may close because of edema and cause obstructive hydrocephalus and acute intracranial pressure increase. Temporary external ventricular drainage or permanent shunt systems and surgical decompression of the posterior fossa may be considered to prevent progressive neurologic worsening. In conclusion, we wished to point out that a timely surgical procedure in a cerebellar infarct case where acute hydrocephalus developed could be life saving.

Complications related with postoperative enteral nutrition in patients with massive cerebellar infarction / 中华临床营养杂志

Objective To investigate the complications of different enteral nutrition in patients after surgery for massive cerebellar infarction,so as to guide rational application of enteral nutrition in patients.Methods Forty-nine patients with massive cerebellar infarction were divided into three groups randomly:conventional nasogastric tube feeding group (group A,n =12),nasogastric tube feeding plus gastric motor drug group (group B,n =18),and nasojejunal tube feeding group (group C,n =19).The incidences of diarrhea,reflux,aspiration,upper gastrointestinal bleeding and aspiration pneumonia within 3 weeks after initiation of enteral nutrition were observed and compared among the groups.Results The incidence of diarrhea showed no statistically significant difference among the 3 groups (x2 =0.092,P =0.955).Compared with group A,the incidences of reflux,aspiration and aspirafion pneumonia were significantly lower in group B and group C (P ＜ 0.05),and lower in group C compared with group B (P ＜ 0.05).Compared with group C,the incidence of upper gastrointestinal bleeding was significantly lower in group C than in group A and group B (x22 =4.748,P2 =0.029;x23 =4.284,P3 =0.038),but the difference between group A and group B was not significant (x21 =0.000,P1 =1.000).Conclusions Because of the unique pathophysiological features in patients after surgery for massive cerebellar infarction,early enteral nutrition by conventional nasogastric tube feeding may be inappropriate.Nasogastric tube feeding plus gastric motor drug may be applied in mild case with short course of disease.Nasojejunal tube feeding may be the approach of choice for enteral nutrition in critical patients with massive cerebellar infarction for its association with lower incidence of complications.

The effects of therapeutic equipment that aim to improve cerebrovascular function combined with automatic standing bed on balance disorder following cerebellar infarction / 天津医药

Objective To investigate the effects of therapeutic equipment that aimed to improve cerebrovascular func?tion combined with electric standing bed on balance disorder following cerebellar infarction. Methods Fifty patients with balance disorder after cerebellar infarction were randomized into study and control groups. Agreed routine rehabilitation ther?apy including automatic standing bed and medication were given to both groups. In addition, therapeutic equipment that aim to improve cerebrovascular function were delivered to patients in study group. The effects were assessed using Fugl-Meyer balance function scale and Barthel index (BI) before and after 4 weeks of treatment. Results Study group and control group did not present difference between FM-B grade and BI before treatment (P>0.05). Both FM-B and BI were improved after treatment (P<0.05), but it improved more in study group than in control group (P<0.05). The total efficiency in treatment group is higher than that in control group (P<0.05). In the process of treatment, no obvious adverse reactions was observed. Conclusion The therapeutic equitment that aim to improve cerebrovascular function combined with automatic standing bed can improve balance disorder and daily activity after cerebellar infarction.

Isolated Lateral Sinus Thrombosis Presenting as Cerebellar Infarction in a Patient with Iron Deficiency Anemia

As a rare cerebrovascular disease, cerebral venous thrombosis (CVT) is caused by various conditions including trauma, infection, oral contraceptive, cancer and hematologic disorders. However, iron deficiency anemia is not a common cause for CVT in adult. Posterior fossa infarction following CVT is not well demonstrated because posterior fossa has abundant collateral vessels. Here, we report a case of a 55-year-old man who was admitted with complaints of headache, nausea, and mild dizziness. The patient was diagnosed with isolated lateral sinus thrombosis presenting as cerebellar infarction. Laboratory findings revealed normocytic normochromic anemia due to iron deficiency, and the patient's symptoms were improved after iron supplementation.

Emergent Endovascular Embolization for Iatrogenic Vertebral Artery Injury during Cervical Discectomy and Fusion

Injury to the vertebral artery during anterior cervical discectomy is rare but potentially fatal. We report a case of cerebellar infarction after endovascular embolization for iatrogenic vertebral artery injury at C5-C6 during an anterior cervical discectomy and fusion. A 61-year-old man had an intraoperative injury of the right vertebral artery that occurred during anterior cervical discectomy and fusion at C5-C6. Hemorrhage was not controlled successfully by packing with surgical hemostatic agents. While the patient was still intubated, an emergency angiogram was performed. The patient underwent endovascular occlusion of the right V2 segment with coils. After the procedure, his course was uneventful and he did not show any neurologic deficits. Brain computed tomographic scans taken 3 days after the operation revealed a right cerebellar infarction. Anti-coagulation medication was administered, and at 3-month follow-up examination, he had no neurologic sequelae in spite of the cerebellar infarction.

A Case of Cerebellar Infarction with Pulmonary Arteriovenous Malformation / 대한뇌졸중학회지

Pulmonary arteriovenous malformation (PAVM) is a rare vascular anomaly. The vascular anomaly usually occurs congenitally, and enlarges progressively with aging. Although PAVM has many pulmonary manifestations, its most common symptom is known to be dyspnea on exertion. Non pulmonary complications, such as ischemic stroke, have rarely been reported. In this paper, we report a case of a patient with both cerebellar infarction and an isolated PAVM. The PAVM was diagnosed with transesophageal echocardiography, transcranial Doppler and pulmonary angiography, and treated with embolization.

Infarto pseudotumoral del cerebelo / Malignant cerebellar infarction

El diagnóstico de infarto cerebeloso en su presentación inicial puede ser difícil, su reconocimiento tardío puede asociarse a graves complicaciones. Aunque sólo representa 2 por ciento a 3 por ciento de los infartos encefálicos, afecta a un importante número de pacientes, muchos de los cuales son jóvenes. De todos los infartos de cerebelo sólo 10 por ciento evolucionará en forma maligna, siendo denominado infarto pseudotumoral de cerebelo. Las causas más habituales son la embolia, la disección de la arteria vertebral y la aterotrombosis. La arteria cerebelosa póstero-inferior es la más frecuentemente comprometida, y en un tercio de los casos se encuentra una fuente cardioembólica. Su rasgo distintivo es el efecto de masa, el mismo que ocasiona compresión de troncoencéfalo e hidrocefalia aguda, generando un deterioro cuantitativo de conciencia. Las neuroimágenes, tomografía computada y resonancia magnética de encéfalo, son de vital importancia para establecer la presencia de un infarto cerebeloso e identificar potenciales complicaciones. Es importante recordar que la tomografía computada es menos sensible que la resonancia magnética para establecer el diagnóstico. El manejo especializado multidisciplinario y la implementación de las medidas de soporte generales y específicas pueden mejorar las posibilidades de sobrevida y recuperación funcional. Ante la presencia de un deterioro de conciencia, un abordaje quirúrgico agresivo pareciera ser la mejor opción de tratamiento.

The diagnosis of cerebellar infarction at initial presentation can be difficult, delayed recognition can be associated with serious complications. Although representing only 2 percent to 3 percent of brain infarcts, affects a significant number of patients, many of whom are young. Only 10 percent of cerebellar infarcts evolve into malignant form, being named pseudotumoral cerebellar infarction. Common causes include embolism, vertebral artery dissection and atherothrombosis. The postero-inferior cerebellar artery is the most frequently committed, and one third of cases there is a cardioemboIic sourse. Its distinguishing feature is the mass effect, causing brain stem compression and acute hydrocephalus, and generating a quantitative impairment of consciousness. The brain imaging, computed tomography and magnetic resonance imaging of brain, are of vital importance to establish the presence of a cerebellar infarct and identify potential complications. It is important to remember that computed tomography is less sensitive than magnetic resonance for diagnosis. The multidisciplinary specialized management and implementation of measures of general and specific support can improve the chances of survival and functional recovery. In the presence of impaired consciousness, an aggressive surgical approach appears to be the best treatment option.

The curative effect study of edaravone on patients with acute lagre areacerebellar infarction / 中国基层医药

Objective To observe the clinical curative effect of edaravone on treatment of acute lagre area cerebellar irdarction(ALACI). Methods 31 ALACI patients attacked within 72h were randomly assigned to therapygroup( n = 16) and control group( n = 15). Therapy group took the basic treatment as well as edaravone infused at a dose of 30mg,twice a day for 14 days. Control group took similar treatment to therapy group expect for edaravone.At 0th ,7th, 14th ,21th day after treatment, the C.SS and ability of daily living(ADL) were used to evaluate the recovery of neurological functions. Results Significant difference of CSS and ADL grading were detected between therapygoup and control group at 7th, 14th day( P < 0.05 ), with lower grading in therapy group ; there were significant differ-ence of CSS and ADL grading between therapy goup and control group at 21th day( P < 0.01 ), with lower grading in therapy group. No evident side effect was detected in edaravone therapy group. Conclusion Edaravone is a safe a-gent. It can effectively improve the neurological deficits and daily living ability of ALACI patients.

A Cerebellar Infarction Presented with a Clinical Seizure / 대한간질학회지

Classically, only lesions in the cerebral cortex have been thought to cause the epilepsy. Although the cerebellar infarction is presented with ataxia, dysmetria and dizziness, we experienced a patient of cerebellar infarction developed immediately after or simultaneously with a clinical seizure. A brain magnetic resonance imaging (MRI) showed acute cerebellar infarction on the bilateral cerebellar hemisphere.

Opalski's Syndrome with Cerebellar Infarction

A 64-year-old man presented with sudden onset of right-sided hemiparesis, headache, gait disturbance, and recurrent vomiting. A physical examination revealed right-sided hemiparesis, right Horner syndrome, ataxia of the right limbs, and diminished sensation on the left side of his body. Diffusion-weighted MRI revealed an acute right lateral medullary infarction extending from the rostral medulla to the upper cervical cord, and an acute cerebellar infarction in the territory of the medial branch of the posterior inferior cerebellar artery. Magnetic resonance angiography revealed suspicious severe stenosis or near occlusion of the proximal and distal parts of the right vertebral artery, and hypoplasia of the left vertebral artery. We diagnosed ipsilateral hemiparesis with lateral medullary infarction (Opalski's syndrome) and concomitant cerebellar infarction.

Clinical Study on 36 Cases of Cerebellar Infarction Treated with Combined Treatment of Traditional Chinese and Western Medicine / 中国中医药信息杂志

Objective To observe the efficacy of Shuilongjian in treating cerebellar infarction, and compare with the pure western medicine. Methods 67 inpatients with cerebellar infarction enrolled were divided into two groups according to the method of random digits table, 36 cases in the treatment group and 31 cases in the control group. The control group was given 500 mL dextran by venoclysis, once a day. The treatment group was given Shuilongjian as an additional drug. The therapeutic effect was evaluated according to the nerve function and the total capability in dealing with daily activities. Result All the 67 cases of cerebellar infarction were included in the analysis. The effective rate of the treatment group was better than that of control group with 83.3% and 58.1% (P

Anterior Inferior Cerebellar Artery Infarction Misdiagnosed as Labyrinthitis: A Case Report / 대한이비인후과학회지

Anterior inferior cerebellar artery infarction is the second most common cause of brainstem stroke, and usually accompanied by vertigo, unilateral deafness, ipsilateral facial weakness and ataxia. These symptoms can be confused with other peripheral causes of sudden hearing loss accompanying dizziness including acute labyrinthitis, idiopathic sudden hearing loss, perilymphatic fistula and acoustic neuroma. This case report presents a man who first visited our clinic for sudden hearing loss with vertigo, and whom we treated for acute labyrinthitis. However, 3 days later, left facial numbness was observed and the magnetic resonance imaging (MRI) showed an anterior inferior cerebellar infarction. The patient was then transferred to the neurology department and treated with anticoagulant and antiplatelet agents. After 7 days of treatment, the hearing loss and dizziness were improved and the facial numbness resolved.

Surgical Management of Acute Cerebellar Infarction

OBJECTIVE: The aim of this study is to determine which patients with progressively deteriorating acute cerebellar infarction would benefit from surgical treatment and which surgical procedure would best benefit them. METHODS: Seventy six patients were treated at our hospital for cerebellar infarction over the past 3 years. Sixty nine patients received conservative management in the neurological department of our hospital. Among them, 7 patients (5 males and 2 females; average age, 49 yrs) were referred to neurosurgical department because of mental deterioration and underwent emergency surgery. Five patients underwent external ventricular drainage with suboccipital craniectomy and two patients underwent suboccipital craniectomy alone. RESULTS: Of the 7 surgically treated patients, 4 patients experienced good recovery and 2 patients experienced moderate disability (disabled but independent) and 1 patient experienced severe disability (conscious but disabled). There was no death. CONCLUSION: In patients conservatively treated for cerebellar infarction and showing mental deterioration and radiologically evident brainstem compression and ventricular enlargement, we strongly recommend suboccipital craniectomy (plus optional external ventricular drainage in case of showing hydrocephalus) as a first treatment option.

An Adolescent Ischemic Stroke Patient with Hyperhomocysteinemia, MTHFR 677TT and CBS 1080TT genotypes

Hyperhomocysteinemia is an independent risk factor for cerebrovascular disease. Hyperhomocysteinemia can be caused by the defect of the remethylation pathway including the 5, 10-methylenetetrahydrofolate reductase (MTHFR) gene or the transsulfuration pathway including the cystathionine beta-synthase (CBS) gene of homocysteine metabolism. The major cause of severe hyperhomocysteinemia is CBS gene mutation. A 16-year-old male was admitted with vertigo. Brain MRI showed right cerebellar infarction. The plasma homocysteine level was 175 mocro mol/L. According to a genetic evaluation, the patient had the MTHFR 677TT and CBS 1080TT genotypes.

A Case of Bilateral Sudden Hearing Loss Caused by Right Anterior Inferior Cerebellar Artery Plus Syndrome and Left Anterior Inferior Cerebellar Artery Infarction / 대한이비인후과학회지

Acute ischemic stroke in the distribution of anterior inferior cerebellar artery (AICA) is known to be associated with vertigo, nystagmus, facial weakness and gait ataxia. A few reports have carefully examined the deafness associated with the AICA infarction. A 55 year old man was presented with right sudden hearing loss, tinnitus and vertigo. The magnetic resonance image of the brain with 4-vessel angiogram showed stenosis in the lower third of the basilar artery due to partial thrombosis and no remarkable lesion in AICA. Although heparin treatment was done, the patient's hearing was not improved. After 3 months of heparin treatment, the patient was presented again with left sudden hearing loss, tinnitus and facial palsy. The magnetic resonance image and angiogram showed increased size of thrombosis and non-visualization of left vertebral artery and basilar artery. Diffusion scan showed focal infarction involving the left AICA territory. Recently, we experienced a case of bilateral sudden hearing loss caused by the right AICA plus syndrome and the left AICA infarction. So authors report this case with a review of literature.

Neurological Features and Mechanisms of Acute Bilateral Cerebellar Infarction

BACKGROUND: Many studies about unilateral cerebellar infarctions (UCI) have been reported to delineate the clinical findings and stroke mechanisms but have not been studied extensively in acute bilateral cerebellar infarctions (BCI). In order to evaluate the neurological features and mechanisms of BCI, we compared those between BCI and UCI. METHODS: Using diffusion-weighted imaging, we divided 103 patients with acute cerebellar infarctions into two groups: BCI and UCI. Clinical features, outcome and their mechanisms were compared between the groups. RESULTS: Among the 103 patients, 45 patients (44%) had BCI and the remaining 58 patients had UCI. The PICA territory was the most frequently involved site in both groups, and 15 patients were non-territorial infarctions. Clinical symptoms and signs were not different between the groups, however, most patients with decreased mentality had BCI (86%) and also had concomitant lesions outside the cerebellum (72%). Patients with BCI showed poorer prognosis than UCI (modified Rankin score, 1.41 and 2.87 respectively). Other factors included the presence of concomitant lesiona outside the cerebellum, however, mass effect did not affect their prognosis. The main cause of BCI was large artery disease (57%), whereas about half of the patients with UCI (51%) had no demonstrable cause of stroke. CONCLUSIONS: Owing to its poorer outcome and its higher frequency of demonstrable causes of stroke, more intensive work-up, such as vascular study, may be warranted in the patients with acute BCI.

Clinical Analysis of Cerebellar Infarctions Diagnosed via the Emergency Department

PURPOSE: Diagnosis of a cerebellar infarct without signs such as weakness, ataxia, or focal neurologic findings is difficult. This study used a clinical review of cerebellar infarctions for the purpose of accurately diagnosing and properly managing such patients. METHODS: We retrospectively studied 94 cerebellar infarct patients who had been admitted to the university hospital via the emergency department from May 1995 to March 2001. We reviewed clinical records and radiologic findings and analyzed risk factors of cerebrovascular disease, chief complaints and associated symptoms, neurologic examinations, electrocardiograms, and brain CT and/or brain MRI findings. RESULTS: Fifty-four (57.4%) of the patients were men and forty (42.6%) were women, and their mean age was 64.1+/- 13.0 years. The most frequent risk factor was hypertension (55.3%), and others were diabetes mellitus (26.6%), cerebrovascular disease (17.0%), ischemic heart disease (10.6%), and atrial fibrillation (6.4%). As to the involved territory, 54 (57.4%) posterior inferior cerebellar artery infarcts, 15 (16.0%) superior cerebellar artery infarcts, 3 (3.2%) anterior inferior cerebellar artery infarcts, and 19 (20.2%) combined-territory infarcts were found. As for symptoms and signs, vertigo (69.1%) and nausea and/or vomiting (64.9%) were the most frequent: others were dysarthria (38.3%), headache (37.2%), ataxia (43.6%), motor weakness (38.3%), nystagmus (30.9%), and so on. Especially, seven (7.4%) patients showed isolated vertigo without paralysis, weakness, or ataxia. CONCLUSION: Vertigo, nausea, and vomiting were frequent clinical findings in 94 cerebellar infarct patients. Nine of these patients showed isolated vertigo. The posterior inferior cerebellar artery was the most frequently involved territory.

Sudden Deafness and Anterior Inferior Cerebellar Artery Infarction

BACKGROUND AND OBJECTIVES : Acute ischemic stroke in the distribution of the anterior inferior cerebellar artery (AICA) is known to be associated with vertigo, nystagmus, facial weakness, and gait ataxia. There have been few reports on deafness associated with the AICA infarction. Furthermore, previous neurological reports have not emphasized the inner ear as a localization of sudden deafness. The aim of this study was to investigate the incidence of deafness associated with the AICA infarction and the sites predominantly involved in deafness. MATERIALS AND METHOD : During two years we prospectively identified 12 consecutive patients with unilateral AICA infarction diagnosed by brain MRI. Pure tone audiogram, speech discrimination testing, stapedial reflex testing, and auditory brainstem responses were performed to localize the site of lesion in the auditory pathways. Electronystagmography was also performed to evaluate the function of the vestibular system. RESULTS :The most common affected site on brain MRI was the middle cerebellar peduncle (11). Four patients had vertigo and/or acute auditory symptoms such as hearing loss or tinnitus as an isolated manifestation from 1day to 2 months prior to infarction. Audiological testings confirmed sensorineural hearing loss in 11 (92%) patients, predominantly involved the cochlea in 6 and retrocochlear in 1. The other 4 patients had a severe to profound hearing loss most likely of cochlear origin. Electronystagmography demonstrated no response to caloric stimulation in 10 (83%) patients. CONCLUSIONS : In our series, sudden deafness was an important sign for the diagnosis of the AICA infarction. Audiological examinations suggest that sudden deafness in AICA infarction is usually due to dysfunction of the cochlea, resulting from ischemia to the inner ear.

A Case of Bilateral Spontaneous Extracranial Vertebral Artery Dissection

The most common mechanism of cerebellar infarction in young patients is arterial occlusion resulting from intracra-nial vertebral artery dissection. We describe a 26-year-old male patient with superior cerebellar artery infarction result-ing from a bilateral spontaneous extracranial vertebral artery dissection. The brain MRI showed an infarction of the left SCA territory and the angiography showed irregular stenosis with mural hematoma in the bilateral extracranial vertebral arteries. The angiography, taken 3 months later, showed recanalization of the arteries after serial treatments.