Insulinoma: reporte de un caso con resección quirúrgica exitosa

El insulinoma es un tumor endocrino del páncreas, el cual produce hiperinsulinismo y provoca disminución severa de la glucemia, con síntomas crónicos como desvanecimiento. Es más frecuente en varones y puede presentarse a cualquier edad, ya sea como neoplasias solitarias o múltiples, estas últimas conocidas por formar parte del grupo de neoplasias endocrinas múltiples tipo 1 (MEN 1). Los insulinomas son de rara presentación y requieren tratamiento quirúrgico resectivo; la resolución de los síntomas es el marcador de curación. En la presente publicación, se describe un caso de insulinoma en una mujer de 51 años, de presentación típica desde el punto de vista clínico, con síntomas y signos de hiperinsulinismo. Los exámenes de laboratorio indican un aumento de la secreción de insulina, mientras que las imágenes por resonancia magnética muestran características del insulinoma, donde se puede apreciar la tumoración pancreática. Este caso se trató mediante resección quirúrgica por medio de laparotomía exploratoria, utilizando la técnica de enucleación del tumor pancreático, la cual se describe al detalle en la publicación; no se presentaron complicaciones intraoperatorias ni posoperatorias, es decir, desde el punto de vista curativo, el resultado fue exitoso. Esta es la técnica quirúrgica que se emplea en el Hospital Nacional Arzobispo Loayza en Lima, Perú, ante casos como el descrito. Este tipo de neoplasia es muy poco común, por lo que se le debe considerar de alta sospecha y, en este caso, las imágenes fueron fundamentales para optar por la resección quirúrgica. En el hospital Arzobispo Loayza se han tratado otros casos de insulinoma mediante cirugía; asimismo, se ha presentado, al menos, un caso de nesidioblastosis, en donde no se pudo administrar un tratamiento adecuado al paciente.

Insulinoma is a pancreatic neuroendocrine tumor that produces hyperinsulinism and causes a severe lowering of blood glucose levels with chronic symptoms such as fainting. It is more common in males and can occur at any age, either as solitary or multiple neoplasms, the latter known to be part of the multiple endocrine neoplasia, type 1 (MEN 1) group. Insulinomas are rare and require resective surgery, with symptoms resolution being the marker of recovery. This article describes a case of insulinoma in a 51-year-old woman with a clinically typical presentation and signs and symptoms of hyperinsulinism. Laboratory tests revealed increased insulin secretion, while magnetic resonance imaging showed features of insulinoma, where the pancreatic tumor could be seen. This case was treated by surgical resection of the pancreatic tumor during an exploratory laparotomy, using the enucleation technique, which is described in detail herein. There were no intraoperative or postoperative complications, i.e., the result was successful in terms of health recovery. This surgical technique is used at Hospital Nacional Arzobispo Loayza in Lima, Peru, when facing cases such as the one described. This type of neoplasm is very uncommon, so it should be considered highly suspicious and, in this case, the images were essential for choosing the surgical resection. Other cases of insulinoma have been treated surgically at the Hospital; moreover at least one case of nesidioblastosis could not receive an adequate treatment.

Síndrome alterno mesencefálico: síndrome de Weber en dos pacientes varones VIH positivos con toxoplasmosis cerebral

En este reporte se describen dos casos de pacientes varones con VIH diagnosticados por serología, que no estaban recibiendo tratamiento. Ambos pacientes desarrollaron el síndrome alterno mesencefálico y la lesión estructural, causada por la infección del sistema nervioso central por toxoplasmosis cerebral, confirmada mediante una resonancia magnética cerebral. Esta condición se constató por serología en líquido cefalorraquídeo. El síndrome de Weber es un tipo de síndrome alterno mesencefálico poco frecuente y existe poca información de su clínica y evolución. Fue descrito por sir Herman David Weber en 1863, y se caracteriza por la lesión ipsilateral del fascículo del III par craneal, con presencia de hemiparesia contralateral debida a la lesión de la vía corticoespinal y corticobulbar del pedúnculo cerebral. Las causas que lo originan incluyen tanto procesos isquémicos o hemorrágicos, que lesionan el fascículo del III par craneal y pedúnculo cerebral, como neoplasias intraencefálicas, aneurismas, hematomas extradurales y procesos infecciosos que se comportan como procesos expansivos. Los pacientes evaluados presentaron clínica de ptosis palpebral, visión doble vertical, dificultad para bipedestación, hemiparesia, hiporreflexia, sensibilidad superficial y profunda disminuidas, equilibrio y coordinación alterados, III par parético, habla incoherente, desorientación en tiempo, espacio y persona de manera intermitente y asimetría facial. Para la toxoplasmosis se aplicó un tratamiento específico con trimetropim-sulfametoxasol, clindamicina y prednisona por vía oral, lo cual permitió una mejoría del cuadro clínico. En el presente caso clínico se presenta la secuencia de los hechos, manejo y breve revisión de la literatura para su consideración como diagnóstico y su relevancia en el paciente con VIH-toxoplasmosis del sistema nervioso central.

This report describes the case of two male HIV-positive patients who were not receiving treatment and whose diagnosis was confirmed by serology testing. Both patients developed midbrain stroke syndrome and the structural injury, which was caused by a central nervous system infection due to cerebral toxoplasmosis, was verified by brain magnetic resonance imaging. This condition was confirmed by cerebrospinal fluid serology testing. Weber's syndrome is a very rare type of midbrain stroke syndrome with little information available on its symptoms and evolution. It was first described by Sir Herman David Weber in 1863 and is characterized by ipsilateral injury of the third cranial nerve fascicle with contralateral hemiparesis due to injury of the corticospinal and corticobulbar tracts of the cerebral peduncle. Its causes range from ischemic or hemorrhagic processes, which damage the third cranial nerve fascicle and cerebral peduncle, to brain tumors, aneurysms, extradural hematomas and infectious diseases that behave like spreading processes. The assessed patients showed clinical signs and symptoms such as ptosis; vertical double vision; difficulty standing up; hemiparesis; hyporeflexia; decreased superficial and deep sensation; poor balance and coordination; third cranial nerve palsy; slurred speech; intermittent disorientation in time, place and person; and facial asymmetry. Oral trimethoprim-sulfamethoxazole, clindamycin and prednisone were administered as specific treatment for toxoplasmosis, which enabled the improvement of the clinical picture. This case report presents the sequence of events, treatment and a brief review of the literature to be considered in the diagnosis and determine its importance in patients with HIV-toxoplasmosis of the central nervous system.

Abnormal changes in gray matter volume and structural covariate network in patients with chronic pontine infarction / 国际脑血管病杂志

Objective:To investigate the changes in gray matter volume (GMV) and abnormalities in structural covariant network (SCN) patterns in patients with chronic pontine infarction (PI).Methods:Patients with unilateral chronic PI (case group) with the first onset admitted to the First Affiliated Hospital of Zhengzhou University and Tianjin Medical University General Hospital from October 2014 to June 2021 were prospectively included. At the same time, healthy subjects matched with age, gender and education years (normal control group) were included. High-resolution three-dimensional T 1 structural MRI images and behavioral scores of the subjects were collected. The voxel-based morphometry and two-sample t test were used to explore the differences in GMV between the groups. Using GMV differential brain regions as seed points, SCN was constructed to explore the abnormality of structural covariant patterns in patients with PI. Spearman rank correlation analysis was used to analyze the correlation between GMV in differential brain regions and behavioral scores. Results:A total of 60 patients with PI were enrolled, including 33 left PI and 27 right PI, while 34 healthy controls were also enrolled. Compared with the normal control group, the GMV in bilateral posterior cerebellar lobe decreased significantly in the left PI group, and the GMV in left anterior and posterior cerebellar lobes and the right posterior cerebellar lobe decreased significantly in the right PI group (Gaussian random field correction with voxel level P<0.001 and cluster level P<0.05, cluster voxel >20), and there was a significant correlation between GMV values in the left anterior and posterior cerebellar lobes and the right posterior cerebellar lobe and the motor function score ( P<0.05). In addition, compared with the normal control group, the right PI group had broader covariate brain regions and a significant increase in the number of structural connections between covariate brain regions (family-wise error correction with voxel level P<0.05, cluster voxel >20). Conclusions:The GMV in bilateral posterior cerebellar lobe decreases significantly in patients with chronic PI, and were secondary to broader covariate brain regions and structural connections. This may be the neural mechanism of impaired behavioral function in patients with PI.

Foville syndrome: a neurological emergency of clinical relevance. case report

Introduction: Foville syndrome (inferior medial pontine syndrome) is a clinical entity that makes part of a subclassification of a broader category of posterior circulation stroke. It is characterized by a blockage of the basilar artery caused by lesions in the pontine tegmentum. This syndrome has a very low incidence worldwide, but its clinical relevance is considerable. Case report: A 41-year-old patient without any medical history was admitted to the emergency department due to signs of focal neurologic deficits. Imaging findings were compatible with an ischemic lesion in the brainstem, and cerebral angiography showed involvement of the basilar artery territory. The patient was diagnosed and followed up in the intensive care unit (ICU) until his recovery. Conclusion: Foville syndrome is a rare disease with high morbidity and mortality. Early recognition and a multidisciplinary approach are decisive to improve the patient's prognosis.

Introducción. El síndrome de Foville (síndrome pontino medial inferior) es una entidad clínica que hace parte de una subclasificación de la categoría más amplia de eventos cerebrovasculares de la circulación posterior, se presenta como resultado de la oclusión de la arteria basilar debido a lesiones en el tegmento pontino. Este síndrome tiene una muy baja incidencia a nivel mundial, pero es de gran relevancia clínica. Presentación del caso. Hombre de 41 años sin antecedentes patológicos, que ingresó al servicio de urgencias por signos de focalización neurológica. Sus hallazgos imagenológicos fueron compatibles con una lesión isquémica en el tronco encefálico y la angiografía cerebral evidenció un compromiso en el territorio de la arteria basilar. El paciente fue diagnosticado y se le dio seguimiento en la unidad de cuidados intensivos (UCI) hasta su rehabilitación. Conclusión. El síndrome de Foville es una enfermedad infrecuente y de alta mortalidad. El reconocimiento temprano de esta afección y un abordaje multidisciplinario son determinantes para mejorar el pronóstico del paciente.

Sequential treatment with tirofiban and argatroban in acute isolated pontine infarction caused by branch atheromatous disease / 国际脑血管病杂志

Objective:To investigate the efficacy and safety of sequential treatment with tirofiban and argatroban in acute isolated pontine infarction (AIPI) caused by branch atheromatous disease (BAD).Methods:Consecutive patients with AIPI caused by BAD within 48 h of onset and admitted to Zhengzhou Central Hospital from April 2021 to April 2022 were enrolled retrospectively. The patients were divided into sequential treatment group and tirofiban group according to their therapeutic modalities. In the tirofiban group, tirofiban was pumped intravenously within 48 h after admission, and dual antiplatelet therapy with aspirin and clopidogrel was added 4 h before tirofiban was discontinued. On the basis of tirofiban treatment, the sequential treatment group was followed by argatroban for 5 days when tirofiban is discontinued. The main outcome measure was the modified Rankin Scale (mRS) score at 3 months after the onset . A score of <2 was defined as a good outcome. The secondary outcome measure was all the adverse events during the treatment and follow-up. Multivariate logistic regression analysis was used to determine the independent factors of the outcomes. Results:A total of 64 patients with AIPI caused by BAD were enrolled, including 32 in the sequential treatment group and 32 in the tirofiban group. There was no statistical difference in baseline data between the two groups, but the rate of good outcomes at 3 months after onset in the sequential treatment group was significantly higher than that in the tirofiban group (78.1% vs. 50.0%; χ2=5.497, P=0.019). Multivariate logistic regression analysis showed that after adjusting for low-density lipoprotein cholesterol, the higher baseline National Institutes of Health Stroke Scale score was independently associated with the poor outcomes (odds ratio 2.067, 95% confidence interval 1.343-3.182; P=0.001), while the sequential treatment was independently associated with the good outcomes (odds ratio 0.248, 95% confidence interval 0.064-0.957; P=0.043). Conclusion:Early application of sequential treatment with tirofiban and argatroban in AIPI caused by BAD may effectively improve the outcomes of patients, and the safety is good.

Clinical and imaging features of bilateral Wallerian degeneration of the middle cerebellar peduncles secondary to isolated pontine infarction / 国际脑血管病杂志

Objective:To investigate the clinical and imaging features of bilateral Wallerian degeneration of the middle cerebellar peduncles secondary to isolated pontine infarction.Methods:Patients diagnosed as bilateral Wallerian degeneration of cerebellar middle peduncle after isolated pontine infarction admitted to the Second Affiliated Hospital of Zhengzhou University from June 2017 to December 2021 were retrospectively included. Patients with bilateral Wallerian degeneration of cerebellar middle peduncle after isolated pontine infarction reported between January 2001 and December 2021 were collected by searching Chinese and English databases, and their clinical and imaging characteristics were summarized.Results:A total of 48 patients with bilateral Wallerian degeneration of cerebellar middle peduncle after isolated pontine infarction were included, including 14 patients admitted to the Second Affiliated Hospital of Zhengzhou University, and 34 patients collected by searching the Chinese and English databases. Thirty-three patients were males (68.75%) and 15 were females (31.25%). Their age was 65.8±10.7 years old (range, 37-88 years). Most patients had vascular risk factors, and hypertension was the most common. Dysarthria and limb weakness were the main clinical symptoms at admission. The infarct sites of all 48 patients were located in the blood supply area of paramedian pontine arteries, of which 37 (77.08%) were unilateral (18 on the left and 19 on the right), 6 (12.50%) were bilateral sides, and 5 (10.42%) had incomplete data. When Wallerian degeneration was diagnosed, 8 patients (16.67%) had dizziness or ataxia, 6 (12.50%) had aggravated original symptoms, and the remaining 34 (70.83%) had no new symptoms or aggravated original symptoms. All patients showed symmetrical abnormal signals in bilateral middle cerebellar peduncles, with obvious hyperintensity on T 2 or diffusion-weighted imaging (DWI). One patient showed T 2 hyperintensity in bilateral middle cerebellar peduncle on the next day after the onset of the infarction, which was the earliest case to find secondary Wallerian degeneration after isolated pontine infarction. Conclusions:Wallerian degeneration should be considered when symmetrical lesions of bilateral middle cerebellar peduncles occur after isolated pontine infarction. Wallerian degeneration may occur early after isolated pontine infarction. Most cases have no new symptoms or aggravated original symptoms. Conventional MRI can identify it early.

Combination of conventional axial and thin-layer sagittal diffusion-weighted imaging to improve the detection ability of acute brainstem infarction / 国际脑血管病杂志

Objective:To investigate whether the combination of conventional axial and thin-layer sagittal diffusion-weighted imaging (DWI) can improve the detection ability of acute brainstem infarction (ABI).Methods:Patients with ABI diagnosed clinically and admitted to Weihai Municipal Hospital, Shandong University from January 2019 to July 2020 were enrolled retrospectively. All patients underwent conventional axial and thin-layer sagittal DWI examination after admission. Those who could not make a definite diagnosis were confirmed by DWI reexamination before discharge. The numbers of positive and negative cases of brainstem infarction at different sites detected by conventional axial and conventional axial+ thin-layer sagittal DWI were recorded.Results:A total of 65 patients with ABI were included. Conventional axial DWI was positive in 51 patients (78.5%) and was negative in 14 (21.5%); conventional axial+ thin-layer sagittal DWI were positive in 60 patients (92.3%) and was negative in 5 (7.7%). In 8 patients with medullary infarction, only 4 (50.0%) were positive on conventional axial DWI, and 6 (75.0%) were positive on conventional axial+ thin-layer sagittal DWI; in 50 patients with pontine infarction, only 44 (88.0%) were positive on conventional axial DWI, and 48 (96.0%) were positive on conventional axial+ thin-layer sagittal DWI; in 4 patients with midbrain infarction, only 1 (25.0%) was positive on conventional axial DWI, and 3 (75.0%) were positive on conventional axial+ thin-layer sagittal DWI; in 3 patients with pontine+ midbrain infarction, only 2 (66.7%) were positive on conventional axial DWI, and 3 (100.0%) were positive on conventional axial DWI+ thin-layer sagittal DWI. The detection rate of ABI on conventional axial+ thin-layer sagittal DWI was significantly higher than that on conventional axial DWI, and difference was statistically significant (92.3% vs. 78.5%; χ2=4.993, P=0.026). Conclusion:The combination of conventional axial and thin-layer sagittal DWI improved the detection rate of ABI. For ABI patients whose axial DWI did not find lesions or whose diagnosis was not clear, thin-layer sagittal DWI should be added.

Posterior internuclear ophthalmoplegia as a sign of pons infarction: a case report / 中华神经科杂志

Posterior internuclear ophthalmoplegia is a rare sign of pons infarction.Due to its mild clinical symptoms,it is easily misdiagnosed.In this article,we report a case of posterior internuclear ophthalmoplegia caused by pons infarction,discuss the causes of misdiagnosis and hope to attract the attention of doctors.By analyzing the clinical features of the case and reviewing the literatures,we try to differentiate the disease from multiple sclerosis,pons tumors and other diseases.The diagnosis was confirmed with thorough physical examination,laboratory test and imaging examination.Posterior internuclear ophthalmoplegia is a sign of pons infarction.

Clinical characteristics and risk factors for bilateral pontine infarction:comparison with unilateral pontine infarction / 国际脑血管病杂志

Objective To compare and analyze the etiology,clinical manifestations and imaging differences of bilateral pontine infarction (BPI) and unilateral pontine infarction (UPI),and investigate the possible independent risk factors for BPI.Methods Consecutive patients with pontine infarction admitted to the Department of Neurology,the First People's Hospital of Kunshan from January 2015 to December 2017 were enrolled retrospectively.They were divided into BPI group and UPI group.The risk factors,laboratory findings,National Institutes of Health Stroke Scale (NIHSS) scores,clinical manifestations,and basilar artery lesions were compared between the two groups.Multivariate logistic regression analysis was used to determine the independent risk factors for BPI relative to UPI.Results A total of 131 patients with pontine infarction were enrolled,aged 66.22 ± 12.29 years,97 patients (72.52％) were male;14 (10.69％) were BPI,and 117 (89.31％) were UPI.In terms of clinical symptoms,consciousness disorder (35.71％ vs.6.83％;x2 =8.657,P =0.003),quadriplegia (50.00％ vs.5.12％;x2 =30.202,P ＜ 0.001),and dysphagia (71.42％ vs.29.91％;x2 =7.804,P =0.005) in the BPI group were more common than those in the UPI group.In terms of etiological classification,vertebrobasilar large artery disease (VLAD) was more common in the BPI group (85.71％ vs.27.35％;x2 =16.567,P ＜ 0.001),while small artery disease (SAD) was more common in the UPI group (49.57％ vs.7.14％;x2 =7.460,P =0.006).In addition,the baseline NIHSS scores (12.43 ±11.1 vs.3.78 ±3.98;t=2.873,P=0.013),white blood cell count ([9.21±2.81] ×109/L vs.[6.92± 2.40] ×109/L;t=3.191,P=0.002),baseline systolic blood pressure (170.57 ±31.21 mmHg vs.156.75 ±23.50 mmHg,1 mmHg =0.133 kPa;t =2.004,P =0.047),as well as the proportion of patients with severe stenosis or occlusion in basilar artery (78.57％ vs.8.55％;x2 =40.49,P ＜ 0.001) and with other site infarction (78.57 ％ vs.11.11％;x2 =33.652,P ＜ 0.001) in the BPI group were significantly higher than those in the UPI group.Multivariate logistic regression analysis showed that severe basilar artery stenosis or occlusion (odds ratio [OR] 20.195,95％ confidence interval [CI]2.308-176.703;P =0.007),baseline NIHSS score (OR 1.147,95％ CI 1.019-1.292;P =0.023),and infarction at other sites (OR 19.483,95％ CI 2.969-127.868;P =0.002) were independently associated with BPI.Conclusion Compared with UPI,patients with BPI had more severe clinical symptoms and most of them with other site infarction.Severe stenosis or occlusion of the basilar artery was an independent risk factor for BPI.

Isolated vertigo and posterior circulation ischemic stroke / 国际脑血管病杂志

Posterior circulation ischemic stroke may present w ith vertigo,imbalance,and nystagmus. Although the vertigo due to a posterior circulation ischemic stroke is usually associated w ith other neurologic symptoms or signs, small infarcts involving the cerebellum or brainstem can develop vertigo w ithout other localizing symptoms. This article review s isolated vertigo and posterior circulation ischemic stroke.

Clinical features and imaging study of brainstem infarction dominantly presented as internuclear ophthalmoplegia / 重庆医学

Objective To describe the clinical features and magnetic resonance imaging (MRl) findings of brainstem infarction producing internuclear ophthalmoplegia (INO) as an predominant clinical manifestation.Methods The clinical data of 9 patients diagnosed with brainstem infarction presenting with INO by angiography and MRI diagnosis in our hospital were collected from January 2010 to October 2016.The clinical features and imaging findings of these patients were analysed,and the pathogenesis mechanisms was analysed by literature research.Results The median age of the 9 patients was 56 years old,and there were 5 young and middle aged cases (under 60 years old),accounted for 55.6％.Among them,8 cases (88.9％) with INO typically presenting with horizontal diplopia,the most common accompanied symptom was dizzness (accounted for 55.6％),and most of them (accounted for 77.8％) were unilateral.A total of 6 cases were anterior INO,3 cases were both anterior and posterior INO.Five cases (55.6％) retained converging movement.The MRI showed that paramedian ventral infarcts located in the the cerebral aqueduct were responsible for INO in 1 case,and paramedian dorsal infarcts located in the pons were responsible for INO in 8 cases.The magnetic resonance angiography (MRA) indicated that vascular occlusion or stenosis was found in posterior circulation in 6 patients,there were 5 cases with stenosis of the posterior cerebral artery which was the most common.The ocular symptoms,including diplopia and blurred vision,of 6 cases (66.7％) disappeared during their hospital stay (range:13-23 d,median:14 d).During following up,ocular symptoms of 1 case finally disappeared within 3 months.Conclusion Brainstem infarction presenting with INO is mainly caused by paramedian dorsal infarcts located in the pons,and most of the patients complicated with posterior circulation atherosclerotic lesions.The pathogenesis varies,and the patients have a good clinical prognosis.For the young and middle-aged patients presenting with diplopia as an initial symptom,it should pay more attention to differential diagnosis.

Basilar Artery Plaque and Pontine Infarction Location and Vascular Geometry / 대한뇌졸중학회지

BACKGROUND AND PURPOSE: Subclinical atherosclerotic plaques are common in patients with pontine infarctions (PIs) but without basilar artery (BA) stenosis. We hypothesized that BA plaque locations may differ by PI type and vertical location as well as vertebrobasilar artery geometry. METHODS: Ninety-six patients with PI but without BA stenosis on magnetic resonance imaging (MRI) and magnetic resonance angiography were enrolled. PIs were classified by type (paramedian, deep, or lateral) and vertical location (rostral, middle, or caudal). Patients underwent high-resolution MRI to evaluate BA plaque location (anterior, posterior, or lateral). The mid-BA angle on anteroposterior view and angle between the BA and dominant vertebral artery (BA-VA angle) on lateral view were measured. RESULTS: The PIs were paramedian (72.9%), deep (17.7%), and lateral (9.4%) type with a rostral (32.3%), middle (42.7%), and caudal (25.0%) vertical location. The BA plaque locations differed by PI type (P=0.03) and vertical location (P < 0.001); BA plaques were most frequent at the posterior wall in paramedian (37.1%) and caudal (58.3%) PIs and at the lateral wall in lateral (55.5%) and middle (34.1%) PIs. The BA-VA and mid-BA angles differed by BA plaque and PI vertical location; the greatest BA-VA angle was observed in patients with posterior plaques (P < 0.001) and caudal PIs (P<0.001). Greatest mid-BA angles were observed with lateral BA plaques (P=0.03) and middlelocated PIs (P=0.03). CONCLUSIONS: Greater mid-BA angulation may enhance lateral plaque formation, causing lateral and middle PIs, whereas greater BA-VA angulation may enhance posterior plaque formation, causing paramedian or caudal PIs.

Medullary infarction / 国际脑血管病杂志

Medulla oblongata is precise in structure and the blood supply is complicated. After its infarction, it is easy to be misdiagnosed or missed because of its various clinical manifestations and lack of specificity. This article reviews the pathogenesis, clinical manifestations, and prognosis of medullary infarction in different sites.

Top of the Basilar Syndrome after 2nd Cervical Spine Fracture

Top of the basilar (TOB) syndrome occurs with occlusion of the rostral portion of the basilar artery that supplies blood to the midbrain, thalamus, and temporal and occipital lobes. Symptoms associated with TOB include decreased alertness, abnormal eye movement, dysarthria, and disorders of cerebellar function. A 47-year-old man was transferred to our hospital to manage C2 vertebral fracture sustained in a traffic accident. He was alert on arrival; however, he lapsed into semicoma. He was diagnosed with TOB. Thrombolytic agents could not be administered due to a contraindication in cervical spine fracture. Brain magnetic resonance imaging showed acute infarction of the pons, cerebellum, and posterior cerebral artery territory. This rare case demonstrates that C2 vertebral fracture can result in TOB.

Advances in medial medullary infarction / 国际脑血管病杂志

With a low incidence and a non-specific clinical manifestation, medial medulary infarction (MMI) can often be misdiagnosed or missed diagnosis. Magnetic resonance imaging(MRI) played a major role in diagnosing the MMI. This article reviews the epidemiology, etiology, pathogenesis, clinical and imaging manifestations, diagnosis and differential diagnosis, and prognosis of MMI.

Correlation between lesion pattern and etiological mechanism in acute isolated pontine infarction / 国际脑血管病杂志

Objective To investigate the correlation between lesion pattern and etiological mechanism in acute isolated pontine infarction.Methods The clinical data in patients with acute isolated pontine infarction were collected retrospectively. Diffusion weighted imaging (DWI) was used to identify the lesion patterns. The correlation between the lesion pattern and etiological subtype was analyzed. Results A total of 146 patients with acute isolated pontine infarction were enrolled in the study, including 136 unilateral infarctions and 8 bilateral infarctions. The DWI lesion pattern analysis showed that there were 98 patients with paranasal infarction, 11 with anterolateral infarction, 18 with tegmentum infarction, and 19 with multiple infarction. Among all the etiological subtypes, basilar artery branch disease (BABD) accounted for the greatest proportion (n = 72, 49.3%), followed by large arterial occlusive disease ( n = 32, 21.9%), small arterial occlusive disease ( n = 25, 17.1%), and other causes/unknown causes ( n = 12, 8.2%). Cardioembolism was minimal (n =5, 3.4%). The distribution patterns of DWI lesions in acute isolated pontine infarction were significantly correlated with the etiological subtypes (C = 0.516, P < 0.001). Among them, 60 patients with paramedian infarction ( χ2 =16.915, P <0.001), 1 with anterolateral infarction ( χ2 =7.701, P = 0.006), 1 with tegmentum infarction ( χ2 =17.401, P <0.001) were closely associated with BABD; 9 patients with paramedian infarction ( χ2 =12.534, P <0.001), 6 with anterolateral infarction ( χ2 =24.365, P <0.001), and 10 with tegmentum infarction ( χ2 =18.312, P < 0.001) were significantly associated with small arterial occlusive disease. Conclusions There are significant correlation between the lesion pattern and etiological mechanism in acute isolated pontine infarction. The cause of acute isolated pontine infarction can be predicted in early stage by DWI revealed infarction distribution characteristics.

Acute brain stem infarction-induced anterior internuclear ophthalmoplegia: Clinical and imaging features of 4 cases / 第二军医大学学报

Objective To investigate the clinical and radiographic features of anterior internuclear ophthalmoplegia caused by acute brainstem infarction. Methods Four cases of anterior internuclear ophthalmoplegia were retrospectively reviewed by analyzing their clinical and radiographic data together with anatomical features. Results All 4 cases were caused by brainstem ischemic lesions, demonstrating dotted infraction on thin-sliced diffused-weighted imaging at the dorsal side of pontine and the ventromedial side of the fourth ventricle. Among 4 cases, 1 was cured and the other 3 cases achieved improved adduction and diplopia. Conclusion Anterior internuclear ophthalmoplegia is characterized by its dotted lesion in the brainstem at the dorsal side of pontine and the ventromedial side of the fourth ventricle. Thin-sliced MRI facilitates the detection of these lesions.

Predictors of progressive motor deficits after isolated pontine infarction:a retrospective case series study / 国际脑血管病杂志

Objective To investigate the predictive factors of progressive motor deficits (PMD) after isolated pontine infarction. Methods Consecutive patients with isolated pontine infarction admitted to hospital within 48 hours after onset were enroled. They were divided into either a PMD group (increase ≥1 within 7 days) or a non-PMD group according to the clinical course and the changes of motor scores of the National Institutes of Health Stroke Scale (NIHSS). The pontine infarction patterns were classified as basal surface infarction and deep infarction, the sides were divided into left and right, the infarct levels were divided into upper, middle, and lower according to diffusion-weighted imaging. The demographics, baseline clinical data, and imaging features were compared between the two groups. Multivariable logistic regression models were used to analyze the predictive factors of PMD after isolated pontine infarction. Results A total of 101 patients with isolated pontine infarction admitted to hospital within 48 h of onset were enroled, including 16 in the PMD group and 85 in the non-PMD group. The proportions of pontine infarction involving the basal surface (87. 5% vs. 47. 1% , χ2 = 8. 851, P = 0. 003), the infarcts on the middle levels (56. 2% vs. 24. 7% , χ2 = 4. 851, P = 0. 028), and basilar artery stenosis or occlusion (62. 5% vs. 27. 1% ,χ2 = 7. 689, P = 0. 006) of the PMD group were significantly higher than those of the non-PMD group, while the proportions of the infarcts on the left sides (18. 8% vs. 56. 5% , χ2 = 7. 664, P = 0. 006) and the infarcts on the upper levels (37. 5% vs. 72. 9% , χ2 = 7. 689, P = 0. 006) of the PMD group was significantly lower than those of the non-PMD group. Multivariate logistic regression analysis identified that pontine infarction involving the basal surface (odds ratio 5. 650, 95% confidence interval 1. 011 - 31. 580, P = 0. 049) and basilar artery stenosis or occlusion (odds ratio 4. 075, 95% confidence interval 1. 127 - 14. 741, P = 0. 032) were the independent risk factors for PMD after isolated pontine infarction. Conclusions Infarction involving the basal surface and basilar artery stenosis or occlusion may be the predictors for PMD after isolated pontine infarction.

Potential hazards and preventive measures in patients with dysphagia after brain stem infarction / 中国医师进修杂志

ObjectiveTo explore the potential hazards and preventive measures in patients with dysphagia after brain stem infarction.Methods Seventy-eight patients with dysphagia after brain stem infarction were divided into indwelling gastric canal group(57 cases) and none-indwelling gastric canal group(21 cases).The pulmonary infection,respiratory tract obstruction,alimentary tract hemorrhage and deglutition function recovery were compared between the two groups.Results The rate of pulmonaryinfection in indwelling gastric canal group was significantly lower than that in none-indwelling gastric canal group [26.3％ (15/57) vs.81.0％ (17/21),P ＜ 0.01 ].The weight in indwelling gastric canal group was significantly higher than that in none-indwelling gastric canal group [ (65.3 ± 13.5 ) kg vs.(56.2 ± 13.2) kg,P ＜ 0.05 ].Two patients in none-indwelling gastric canal group occurred respiratory tract obstruction.There was no significant difference in deglutition function recovery and alimentary tract hemorrhage (P ＞ 0.05).ConclusionPulmonary infection,respiratory tract obstruction,gastrointestinal dysfunction and malnutrition are the potential hazards of dysphagia after brain stem infarction,and indwelling gastric canal,strengthening expectoration and promoting functional recovery are effective preventive measures.

A Case of Airway Obstruction Caused by Bilateral Vocal Cord Palsy in a Patient with Lateral Medullary Infarction / 대한뇌졸중학회지

Lateral medullary infarction can lead to central respiratory failure. However, in Wallenberg's syndrome, obstructive respiratory failure rarely develops. Here, we report a case of obstructive respiratory failure with stridor caused by unilateral lateral medullary infarction. A 74-year-old woman was admitted for acute right lateral medullary infarction. On the 12th day after the stroke, the patient developed respiratory failure necessitating endotracheal intubation. She could maintain good oxygen saturation and ventilation in intubated status without the assistance of mechanical ventilator, even during sleep. The pharyngo-laryngoscopy demonstrated the hypomobility of bilateral vocal cords. This case suggests that unilateral medullary infarction might be a cause of bilateral vocal cord palsy.