Síndrome del ocho y medio secundario a vasculopatía lúpica: presentación de un caso / Eight-and-a-half syndrome secondary to lupus vasculopathy: a case presentation

RESUMEN Introducción: El manejo diagnóstico y terapéutico en los pacientes con lupus eritematoso sistémico que desarrollan una afectación neuropsiquiátrica representa un reto, debido a la heterogeneidad de las formas en que puede presentarse y la ausencia de criterios diagnósticos. Objetivo: Reconocer las formas clínicas de presentación de los síndromes neuroftalmológicos que traducen afectación pontina. Presentación del caso: Hombre de 71 años con antecedente de lupus eritematoso sistémico con afectación neuopsiquiátrica, que de forma aguda desarrolla un cuadro emético en el curso de una emergencia hipertensiva seguido de una parálisis de la mirada horizontal hacia la izquierda, una oftalmoplejía internuclear posterior derecha y una parálisis facial izquierda. En la neuroimagen se constata una afectación multifocal con marcado daño pontino. Conclusiones: Reconocer las formas clínicas de presentación de estos trastornos neuroftalmológicos raros que generalmente se presentan de forma aguda/subaguda permite al neurólogo realizar el diagnóstico topográfico de la lesión a nivel protuberancial con elevada precisión desde la Sala de Urgencias, así como reducir los posibles diagnósticos diferenciales a una etiología vascular, desmielinizante u ocupativa de espacio(AU)

ABSTRACT Introduction: The diagnostic and therapeutic management of patients with systemic lupus erythematosus who develop a neuropsychiatric involvement represents one of the biggest challenges due to the heterogeneity of the ways in which it can occur and the absence of diagnostic criteria. Objective: To recognize the clinical forms of presentation of neurophthalmological syndromes that express pontine involvement. Case presentation: Seventy-one-year-old man with history of systemic lupus erythematosus with neuropsychiatric involvement who acutely develops an emetic episode in the course of a hypertensive emergency followed by a paralysis of the horizontal gaze to the left, a right-sided posterior internuclear ophthalmoplegia and a left facial palsy. In the neuroimaging, a multifocal involvement with marked pontine damage is observed. Conclusions: Recognizing the clinical forms of presentation of these rare neurophthalmological disorders that generally occur in an acute or subacute form allows the neurologist to perform the topographic diagnosis of the lesion at a protuberancial level with high precision from the time when the patient attends the Emergency Department and reduces the possible differential diagnoses to a vascular, demyelinating or occupational etiology of space(AU)

Correlation factor analysis of poor prognosis in patients with acute solitary pontine infarction / 临床神经病学杂志

Objective To analyze the influence factors of poor prognosis in acute solitary pontine infarction. Methods The maximal diameter of the infarct lesion, arterial blood supply distribution and perforating artery atherosclerosis in 73 acute solitary pontine infarction patints were examined by brain MRI. The intracranial vascular stenosis was assessed by brain MRA or CTA. Carotid ultrasound was used to evaluate the atherosclerosis of extracranial artery. According to the mRS score, patients were divided into poor prognosis group ( mRS score≥3) and good prognosis group ( mRS score <3). Results Compared with those in good prognosis group, the rate of diabetes, admission and discharge NIHSS score, early progress rate, fasting blood glucose level in poor prognosis group were significantly higher,and the ratio of males was significantly lower (P<0. 05 -0. 01). Compared with those in good prognosis group, incidence of infarction with multiple blood supply, perforators atherosclerosis, vertebral basilar artery stenosis ratio and maximum diameter of infarction in poor prognosis group were significantly higher (all P<0. 01). The lesion which extended from the deep part of the pontine to the ventral side of the pontine and basilar artery stenosis were independent predictors of poor prognosis in patients with acute solitary pontine infarction (OR=22. 137, 95% CI:2. 563 -191. 228, P=0. 005; OR=28. 552, 95% CI:2. 347 -347. 313, P=0. 009). Conclusion Perforating artery atherosclerosis and basilar artery stenosis are independent predictors of poor prognosis in patients with acute solitary pontine infarction.

Clinical and Radiological Features of Wallerian Degeneration of the Middle Cerebellar Peduncles Secondary to Pontine Infarction / 中华医学杂志(英文版)

<p><b>Background</b>Wallerian degeneration (WD) of bilateral middle cerebellar peduncles (MCPs) can occur following pontine infarction, but its characteristics have not yet been clarified because of the low incidence. Thus, the present study discussed the clinical and radiological features to improve the awareness of this disease.</p><p><b>Methods</b>Clinical and radiological information from consecutive individuals diagnosed with WD of bilateral MCPs following pontine infarction in three hospitals over the past 4 years between October 2012 and October 2016 were retrospectively investigated and compared with a control group (patients with pontine infarction had no secondary WD).</p><p><b>Results:</b>This study involved 30 patients with WD of MCPs, with a detection rate of only 4.9%. The primary infarctions (χ =24.791, P = 0.001, vs. control group) were located in the paramedian pons in 21 cases (70.0%), and ventrolateral pons in nine cases (30.0%). WD of the MCPs was detected 8-24 weeks after pons infarction using conventional magnetic resonance imaging (MRI); all secondary WDs were asymptomatic and detected incidentally. All WD lesions exhibited bilateral, symmetrical, and boundary blurring on MRI. The signal features were hypointense on T1-weighted imaging, hyperintense on T2-weighted imaging and fluid-attenuated inversion recovery, and slightly hyperintense or isointense on diffusion-weighted imaging and apparent diffusion coefficient maps. Secondary brainstem atrophy was found in six (20.0%) cases. A Modified Rankin Scale score 0-2 was found in 10 (33.3%) cases and score >2 in 20 (66.7%) cases at 90 days after discharge, and the short-term prognosis was worse than that in control group (χ =12.814, P = 0.001).</p><p><b>Conclusions</b>Despite the rarity of bilateral and symmetrical lesions of MCPs, secondary WD should be highly suspected if these lesions occur within 6 months after pontine infarction, particularly paramedian pons. Conventional MRI appears to be a relatively sensitive method for detecting WD of MCPs, which might affect the short-term prognosis.</p>

Study of the default mode network alteration after subacute pontine infarction using rs-fMRI / 实用放射学杂志

Objective To investigate the alteration and possible compensation mechanism of the default mode network (DMN) in patients with subacute pontine infarction.Methods Rs-fMRI data were collected from 23 patients with subacute pontine infarction and 23 normal controls.The data was analyzed with the functional connectivity (FC) method and compared between subacute pontine infarction patients and controls.All imaging was performed on a Philips Achieva 3.0T MRI scanner.Posterior cingulated cortox (PCC) was used as seed points to analyze the FC changes in the brain regions between the pontine infarction group and the controls.The discrepancies of experiment data between two groups were compared by using two-sample t-test analysis.Results The FC of the DMN showed a significant increase in the right postcentral gyrus, left medial prefrontal cortex and left precuneus compared with normal controls and a significant decrease in bilateral insula,posterior lobe of the left cerebellum,right parahippocampal gyrus and left inferior occipital gyrus.Conclusion The DMN altered in patients with subacute pontine infarction and the changes of the FC suggested the plasticity of cortical or compensation in the relevant brain areas.

One-and-a-half syndrome with facial diplegia: A case report

One-and-a-half syndrome with facial diplegia, also referred to as the fifteen-and-a-half syndrome, is an extremely rare clinical entity caused by involvement of bilateral tegmentum of pons. Herein, we report a 52-year-old male who presented with one-and-a-half syndrome with left facial paralysis, which was consistent with the so-called eight-and-a-half syndrome. Brain magnetic resonance imaging showed pontine infarction. Five days after initiation of antiplatelet therapy, the patient developed right facial paralysis, a diagnosis of fifteen-and-a-half syndrome was made, repeat MR imaging revealed bilateral pontine tegmentum infarction. Fifteen-and-a-half syndrome is a newly proposed concept associated with pontine infarction. The clinicoradiological features of this specific disease are as yet unclear due to its extreme rarity. The current case would help advance the current understanding of the disease spectrum of pontine infarction.

Pontine Infarct Presenting as Peripheral Type Unilateral Facial Palsy

Acute peripheral facial palsy usually manifests Bell's palsy of unknown cause, and rarely lacunar infarct which located in facial nucleus can mimic peripheral facial palsy. A 73 year-old man with isolated facial asymmetry diagnosed with lacunar infarction which selectively involve the facial fascicles which lie in inferolateral aspect of pons. Clinicians should take into account the possibility of central lesion and brain stem infarction, even when patients present with isolated peripheral type facial palsy.

Misdiagnosis of Paramedian Pontine Infarction / 中国康复理论与实践

@#: Objective To explore the reasons for misdiagnosis of paramedian pontine infarction. Methods 20 cases of paramedian pontine infarction which were misdiagnosed as cerebral hemisphere lesions were collected. The clinical manifestations, signs, and hyperacute cerebral CT scans, MR imaging characteristics within 48 h and other auxiliary examinations were analyzed retrospectively. Results 20 cases which were misdiagnosed as cerebral hemisphere lesions were confirmed as paramedian pontine infarction by MR. Conclusion Paramedian pontine infarction is rather common during daily clinical work, but often misdiagnosed. Early MR examination is helpful to correct diagnosis. For patients who have hemiplegic paralysis and transient dizzy symptoms during early phases, it is specially noticed that the lesions may be located in brain stem.

Pendular Nystagmus After Pontine Infarction in a PatientWith Asymptomatic Olivary Hypertrophy due to Pontine Hemorrhage

No abstract available.

Restricted Spinothalamic Sensory Loss Below Thoracic Dermatomal Level Caused by Pontine Infarction

Cerebral lesions can cause dermatomal sensory deficit. The most commonly reported site is the medulla oblongata due to its well-separated sensory systems. Dermatomal sensory deficit that has developed after pontine infarctions have been reported in several cases, the majority of which involved the medial lemniscus. However, restricted spinothalamic sensory loss has rarely been reported in pontine infarctions. We report herein a patient who presented with dermatomal spinothalamic sensory deficits below the tenth thoracic level after pontine infarction.

A Small Dorsal Pontine Infarction Presenting with Total Gaze Palsy Including Vertical Saccades and Pursuit

A small localized infarction in the dorsal pontine area can cause various eye-movement disturbances, such as abducens palsy, horizontal conjugate gaze palsy, internuclear ophthalmoplegia, and one-and-a-half syndrome. However, complete loss of vertical saccades and pursuit with horizontal gaze palsy has not been reported previously in a patient with a small pontine lesion. We report a 67-year-old man with a small dorsal caudal pontine infarct who exhibited total horizontal gaze palsy as well as loss of vertical saccades and pursuit.

Transient Upbeat Nystagmus Due to Unilateral Pontine Infarction

Upbeat nystagmus has been described in bilateral lesions of the medulla, the ventral tegmentum, the anterior cerebellar vermis, the adjacent brachium conjunctivum, and the midbrain. Imbalance of the vertical vestibulo- ocular reflex (VOR) favoring the downward VOR activity would therefore result in upbeat nystagmus. We report a patient with transient upbeat nystagmus due to unilateral pontine infarction that may have disrupted bilateral upward VOR pathways running in the ventral tegmental tracts.

Episodic Central Neurogenic Hyperventilation in an Awake Patient with Unilateral Pontine Infarction

Central neurogenic hyperventilation (CNH) is characterized by sustained tachypnea inspite of an elevated arterial PaO2, pH and a low arterial PaCO2. CNH is common in patients with brainstem injury accompanied by a decreased level of consciousness but this also has been described in some alert patients with an invasive brainstem tumor. We report one case with CNH resulting from a unilateral pontine infarction. His consciousness was clear, and CNH spontaneously disappeared without any medication.

Clinical and MRI study of pontine infarction caused by BAD / 中国实用内科杂志

Objective\ To introduce the speciality of pontine infaction in clinic and screenage.Method\ we made retrospective study on clinical data and image data of pontine infarction caused by BAD,and compared with the data of 31 patients with lacunar infarction in pontine.Result\ Clinical spetiality of BAD group:There are a few disturbance of consciousness,mainly the movement disturbance and dysarthria with ocular movement disturbance.Compared with the control group,there is difference between the two groups(P

Clinical Significance of T2 Sagittal Image and the Flow Void of Basilar Artery in Pontine Infarction

BACKGROUND: Pontine infarction extending to the basal surface has been reported to possess different characteristics from deep pontine infarction without extending to the basal surface. METHODS AND RESULTS: We studied 54 patients ; 30 patients with pontine infarction extending to the basal surface (group SE) and 24 patients with deep pontine infarction without extension (group DL) based on the site of the infarcts on precontrast sagittal T2WI. We assessed angiographic findings(MRA, 54; DSA, 31), risk factors, clinical features and the effectiveness of the intraluminal signal changes on spin-echo MRI in the diagnosis of occlusion or stenosis of the basilar artery. The incidence of basilar artery stenosis or occlusion in MRA or DSA in group SE(60%) was significantly more frequent than group DL(12.5%), whereas the incidence of vertebral artery stenosis or occlusion was not different between two groups. A noteworthy finding was that five patients (17%) of the group SE had not been extended to the basal surface on axial T2WI. The risk factors were similarly distributed between the two groups. The effectiveness of abnormal signal void of axial MRI was poor in the diagnosis of basilar artery occlusion or stenosis. CONCLUSIONS: Our results suggest that the two types of pontine infarction may be caused by different arterial pathology. Although the presence of abnormal flow void on MRI cannot predict the stenosis or occlusion of basilar artery, sagittal T2WI and angiographic study help to evaluate the patients with pontine infarction.

Correlation between Clinicoradiological Findings and Prognosis in Paramedian Pontine Infarction

BACKGROUND: To clarify the clinicoradiological correlation and prognosis of acute ischemic stroke involving para-median territory of pons. METHODS: We studied 37 patients with first-ever ischemic stroke involving paramedian terri-tory of pons and divided them based on the shape and level of lesion shown in their MRI. The clinical features, MRI findings, and prognosis were assessed. RESULTS: The paramedian infarctions extending to the basal surface were found in 28 patients (76%), and small infarctions separated from the basal surface were found in 9 patients (24%). In patients with infarction extending to the basal surface, 23 patients (82%) had progressive or fluctuating onset, whereas all patients with small infarction separated from the basal surface had non-progressive onset. In the group with upper pon-tine lesion (14 patients), dysarthria-clumsy hand syndrome was found in 4 patients, ataxic hemiparesis (AH) in 3, pure motor hemiparesis (PMH) in 2, and pure sensory stroke in 1. In the group with middle and lower pontine lesion (22 patients), PMH was found in 9, AH in 3, and sensory motor stroke in 2. The mean Modified Rankin Disability Scale scores on admission and after follow-up (mean 29 months) of the group with upper pontine lesion were 2.36 +/-0.50 and 1 . 0 0 +/-0.55, those with mid-lower pontine lesions, 3.48 +/-0.51 and 1.17 +/-0.49 (P0.05 respectively). CONCLUSIONS: Paramedian pontine infarction extending to the basal surface usually presents with progressive onset. Paramedian pontine infarction most often produces classic lacune syndrome of which PMH is the most common. In our study, patients with mid-lower paramedian pontine infarction had more severe initial neurological deficits than those with upper paramedian pontine infarction. However, a late outcome was found to be favorable in both groups.

Combined Facial and Abducens Nerve Palsy in Pontine Infarction

Isolated cranial neuropathies involving the facial nerve are very rare manifestations of pontine infarction, and have not been described in paramedian pontine infarction. We report a 67-year-old woman who developed sudden and long-lasting right facial nerve paralysis accompanied by transient ipsilateral abducens nerve palsy. Brain magnetic resonance imaging showed two discrete simultaneous infarctions in the right inferior paramedian pontine area, which seemed to correspond to the facial nerve fascicle and the abducens nerve fascicle, respectively. Paramedian pontine infarction can be one of the causes of facial nerve palsy and present as an isolated or predominant sign.