Revisão de anatomia e correlações clínicas do tronco encefálico, parte i: bulbo / Review of brain anatomy and clinical correlations, part i: medulla

O Tronco encefálico (TE) é uma estrutura singular do sistema nervoso central, pois nele passam tratos sensoriais ascendentes da medula espinal, tratos sensoriais da cabeça e do pescoço, os tratos descendentes motores originados no prosencéfalo (divisão mais rostral do encéfalo), e as vias ligadas aos centros de movimento dos olhos. Contém ainda os núcleos dos nervos cranianos e está envolvido na regulação do nível de consciência através de projeções ao prosencéfalo oriundas da formação reticular. Todas essas estruturas coexistem em um espaço muito exíguo, o que faz com que o TE seja um local muito sensível às alterações patológicas, sendo que os pacientes apresentam muitos sinais neurológicos mesmo com lesões muito pequenas nesse local. Compreender a anatomia interna do TE é essencial para o diagnóstico neurológico e a prática da medicina clínica. Outros profissionais da saúde também se beneficiam desse conhecimento para melhor manejo dos seus pacientes neurológicos. Essa revisão apresenta detalhes da anatomia macroscópica e microscópica do bulbo, bem como seus correlatos clínicos frente às lesões mais comuns dessa divisão particular do TE, conhecidas como síndromes bulbares.

The brainstem is a unique structure in the central nervous system, since it gives way to ascending sensory tracts from the spinal cord, sensory tracts from the head and neck, motor descending tracts originating from the forebrain, and the pathways connected to the eye movement centers. It also contains the cranial nerve nuclei and is involved in the regulation of consciousness levels through projections to the forebrain originating in the reticular formation. All these structures coexist in a very small space, which makes the brainstem very sensitive to pathological changes, with patients presenting several neurological symptoms even with very small brainstem lesions. Understanding the internal anatomy of the brainstem is essential for neurological diagnosis and the practice of clinical medicine. Other health professionals also benefit from this knowledge to better manage their neurological patients. This review presents detailed information on the macroscopic and microscopic anatomy of the medulla, as well as its clinical correlates in the face of the most common lesions of this particular division of the brainstem, known as medullary syndromes.

Blepharoptosis and dysarthria in a boy aged 2 years / 中国当代儿科杂志

A boy, aged 2 years and 4 months, had a sudden onset of blepharoptosis of the right eyelid, accompanied by the mouth deviated to the right side, drinking cough, nystagmus, and developmental regression. Cranial MRI showed softening lesions formed after infarction of the right dorsolateral medulla oblongata, while head CT angiography showed no imaging of the proximal part of the V4 segment of the right vertebral artery. The child was diagnosed with dorsolateral medulla oblongata syndrome and was treated with gamma globulin to regulate immune function, with mannitol to reduce neuronal edema, with low-molecular-weight heparin sodium to improve local hypercoagulation of occluded blood vessels, with hyperbaric oxygen to improve local ischemia and hypoxia and promote the recovery of brain function, and with neuromuscular electrical stimulation to promote the recovery of neuromuscular function. Before discharge, only mild right ataxia and Horner syndrome remained. This article reports the first case of infantile dorsolateral medulla oblongata syndrome and provides experience for the diagnosis and treatment of the disease.

Síndrome de Wallenberg: reporte de caso / Wallenberg Sindrome: a case report

El Síndrome de Wallenberg representa el 36% de los infartos del tronco cerebral. Se debe a la oclusión de la Arteria cerebelosa posterior inferior, afectando estructuras encontradas en el cerebelo y la parte lateral del bulbo raquídeo. El principal factor de riesgo es la aterosclerosis. El caso se trata de paciente masculino de 57 años de edad con antecedente de Infartos lacunares en cerebelo, Diabetes mellitus tipo 2No controlada, tabaquismo y dislipidemia. Inicia con cuadro clínico de cefalea occipital, intensa, súbita, sin atenuantes concomitantemente vértigo, hipo, nauseas, vómitos y parestesia de miembros inferiores. Al examen físico pulsos periféricos disminuidos, presenta Síndrome de Horner, hipo, hipoestesia en hemicara izquierda y hemicuerpo contralateral, con ataxia, dismetría y disdiadococinesia. Se realiza IRM con difusión con conclusión diagnostica: Imagen hiperintensa de morfología irregular en el contorno lateral izquierdo del bulbo raquídeo por restricción molecular, compatible con evento isquémico (Síndrome Wallenberg). Se indica tratamiento antitrombótico y terapia física. Paciente es evaluado 2 meses después mostrando amplia mejoría de su cuadro. Es un síndrome muy específico, cuya manifestación clínica depende de la región anatómica afectada y abstrae al clínico de otros diagnósticos.

Wallenberg's Syndrome represents 36 % of strokes in the brainstem. It is due to occlusionof the inferior cerebellar artery, affecting structures found in the cerebellum and the lateral part of themedulla oblongata. The main risk factor is atherosclerosis. The case is about a 57-year-old male patient witha history of lacunar infarcts in the cerebellum, type 2 diabetes mellitus, smoking and dyslipidemia. It beginswith an intense and sudden occipital headache, without attenuating, concomitantly vertigo, hiccups, nausea,vomiting and paresthesia of lower limbs. At the physical examination, decreased peripheral pulses presentHorner's syndrome, hypoesthesia, hypoesthesia in left hemiface, and contralateral hemibody, with ataxia,dysmetria and dysdiadochokinesia. MRI was performed with diffusion with diagnostic Hyperintense image ofirregular morphology in the left lateral contour of the medulla oblongata, compatible with ischemic event(Wallenberg syndrome). Antithrombotic treatment and physical therapy was indicated. Patient was evaluated2 months later showing ample improvement. It is a very specific syndrome, whose clinical manifestationdepends on the anatomical region affected and abstracts the clinician from other diagnoses.

Lateral medullary infarct/Wallenberg Syndrome: Jamaica / Síndrome de Wallenberg/Infarto medular lateral: Jamaica

We describe two cases of lateral medullary syndrome at the University Hospital of the West Indies, Mona, Jamaica. This diagnosis is often missed and not well understood, so we will discuss the underlying pathophysiology.

Se describen dos casos de síndrome medular lateral en el Hospital Universitario de West Indies, Mona, Jamaica. Este diagnóstico pasa a menudo inadvertido y no es bien entendido. Por esa razón se discute aquí la patofisiología subyacente.

Síndrome de Wallenberg: a propósito de un caso / Wallenberg syndrome: report of a case

Se trata de paciente de sexo masculino, de 47 años de edad, quien ingresa a la emergencia del Hospital “Dr Héctor Nouel Joubert” del IVSS de Ciudad Bolívar por presentar disartria de aparición brusca, disfagia, hemiparesia derecha e hipo intermitente. Al examen físico se encontraron cifras tensionales elevadas (160/80mmHg), voz ronca, lengua lateralizada a la derecha, ptosis velopalatina derecha discreta, hemihipoestesia facial derecha con hemihipoestesia térmica izquierda, hemiparesia derecha, reflejo nauseoso ausente en el lado derecho, todo por afectación de los pares craneales: V, VII, IX, X y XII. Se realizó resonancia magnética contrastada con énfasis en fosa posterior, revelando imagen de 6 mm en bulbo raquídeo, correspondiente a oclusión aterotrombótica de la arteria cerebelosa posterior izquierda, lo cual explica la clínica del paciente. Debe resaltarse el inicio brusco de la sintomatología del paciente y que, a diferencia de otros casos presentados, éste no comenzó con vértigo, náuseas y vómitos, así como tampoco la presencia del Síndrome de Horner ipsilateral, descrito en algunos casos de Síndrome de Wallenberg

A 47-years old male patient admitted to the emergency service of the Dr. Héctor Nouel Joubert Venezuelan Institute of Social Security Hospital of Ciudad Bolivar presented with sudden-onset dysarthria, dysphagia, right-sided hemiparesis, and intermittent hiccups. A physical evaluation revealed high blood pressure (160/80mmHg), hoarseness, tongue deviation to the right, discrete ptosis of the soft palate, right facial hemihypoesthesia with left thermal hemihypoesthesia, right-sided hemiparesis and absent gag reflex on the right side all due to impairment of cranial nerves V, VII, IX, X, and XII. A contrast-enhanced MRI with focus on the posterior fossa revealed a 6mm image in the medulla oblongata, corresponding to an atheroembolic occlusion of the left posterior cerebellar artery, which explains the patient’s bodily disorder. It is worth noting that the symptoms appeared suddenly and, unlike in other cases, they did not include vertigo, nausea, pr vomits, nor the ipsilateral Horner’s Syndrome described in some cases of Wallenberg’s Syndrome

Síndrome de Wallenberg: hallazgos en resonancia magnética con correlación clínica / Wallenberg syndrome: magnetic imaging findings and clinical correlation

El síndrome de Wallenberg es una de las entidades clínicas más frecuentemente reconocidas como parte de la patología vascular del tallo cerebral. En la actualidad puede ser identificada con rapidez gracias a las modernas técnicas en neuroimagen. Presentamos un paciente con cuadro clínico de miosis, disfonía, disfagia, seguido de ataxia. Se efectuó evaluación con resonancia magnética utilizando técnicas de difusión, coeficiente aparente de difusión, FLAIR (fast fluid-attenuated inversion recovery) y perfusión. Se describe la correlación clínica de los síntomas con la localización anatómica de la lesión, y se discuten los hallazgos de imagen. La descripción de este caso enfatiza la utilidad de la resonancia magnética para una adecuada evaluación y correlación clínica de los hallazgos en imagen con la exploración neurológica.

Wallenberg's syndrome is one of the most common clinically recognized conditions due to brain stem infarct, which can nowadays be identified by modern neuro-imaging techniques. We describe a patient complaining of miosis, dysphonia, and dysphagia followed by ataxia. An MRI evaluation was performed including diffusion-weighted imaging, apparent diffusion coefficient, T2-weighted images, fluid attenuated inversion recovery (FLAIR) and perfusion. A brief discussion of imaging findings is presented as well as a clinical correlation of the symptoms with the anatomic location of the lesion. This case report emphasizes the importance of imaging findings and their clinical correlation with neurological examination.

Spontaneous artery dissection in a patient with Human Immunodeficiency Virus (HIV) infection

INTRODUÇÃO: A relação entre AVC e infecção pelo vírus da imunodeficiência humana (HIV) pode ser atribuída em alguns casos a uma vasculopatia subjacente, assim como ocorre nas dissecções arteriais cervicais espontâneas. RELATO DO CASO: Relatamos o caso de um paciente com infecção pelo HIV que desenvolveu uma síndrome de Wallemberg devido a dissecção da artéria vertebral. Os exames laboratoriais revelaram aumento da homocisteina sérica e proteína C reativa. CONCLUSÃO: Este é o primeiro caso na literatura descrevendo a associação entre dissecção arterial e infecção pelo HIV. Sugerimos que o diagnóstico de dissecção arterial deve ser lembrado como um possível mecanismo de AVC isquêmico em pacientes com infecção pelo HIV.

Disección de arteria vertebral: presentación de un caso y revisión de la literatura / Vertebral artery disection: 1 case report and literature review

Vertebral artery dissection seems to be a frequent cause of stroke in young adults. We report a 34 years old female that suffered a cardiac arrest while practicing aerobics, with complete recovery and four months later developed an acute Wallenberg`s syndrome. Magnetic resonance imaging showed an infarction in the right cerebellar hemisphere. Angiography revealed an occlusion of the third segment (V3) of the right vertebral artery which was hypoplastic. The patient was anticoagulated with a favorable clinical outcome. A follow up angiography, performed six months later, showed an incomplete recanalization of the vessel. Vertebral artery dissection should be suspected in every patient with ischemic symptoms or signs related to the vertebrobacilar territory, specially in young or middle aged patients with a history of trauma. magnetic resonance imaging and ultrasound-doppler examinations are the diagnostic test of choice