Clinical analysis of different parts of medullary infarction / 中华神经科杂志

Objective:To investigate the clinical, imaging, etiological and prognostic features of patients with infarctions in different locations of the medulla oblongata.Methods:Patients with acute medullary infarction hospitalized at Tianjin Huanhu Hospital from July 2017 to July 2022 were included. The risk factors, clinical manifestation, stroke mechanism and 90-day prognosis of these patients were analyzed retrospectively.Results:Among the 256 patients enrolled, 150 (58.6%) had lateral medullary infarction (LMI), 106 (41.4%) had medial medullary infarction (MMI). The most frequent clinical manifestation of patients with LMI was dizziness (84.7%,127/150). And motor disorders (83.0%,88/106) was the most frequent clinical manifestation of patients with MMI. LMI lesions were mostly located in the middle (42.7%,64/150) and MMI lesions were mostly located in the upper (60.4%,64/106) medulla oblongata, with statistically significant difference (χ 2=47.53, P<0.001). Large artery atherosclerosis (LAA) was the main stroke mechanism in LMI and MMI [57.3%(86/150) vs 56.6%(60/106)]. Early neurological deterioration was more common in MMI (25.5%,27/106) and less common in LMI (7.3%,11/150), with statistically significant difference (χ 2=16.17, P<0.001). At discharge, more patients with MMI showed poor prognosis in short term [45.3% (48/106) vs 24.0% (36/150), with statistically significant difference (χ 2=12.76, P<0.001)] and even long term at 90-day follow-up [33.0% (35/106) vs 12.7% (19/150), also with statistically significant difference (χ 2=15.48, P<0.001)] than those with LMI. A total of 10 patients (4.0%, 10/256) developed respiratory failure during hospitalization, including 7 patients with LMI (4.7%, 7/150) and 3 patients with bilateral MMI (2.8%,3/106). Early neurological deterioration ( OR=3.38, 95% CI 1.25-9.10, P=0.016) and LAA (compared with small artery occlusion) ( OR=3.08, 95% CI 1.13-8.37, P=0.028) were independent risk factors for poor prognosis in MMI. Age ( OR=1.01, 95% CI 1.01-1.17, P=0.026) and early neurological deterioration ( OR=20.19, 95% CI=2.63-155.06, P=0.004) were independently correlated with poor outcome in LMI. Conclusions:LMI and MMI had similar etiology and significant differences in clinical manifestations, early neurological deterioration and prognosis. Further classification of medullary infarction was of great significance for diagnosis, treatment and prognosis evaluation.

Imaging features and main clinical manifestations of patients with respiratory and/or cardiac arrest in medullary infarction:A single center retrospective study / 中风与神经疾病杂志

@#Objective　To investigate the imaging characteristics and main clinical manifestations of patients with respiratory and/or cardiac arrest after medullary infarction (MI).Methods　The study included patients with respiratory and/or cardiac arrest after MI,who were hospitalized in the Department of Neurology of Huanhu hospital between 2016 and 2021.The patients were divided into groups and analyzed according to the infarct location and infarct size shown by MRI-DWI,the degree of vascular stenosis shown by MRA and the main clinical manifestations.Results　The study enrolled a total of 28 patients, including 19 patients with lateral medullary infarction (LMI) and 9 patients with medial medullary infarction (MMI).For LMI patients,from head to tail,there were 4 cases with upper MI,11 cases with middle MI,and 4 cases with lower MI.On the axial plane,there were 4 cases in the middle,14 cases in the dorsal,and 1 case through the middle and dorsal.Among the 28 patients,50% were large area MI (DWI high signal≥1/3 of the total area of medulla oblongata) and medium area MI (1/4 of the total area of medulla oblongata≤DWI high signal<1/3 of the total area of medulla oblongata).Sixteen cases completed brain MRA examination,of which 12 cases were moderate and severe vascular stenosis.Among the 28 patients,16 cases were complicated with infarction in other parts,of which 9 cases were complicated with cerebellar infarction.The main clinical symptoms were dizziness and dysarthria.For the 19 LMI patients,dizziness was the main complaint in 16,dysarthria in 16,dysphagia in 10,limb weakness in 7.For the 9 MMI patients,dizziness was the main complaint in 6,dysarthria in 8,dysphagia in 3,limb weakness in 7.Conclusion　LMI is the main type of respiratory and/or cardiac arrest after MI,and it is more common in patients with dorsal medulla oblongata in the middle part.The proportion of patients with medium and large area MI is relatively high.Most patients have moderate and severe vascular stenosis and often complicated with cerebellar infarction.The main complaints were dizziness and dysarthria.LMI was more prone to dysphagia and MMI to limb weakness.

Analysis of prognosis of infarction in different areas of medulla oblongata / 中风与神经疾病杂志

@#Objective　To study the clinical characteristics and prognostic factors of different areas of medulla oblongata infarction. Methods　From April 2019 to November 2019，63 patients with acute medullary infarction in the Department of Neurology，the First Affiliated Hospital of Harbin Medical University were selected as the research objects. The clinical information of the patients was collected，including general information，clinical symptoms and signs，complications，imaging characteristics. NIHSS score was used to evaluate the severity of the disease，and mRS score was used to evaluate the prognosis. Results　（1） The incidence rate of male patients with medullary infarction was higher than that of females. The most common sites of medullary infarction were lateral，head and left. The lateral infarction of medulla oblongata is more common in the middle of medulla oblongata，while the medial infarction is more common in the head of medulla oblongata. The peak age was 61～70 years old. Among them，the incidence rate of male at 51～60 is higher than that of female，and the incidence rate of female is higher than that of male at 61～70 years old. （2） In a single factor analysis，dysphagia and abnormal pharyngeal reflex were higher than the poor prognosis group in the 30-day good prognosis group，dizziness or dizziness，nausea and vomiting in the 90-day good prognosis group were higher than the poor-prognosis group，and quadriplegia in the 90-day poor prognosis group was higher than the good prognosis group，and the differences between the groups are statistically significant. In lateral infarction，the good prognosis group was higher than the poor prognosis group at 90 days，and the difference between the groups was statistically significant. The dyspnea in the 90-day poor prognosis group was higher than that in the good prognosis group，and the difference between the groups was statistically significant. Progressive stroke in the 30-day and 90-day poor prognosis group was higher than the good prognosis group，the difference between the groups was statistically significant. （3） In multivariate logistic regression analysis，dysphagia is negatively correlated with a 30-day poor prognosis，and lateral infarction，nausea，and vomiting are negatively correlated with a 90-day poor prognosis. Central facial paralysis is an independent risk factor for a poor prognosis at 30 days. Progressive stroke is an independent risk factor for a poor prognosis at 30 and 90 days. Conclusion　（1） The incidence of medullary infarction is higher in men than women，and the peak age of women is higher than men. （2） The incidence of medullary cephalic infarction is higher than that of the middle and tail，and the incidence of lateral infarction is higher than that of medial infarction. Lateral medullary infarction has a better prognosis than other regions. （3） Central facial paralysis is an independent risk factor for poor prognosis of medullary infarction within 30 days. Progressive stroke is an independent risk factor for poor prognosis of bulbar infarction.

Lateral medullary infarction resembling myelopathy :a case report and literature review / 中国脑血管病杂志

The incidence of lateral medullary infarction is higher in clinical practice,which is mainly manifested as crossed sensory dysfunction .while the lateral medullary infarction with segmental development of sensory level is rare and easily confused with myelopathy. In this paper,we report the clinical data of a patient with lateral medullary infarction resembling myelopathy,and analyzes the classification,infarct site, responsible vessel,etiology,treatment and prognosis of lateral medullary infarction with sensory dysfunction level in combination with previous literature,so as to provide reference for the diagnosis and treatment of similar cases.

Clinical and imaging characteristics of bilateral medial medullary infarction in elderly patients / 中华老年医学杂志

Objective To investigate the clinical features of bilateral medial medullary infarction (BMMI)in elderly patients.Methods Clinical and imaging data of 8 elderly BMMI patients with different morphology on diffusion-weighted magnetic resonance imaging (DWI-MR) were retrospectively analyzed.All patients were diagnosed by MRI,while 4 patients received CTA and vascular ultrasound testing,and the other 4 patients received vascular ultrasound testing.Results All 8 cases(100.0％) had acute-onset BMMI.Patients showed varying degrees of acroparalysis(7/8,87.5 ％),dizziness (5/8,62.5 ％),dysarthria(6/8,80.0 ％),dysphagia(3/8,37.5 ％),deep or superficial sensory dysfunction(5/8,62.5 ％),consciousness disorders (2/8,25.0 ％),dyspnea (2/8,25.0 ％),and tinnitus(1/8,12.5 ％).Lesions in most patients were located in the upper part of medulla oblongata(7/8,87.5 ％).In the transverse direction of DWI,the lesions as the inverted V shape were seen in 3 cases (37.5％),the V shape(12.5％)in 1 case,the Y shape(37.5％)in 3 cases,and the heart shape(12.5％) in 1 case.All 8 patients were complicated with posterior cerebral artery stenosis or occlusion,of whom patients with heart-or Y-shaped lesions showed progressive exacerbation.After treatment,4 cases (50.0 ％) recovered,3 cases (37.5 ％) improved,and 1 case (12.5 ％) unrecovered before discharge from the hospital.Conclusions Most elderly BMMI patients have concurrent posterior circulation artery stenosis,and patients with heart-or Y-shaped lesions on MR-DWI show rapid progression and have a poor prognosis.Cranial examination with MR-DWI is helpful for early clinical diagnosis of BMMI,prediction of disease progression and effective prevention of complications.

Neural Correlates of Urinary Retention in Lateral Medullary Infarction / 대한배뇨장애요실금학회지

PURPOSE: The brainstem plays an important role in the control of micturition, and brainstem strokes are known to present with micturition dysfunction. Micturition dysfunction in cases of lateral medullary infarction (LMI) is uncommon, but often manifests as urinary retention. In this study, we investigated the neuro-anatomical correlates of urinary retention in patients with LMI. METHODS: This was a hospital-based retrospective study conducted in the neurology unit of a quaternary-level teaching hospital. Inpatient records from January 2008 to May 2018 were searched using a computerized database. Cases of isolated LMI were identified and those with micturition dysfunction were reviewed. MRI brain images of all patients were viewed, and individual lesions were mapped onto the Montreal Neurological Institute (MNI) space manually using MRIcron. Nonparametric mapping toolbox software was used for voxel-based lesion-symptom analysis. The Liebermeister test was used for statistical analysis, and the resultant statistical map was displayed on the MNI template using MRIcron. RESULTS: During the study period, 31 patients with isolated LMI were identified. Their mean age was 48 years and 28 (90%) were male. Six of these patients (19%) developed micturition dysfunction. All 6 patients had urinary retention and 1 patient each had urge incontinence and overflow incontinence. In patients with LMI, the lateral tegmentum of the medulla showed a significant association with urinary retention. CONCLUSIONS: In patients with isolated LMI, we postulate that disruption of the descending pathway from the pontine micturition centre to the sacral spinal cord at the level of the lateral tegmentum results in urinary retention.

A clinical study of neurological signs of medullary infarction evaluated with expanded-National Institutes of Health Stroke Scale / 中华神经医学杂志

Objective To study the value of expanded-National Institutes of Health Stroke Scale (e-NIHSS) in evaluating the neurological signs of medullary infarction.Methods One hundred and thirteen patients with primary medullary infarction proved by magnetic resonance imaging were enrolled and divided into medial medullary infarction (MMI) group (n=41) and lateral medullary infarction (LMI) group (n=72).Risk factors of stroke and neurological signs evaluated by NIHSS and e-NIHSS were recorded and compared between the two groups.Results The age and prevalence of diabetes in MMI group were significantly older/higher than those in LMI group (P＜0.05).The major neurological signs of MMI were limb weakness (95.12％),dysphagia (36.59％),facial plasy (34.15％) and dysarthria (31.71％).And the major neurological signs of LMI were dysphagia (63.89％),truncal ataxia (54.17％),sensory dysfunction (50.00％) and dysarthia (48.61％).All the patients had significantly higher e-NIHSS scores than NIHSS scores (5.40±2.74 vs.2.96±2.22,P=0.000),which was similar in MMI group (e-NIHSS:5.34±3.20 vs.NIHSS:4.07±2.55,P=0.000) and in LMI group (e-NIHSS:5.43±2.47 vs.NIHSS:2.33±1.74,P=0.000).The e-NIHSS scores increased 2.57±1.99 than NIHSS scores in all the patients,which were 1.63±2.25 in MMI group and 3.10±1.62 in LMI higher than NIHSS scores;the differences were statistically significant (P＜0.05).Conclusion The e-NIHSS could improve the sensitivity of NIHSS in evaluating the neurological signs of medullary infarction,which is better in evaluating LMI than in evaluating MMI.

"A case of typical""Y""-shaped medullary infarction" / 天津医药

The medulla oblongata is located at the lower end of the brain stem, and it has abundant blood supply. The incidence of medial medullary infarction is low in cerebrovascular diseases. Bilateral medial medullary infarction is even rare. Bilateral medial medullary infarction is mainly characterized by paralysis. The respiratory failure can occur in severe cases. Magnetic resonance diffusion imaging can present aheartorYshaped lesion. We treated 1 patient with a typicalYshaped bilateral medial medullary infarction.

Dysphagia May Be an Independent Marker of Poor Outcome in Acute Lateral Medullary Infarction

BACKGROUND AND PURPOSE: The functional recovery after the lateral medullary infarction (LMI) is usually good. Little is known about the prognostic factors associated with poor outcome following acute LMI. The aim of this study was to identify the factors associated with poor long-term outcome after acute LMI, based on experiences at a single center over 11 years. METHODS: A consecutive series of 157 patients with acute LMI who were admitted within 7 days after symptom onset was evaluated retrospectively. Clinical symptoms were assessed within 1 day after admission, and outcomes were evaluated over a 1-year period after the initial event. The lesions were classified into three vertical types (rostral, middle, and caudal), and the patients were divided into two groups according to the outcome at 1 year: favorable [modified Rankin Scale (mRS) score or =2). RESULTS: Of the 157 patients, 93 (59.2%) had a favorable outcome. Older age, hypertension, dysphagia, requirement for intensive care, and pneumonia were significantly more prevalent in the unfavorable outcome group. The frequencies of intensive care (13%) and mortality (16.7%) were significantly higher in the rostral lesion (p=0.002 and p=0.002). Conditional logistic regression analysis revealed that older age and initial dysphagia were independently related to an unfavorable outcome at 1 year [odds ratio (OR)=1.04, 95% confidence interval (95% CI)=1.001-1.087, p=0.049; OR=2.46, 95% CI=1.04-5.84, p=0.041]. CONCLUSIONS: These results suggest that older age and initial dysphagia in the acute phase are independent risk factors for poor long-term prognosis after acute LMI.

High-Resolution Contrast-Enhanced 3D-Spoiled Gradient-Recalled Imaging for Evaluation of Intracranial Vertebral Artery and Posterior Inferior Cerebellar Artery in Lateral Medullary Infarction

PURPOSE: To determine whether high-resolution contrast-enhanced three dimensional imaging with spoiled gradient-recalled sequence (HR-CE 3D-SPGR) plays a meaningful role in the assessment of intracranial vertebral artery (ICVA) and posterior inferior cerebellar artery (PICA) in lateral medullary infarction (LMI). MATERIALS AND METHODS: Twenty-five patients confirmed with LMI were retrospectively enrolled with approval by the IRB of our institute, and 3T MRI with HR-CE 3D-SPGR and contrast-enhanced magnetic resonance angiography (CE-MRA) were performed. Two radiologists who were blinded to clinical information and other brain MR images including diffusion weighted image independently evaluated arterial lesions in ICVA and PICA. The demographic characteristics, the area of LMI and cerebellar involvement were analyzed and compared between patients with arterial lesion in ICVA only and patients with arterial lesions in both ICVA and PICA on HR-CE 3D-SPGR. RESULTS: Twenty-two of twenty-five LMI patients had arterial lesions in ICVA or PICA on HR-CE 3D SPGR. However twelve arterial lesions in PICA were not shown on CE-MRA. Concurrent cerebellar involvement appeared more in LMI patients with arterial lesion in ICVA and PICA than those with arterial lesion in ICVA alone (p = 0.069). CONCLUSION: HR-CE 3D-SPGR can help evaluate arterial lesions in ICVA and PICA for LMI patients.

Lateral Medullary Infarction with Ipsilesional Gaze-Evoked and Head-Shaking Nystagmus / 대한평형의학회지

For differential diagnosis between vestibular neuritis and lateral medullary infarction with similar clinical features, bedside examination of nystagmus is important. We report a 45-year-old male who presented with acute vertigo for two days. He showed spontaneous right-beating nystagmus. However, left-beating nystagmus was evoked during bilateral horizontal gaze and by horizontal head oscillation. Brain MRI revealed an acute infarction in the left lateral medulla.

Isolated Axial Lateropulsion in Lateral Medullary Infarction

The Wallenberg's syndrome is produced by infarction of lateral medulla. Isolated ipsilateral axial lateropulsion without other common symptoms of Wallenberg syndrome has rarely been reported as manifestation of lateral medullary infarction. The responsible anatomical structure of ipsilateral axial lateropulsion is still uncertain. We describe a patient with lateral medullary infarction who present with isolated ipsilateral axial lateropulsion without other symptoms of Wallenberg syndrome.

Isolated Body Lateropulsion as a Presenting Symptom of Lateral Medullary Infarction / 대한평형의학회지

Body lateropulsion is a common manifestation of lateral medullary infarction (LMI), and usually associated with vertigo, limb ataxia, sensory disturbance, and Horner's syndrome. However, isolated body lateropulsion as a presenting symptom of LMI is rare, and the responsible lesion for lateropulsion remains uncertain. We report a 71-year-old woman who showed isolated body lateropulsion as a presenting symptom of LMI. Ipsilateral body lateropulsion in our patient may be ascribed to the involvement of the ascending dorsal spinocerebellar tract rather than the descending lateral vestibulospinal tract, which runs more ventromedially.

A Case of Lateral Medullary Infarction after Endovascular Trapping of the Vertebral Artery Dissecting Aneurysm

We report an unusual case of lateral medullary infarction after successful embolization of the vertebral artery dissecting aneurysm (VADA). A 49-year-old man who had no noteworthy previous medical history was admitted to our hospital with a severe headache. Computed tomography (CT) revealed a subarachnoid hemorrhage, located in the basal cistern and posterior fossa. Cerebral angiography showed a VADA, that did not involve the origin of the posterior inferior cerebellar artery (PICA). We treated this aneurysm via endovascular trapping of the vertebral artery distal to the PICA. After operation, CT revealed post-hemorrhagic hydrocephalus, which we resolved with a permanent ventriculoperitoneal shunt procedure. Postoperatively, the patient experienced transient mild hoarsness and dysphagia. Magnetic resonance image (MRI) showed a small infarction in the right side of the medulla. The patient recovered well, though he still had some residual symptom of dysphagia at discharge. Such an event is uncommon but can be a major clinical concern. Further investigation to reveal risk factors and/or causative mechanisms for the medullary infarction after successful endovascular trapping of the VADA are sorely needed, to minimize such a complication.

Long Term Improvement of Dysphagia in Lateral Medullary Infarction: A Case Report / 이화의대지

This report concerns a male patient suffered from refractory dysphagia after subarachnoid hemorrhage. A 49-year-old man admitted with severe headache followed by mental change. Imaging studies revealed that subarachnoid hemorrhage was located in basal cistern, and demonstrated ruptured vertebral dissecting aneurysm. After operation, the patient recovered well except severe dysphagia. Initial VFSS showed aspiration in fluid trial, penetration in semisolid bolus, and large amount of pharyngeal residue with poor relaxation of upper esophageal sphincter. For about 5 months, his symptom and several follow-up VFSS findings did not show marked improvement by various treatments. On magnetic resonance imaging for further evaluation of his brain lesion, an old infarction in right lateral side of medulla was found. He kept dysphagia rehabilitation more than one year, and his symptom improved to the level of oral feeding at last.

A Case of Ipsilateral Hemiparesis in Lateral Medullary Infarction: As a Warning Sign of Acute Progression of Vertebral Artery Thrombosis / 대한뇌졸중학회지

A 70-year-old man presented with acute dysarthria and dizziness. He denied any history of trauma or cervical manipulations within several weeks before symptom onset. We could make a presumptive diagnosis of left Wallenberg syndrome through the results of neurologic examination, which include left limb ataxia, alternating hyp(o)esthesia, spontaneous nystagmus to right side, and left side Honer's syndrome. Initial diffusion weighted imaging performed at admission showed small and discrete high signal lesions in left lateral medulla, left cerebellar hemisphere, and bilateral occipital areas. Contrast enhanced MRA demonstrated a filling defect in long segment of distal left vertebral artery. On 4th days after symptom onset, the patient developed a severe form of ipsilateral hemiparesis. Follow-up brain MRI showed a downward extension of the initial ischemic lesion in upper medulla to upper cervical region. This case suggests that a severe form of ipsilateral hemiparesis may be complicated in the clinical setting of acute lateral medullary infarction with vertebral artery occlusion.

Clinical characteristics of medial medullary infarction and their relationship with vascular lesions: A preliminary study / 中国脑血管病杂志

Objective: To investigate the clinical characteristics of medial medullary infarction (MMI) and their relationship with vascular lesions. Methods: Eighteen patients with clinical symptoms of MMI and confirmed by magnetic resonance imaging (MRI) were selected. Among them, 10 were performed head CTA examination, and 4 were performed cerebral panangiography. The clinical and imaging findings and the outcomes were observed. Results: Circled digit oneAmong the 18 patients, the lesions in 6 patients only affected the medial-ventral part of medulla (mainly causing contralateral limb movement disorder), in 2 patients affected the central part of medulla oblongata (mainly causing sensory dysfunction), and in 4 patients affected the dorsal side of medulla oblongata (mainly causing nystagmus and dizziness). The whole medial medulla were injured in the remaining 6 patients. Circled digit twoThe lesions were detected in 15 patients on T1WI, T2WI, and DWI sequences. The lesions were only detected in 2 patients on T2WI sequence. One patient showed equal signal on T1WI, T2WI, and a lesion was detected on T2WI one week after MRI reexamination. Circled digit threeAmong the 18 patents with MMI, 8 were complicated with diabetes. Six of them performed CTA/DSA examinations, and no vertebral artery lesions were detected. Ten patients were not complicated with diabetes (all with hypertension and elevated low-density lipoprotein), and 8 of them performed CTA/DSA examinations, and the vertebral artery lesions were detected in 7 patients. Conclusions: MMI mainly damages the ventral part of medulla oblongata. MRI is a preferred method at present in the diagnosis of medullary infarction. Diabetes causes small vascular disease and vertebral artery disease may participate the pathogenic process of MMI.

Abnormal Vestibular Evoked Myogenic Potentials in Medial Medullary Infarction

BACKGROUND: The medial vestibulospinal tract (MVST), which descends in the medial longitudinal fasciculus (MLF), may mediate the vestibular evoked myogenic potentials (VEMPs) in the contracting sternocleidomastoid muscle. We report herein abnormal VEMPs in a patient with medial medullary infarction (MMI) that appeared to involve the MLF. CASE REPORT: A patient with infarction involving the right medial medulla showed decreased p13-n23 amplitude and increased p13/n23 latencies of the VEMPs on the right side. These abnormal VEMPs recorded in an MMI patient support the theory that VEMPs are mediated by the MVST contained within the MLF. CONCLUSIONS: VEMPs may represent a valuable tool for investigating vestibular dysfunction originating from the saccule, even in patients with central vestibulopathies, which is not readily defined by conventional vestibular function tests.

Medial Medullary Infarction With Decreased Pain and Temperature Sensation

No abstract available.

Treatment and Mechanism of Surface Electrical Stimulation for Severe Dysphagia Caused by Lower Brainstem Infarction / 中国康复理论与实践

@#Objective To study the potential mechanism of recovery from dysphagia after surface electrical stimulation. Methods 3 cases recovery from dysphagia caused by lower brainstem infarction after surface electrical stimulation of lower mandible and trigeminal nerves were analyzed. Results After 3～16 weeks surface electrical stimulation, the swallow assessment scores reached from 0 to 6 in all the 3 patients. Conclusion Surface electrical stimulation can facilitate the recovery of swallow function, which may be involved with the sensory input, especially the integration of nucleus of the solitary tract (NTS).