Dorsal midbrain syndrome from thalamocapsuloganglionic hemorrhage: A case report

@#Dorsal midbrain syndrome (DMS) is a supranuclear palsy of vertical gaze characterized by conjugate upgaze palsy, light-near dissociation, convergence-retraction nystagmus, lid retraction, and skew deviation. Majority of cases are due to primary midbrain lesions such as strokes or neoplasms, or due to pineal gland tumors compressing the said area. Presented here is the case of a 57-year-old male who came in with a chief complaint of diplopia and the typical signs of DMS. Cranial tomography scan revealed a parenchymal hemorrhage at the left thalamocapsuloganglionic region, a rarely reported site of a primary lesion causing DMS. In this case, the syndrome may have been a consequence of the mass effects and perilesional edema associated with the thalamocapsuloganglionic hemorrhage, or may have been due to disruption of supranuclear inputs to the dorsal mibdrain. This case provides further evidence that DMS may arise from lesions without obvious involvement of the said region. This case also highlights the importance of a thorough physical examination to elicit the findings associated with DMS, and the need to correlate these with a keen analysis of diagnostic test results.

Endoscopic surgery for thalamic hemorrhage breaking into ventricles: Comparison of endoscopic surgery, minimally invasive hematoma puncture, and external ventricular drainage / 中华创伤杂志(英文版)

Purpose:@#Thalamic hemorrhage breaking into ventricles (THBIV) is a devastating disease with high morbidity and mortality rates. Endoscopic surgery (ES) may improve outcomes, although there is no consensus on its superiority. We investigated the efficacy and safety of ES and compared the outcomes of different management strategies by ES, hematoma puncture and drainage (HPD), and external ventricular drainage (EVD) in patients with THBIV.@*Methods:@#We retrospectively analyzed patients with THBIV treated by ES, HPD, or EVD at our hospital from June 2015 to June 2018. Patients were categorized into anteromedial and posterolateral groups based on THBIV location, and then the two groups were further divided into ES, HPD, and EVD subgroups. Individualized surgical approach was adopted according to the location of the hematoma in the ES subgroups. Patient characteristics and surgical outcomes were investigated.@*Results:@#We analyzed 211 consecutive patients. There were no significant differences in clinical characteristics or incidence of perioperative procedure-related complications (postoperative rebleeding and intracranial infection) in either anteromedial or posterolateral groups. Compared with other therapeutic methods, the ES subgroups had the highest hematoma evacuation rate, shortest drainage time, and lowest incidence of chronic ventricular dilatation (all p < 0.05). Among the three anteromedial subgroups, ES subgroup had the best clinical outcomes which was assessed by the modified Rankin Scale, followed by HPD and EVD subgroups (p < 0.01); while in the posterolateral subgroups, clinical outcomes in the ES and HPD subgroups were similar and better than that in the EVD subgroup (p = 0.037).@*Conclusion:@#Individualized surgical ES approach for removal of thalamic and ventricular hematomas is a minimally invasive, safe, and effective strategy for the treatment of THBIV with a thalamic hematoma volume of 10-30 mL.

Clinical effects of Sanqi wound tablets combing with Western medicine to conservative treatment of acute thalamic hemorrhage / 中国生化药物杂志

Objective To observe clinical effects of Sanqi wound tablets combing with Western medicine to conservative treatment of acute thalamic hemorrhage.Methods72 patients with acute thalamic hemorrhage from Department of Neurosurgery from December 2014-June 2016 were grouped two groups by random number table method.The control group was treated with Western medicine, and observation group was treated with Sanqi wound tablets combing with Western medicine.Relevant indicators were analyzed between two groups.ResultsEffective rate of observation group was 88.89%, higher than control group with 69.44%(P<0.05).NSE and hs-CRP level of observation group were (7.02±1.86)μg/L,(11.75±2.64)mg/L, lower than control group(13.98±2.01)g/L,(19.82±3.07)mg/L(all P<0.05).Fugl-Meyer and NIHSS of observation group were (93.07±4.25),(12.01±2.30)points, better than control group(81.16±4.10),(18.42±2.45)points(all P<0.05).Thalamic residual bleeding of observation group was (2.82±0.41)mL, lower than control group (3.97±0.57)mL(P<0.05).ConclusionOn the basis of Western medicine, Sanqi wound tablets can improve the therapeutic effect, reduce inflammation, improve the patient's motor function and nerve defect degree and accelerate the absorption of hematoma.

Study of Amnesia Caused by Thalamic Hemorrhage / The Japanese Journal of Rehabilitation Medicine

Background and Purpose : Many cases of amnesia caused by thalamic hemorrhage involve anterior nucleus hemorrhage, dorsomedial nucleus hemorrhage, and intraventricular rupture. In the present study, intraventricular rupture was studied with a focus on cases with hematoma compression at the fornix. Methods : Of 116 patients with thalamic hemorrhage admitted to our hospital, 50 patients aged <70 years who had hemorrhage during their first stroke confined to the thalamus, internal capsule, and corona radiata, and who neither developed hydrocephalus nor showed dementia prior to onset were investigated. Thalamic hemorrhages were classified by CT findings and the extent of intraventricular rupture. Memory was studied by the FIM memory scores on admission and discharge. Results and Conclusion : Patients with dorsomedial nucleus hemorrhage showed no tendency toward amnesia and were equivalent to patients with posterolateral nucleus hemorrhage, which does not usually result in amnesia on its own. Of the 30 patients with posterolateral nucleus hemorrhage, a high degree of amnesia was observed in the 18 with intraventricular rupture. A high proportion of patients with dorsomedial nucleus hemorrhage experienced intraventricular rupture (5 of 6 patients). Equivalent degrees of amnesia were observed in patients with intraventricular rupture with dorsomedial nucleus hemorrhage and those with posterolateral nucleus hemorrhage. The present findings in conjunction with the fact that amnesia in thalamic hemorrhage involves episodic memory impairment suggest that amnesia in patients with dorsomedial or posterolateral nucleus hemorrhage or with intraventricular rupture does not stem from damage to the dorsomedial nucleus, which is part of the Yakovlev circuit involved in emotional memory. Instead, the primary cause appears to be the effects of intraventricular rupture on the Papez circuit surrounding the lateral ventricle and foramen of Monro.

Rehabilitation of Auditory Agnosia for Bilateral Thalamic Hemorrhage : A Case Report / The Japanese Journal of Rehabilitation Medicine

Bilateral lesions damaging the primary auditory cortex or the auditory radiation may cause auditory agnosia. We describe a 67-year-old woman with auditory agnosia after bilateral thalamic hemorrhage. Initially, she showed subcortical deafness for words and environmental sounds. Pure tone audiometry showed a moderate-to-severe hearing loss (mean hearing level, right 56 dB ; left 57 dB), while the recording of auditory brainstem response was normal. Brain CT demonstrated a hematoma in the left thalamus and a narrow low density area suggesting a sequel of the right thalamic hemorrhage. Hearing training was begun using sound sources that were easily recognizable for the patient. Her recognition was better for words than for individual Japanese vowel or consonant-vowel sounds, and the use of lip reading contributed to her better recognition of words. After 2 months, she was able to communicate with medical staff and family members in daily conversation.

Acute Esotropia Secondary to Thalamic Hemorrhage / 대한뇌혈관외과학회지

Acute esotropia following supranuclear cerebral lesions is rare. Although little is known about its mechanism, it may be seen secondary to thalamic and brainstem lesions. We describe 3 patients who showed unilateral esotropia from thalamic hemorrhage. One patient developed an ipsilesional esotropia with bilateral upgaze paralysis. The other patient showed contralesional esotropia with bilateral upgaze paralysis. Another patient had only contralesional esotropia. We discuss the possible mechanism of esotropia in patients with thalamic hemorrhage and review the literature.

Thalamic hemorrhage: Predictors of mortality and comparison of outcome

BACKGROUND: Surgical management of patients with thalamic hemorrhage lacks evidence of benefit GENERAL OBJECTIVE: To compare the outcomes of patients with thalamic hemorrhage managed surgically and non-surgically, and to determine the predictors of mortality SPECIFIC OBJECTIVES: To describe baseline demographic and clinical characteristics of patients with thalamic hemorrhage, determine which are predictors of mortality, and to compare the mortality rate of those managed surgically and non-surgically METHODOLOGY: Data from patients with thalamic hemorrhage admitted within July 1, 2000 to June 30, 2003 were recorded. Univariate and multivariate analyses were done using SPSS for Windows v9.0. P0.05 was considered significant. RESULTS AND CONCLUSIONS: Among 119 patients, average age was 58 years, predominantly males (68.3 percent), hypertensive (90.8 percent) and had IVE (79 percent). Obstructive hydrocephalus was present in 43.7 percent. Most common sign and symptom was hemiparesis. Prognostic factors significantly associated with mortality were GCS 12 (p30 cc (p=0.023), presence of obstructive hydrocephalus (p=0.003), hypertension (p=0.005) and ischemic heart disease (0.009). Patients in the surgical arm had a higher mortality rate (65 percent vs 37 percent), but surgery was not shown to be a significant predictor of mortality (p=0.23). The poorer outcome in surgical patients may be secondary to their having lower GCS scores, bigger hematoma sizes and greater frequency of hydrocephalus.

A Case of Acute Necrotizing Encephalopathy with a Thalamic Hemorrhage / 대한소아신경학회지

Acute necrotizing encephalopathy predominantly affects young children and infants living in Japan and Taiwan, and is characterised by acute encephalopathy with seizures and decreased level of consciousness. The Hallmark of the disease is diffuse and symmetrical CNS lesions of both thalami, brainstem tegmentum, cerebral periventricular white matter and cerebellar medula. The clinical, radiological and pathological features of this disease, a disease entity established recently, is proposed by Masashi Mizuguchi et al in 1995. The aetiology is unknown but infectious or parainfectious process seems likely. The diagnosis can be made without difficulty on the basis of the combination of a typical clinical figures and characteristic radiologic findings. There is no specific therapy or prevention. The prognosis was poor in the 1980s but has improved recently. We experienced a case of 6-month-old female infant with acute necrotizing encephalopathy and a thalamic hemorrhage. We report this case with a review of the related literatures.

Significance of an Early Clinical Course during the External Ventricular Drainage in Thalamic Hemorrhage

OBJECTIVE: The purpose of this study is to investigate the significance of an early clinical course during the external ventricular drainage(EVD) in patients with thal amic hemorrhage. METHODS: During the last 11 years(1990-2000), a hundred patients with thalamic hemorrhage who underwent EVD were studied. Thirty-four patients underwent temporary closing of EVD at the mean interval of 4.5 days after EVD. The clinical course was divided into 3 groups according to change of Glasgow Coma Scale(GCS) scores of 2 or more within 3 days after EVD compared with those just before EVD: deteriorated, unchanged, and improved. RESULTS: The factors affecting mortality were unchanged(odds ratio [OR] 0.05, 95% confidence interval [CI]0.01-0.38, p=0.0028) and deteriorated clinical course(OR 0.06, 95% CI 0.01-0.38, p=0.0033), GCS scores at the time of admission(OR 1.3, 95% CI 1.02-1.66, p=0.0346), amount of hematoma(OR 0.91, 95% CI 0.83-1.00, p=0.0461) and hematoma enlargement(OR 0.06, 95% CI 0.01-0.65, p=0.0198). The factor affecting the early clinical deterioration was the hematoma enlargement(OR 0.11, 95% CI 0.03-0.38, p=0.0005). The shunt operation was predicted in patients who showed the clinical improvement after EVD followed by the clinical deterioration within 48 hours after temporary closing of EVD. CONCLUSION: It is suggested that an early clinical course during the maintenance of EVD is important to predict mortality and necessity of shunt operation.

Tonic inward and downward deviation of the eye

BACKGROUND: Tonic inward and downward deviation of the eyes ('peering at the tip of the nose') is regarded as a unique feature of thalamic hemorrhage, but the mechanisms of this ocular finding remain obscure. OBJECTIVE: To report on four patients who showed tonic inward and downward deviations of the eyes from either brainstem or thalamic lesions, and to discuss the possible mechanisms involved. DESIGN: Case report SETTING: Secondary and tertiary referral hospitals RESULTS: One patient developed alternating esotropia with downward ocular deviation from thalamic hemorrhage compressing the midbrain. Two patients showed multiple infarctions in the territory of the posterior circulation with or without the involvement of the thalamus. Another patient had lateral pontine hemorrhage extending up to the midbrain tegmentum. Ocular bobbing preceded or accompanied tonic ocular deviation in three patients. CONCLUSION: Tonic inward and downward deviation of the eye may develop in thalamic or brainstem lesions. Irritation or destruction of the neural structures involved in the vergence and vertical gaze may cause this ocular sign in mesodiencephalic lesions. Skew deviation and esotropia from abduction deficit may be involved in some patients. Ocular bobbing and tonic downward deviation may share a common pathophysiology.

Clinical Analysis of Stereotactic Aspiration and Conservative Management in Spontaneous Thalamic Hematoma

OBJECTIVES: The purpose of this study is to review our experience with spontaneous thalamic hemorrhage. Clinical outcome of patients was brought about by comparing stereotactic aspiration and conservative medical therapy. METHODS: The study consists of seventy-three cases with spontaneous thalamic hemorrhage which were treated from the period of Jan. 1993 to Dec. 1999. Thirty-eighty patients were treated with computed tomography (CT) guided stereotactic aspiration and thirty-five patients were treated conservatively. We compared the factors affecting treatment and the factors are as follows: age and sex, conscious level on admission, hematoma volume, hematoma sites, presence of ventricular penetration. RESULTS: The results in the thirty eight stereotactic aspirated cases for the 6 months from oneset are as follows: good recovery or moderate disability in 43%, severe disability in 32%, vegitative state in 11%, dead in 13% respectively. The clinical result was more favorable in stereotactic aspiration, with 11-30cc hematoma volume, extend to internal capsule of hematoma, poor conscious level on admission than conservative medical therapy. But age and sex, conscious level on admission, presence of ventricular penetration were not influential in the statistical outcome between stereotactic aspiration and conservative medical therapy. CONCLUSION: Treatment modality of spontaneous thalamic hemorrhage is still controversial. But stereotactic aspiration is more recommended for improvement therapeutic results than conservative treatment or open craniotomy in case of 11-30cc hematoma volume, extend to internal capsule of hematoma and poor conscious level on admission.

Prognostic Factors in Spontaneous Thalamic Hemorrhage

OBJECT: Object of this study is to study which factors affect the prognosis in spontaneous thalamic hemorrhage treated with conservative method, stereotactic surgery and extraventricular drainage. MATERIAL AND METHODS: We analyzed 127 patients with spontaneous thalamic hemorrhage for evaluating the factors affecting prognosis. Various factors such as age, sex, location of hematoma, Glasgow coma scale(GCS) on admission, intraventricular hemorrhage(IVH), ventricular dilatation, CT classification, hematoma diameter, 4th ventricle dilatation, and treatment modality. RESULTS: The results were as follows: 1) Of the 40 patients with GCS of 3 to 8, 15 patients(37.5%) died. Of the 34 patients with GCS of 13-15, 33 patients(97%) survived 2) The 99 patients had intraventricular hemorrhage and 25 patients(25.2%) died. The 28 patients had no intraventricular hemorrhage and they all survived. 3) Of the 24 patients in whom the cerebrocaudate index(CCI) was more than 0.25, 10 patients(41.6%) died and only 2 patients had good prognosis. The 35 patients had no ventricular dilatation and all 35 patients survived 4) Of the 23 patients extending to hypothalamus or midbrain with ventricular hemorrhage, 11 patients(47.8%) died and 12 patients(52.1%) survived. 5) Of the 10 patients in whom hematoma diameter was more than 45mm, 4 patients(40%) died and 6 patients(60%) had a poor prognosis. 6) The 31 patients had hemorrhagic dilatation of the fourth ventricle and 16 patients(51.6%) died. Of the 29 patients with ventricular hemorrhage and no dilatation, 6 patients(20.6%) died. CONCLUSION: Multiple logistic regression analysis showed prognostic factors: GCS score(p<1/20.0001), extending to hypotahalamus or midbrain with ventricular hemorrhage(p<1/20.0001), thalamic hematoma with IVH(p<1/20.0001), dilated 4th ventricle hemorrhage(p<1/20.0012), hematoma diameter(p<1/20.0001), CCI(p<1/20.0001).

The Late Blink Reflex Response in Patients with Thalamic Hemorrhage

BACKGROUND: This study was designed to understand the possible pathways of R2 responses by testing the blink reflex in patients with a thalamic hemorrhage. METHOD: Blink reflexes were obtained in 11 patients with a thalamic hemorrhage. The mean interval of the first test of the thalamic hemorrhage was 21.7(24.4days, and follow-up tests were performed in 5 patients about 10 months later. RESULTS: All subjects showed normal R1 responses on affected or normal sides. However, R2 responses were abnormal in 9 patients (81.8%). R2 responses were not recorded in 4, and prolonged in 3. Two patients showed both absent and prolonged R2 responses. The abnormal R2 responses were grouped as follows. First, R2 was abnormal bilaterally by the stimulation on the affected side (afferent type, N=4). Second, R2 was abnormal bilaterally by the stimulation on the affected side and abnormal contralaterally by the stimulation on the normal side (mixed type, N=2). Third, R2 was abnormal contralaterally by the stimulation on the affected side (undetermined type, N=2). One showed abnormal R2 bilaterally by the stimulation on the affected and normal side (coma type). On follow-up tests, all showed normalized R2 responses. CONCLUSIONS: Thalamic hemorrhages caused various abnormal R2 responses in blink reflexes, which were normalized in several months. It is suggested that the abnormal R2 responses of thalamic hemorrhage result from the removal of crossed cortical facilitation on brainstem interneurons rather than an interrupted central pathway of the R2 response.

Prognostic Factors in Patients with Hypertensive Basal Ganglionic - Thalamic Intracerebral Hemorrhage

The authors carried out various treatment modalities in 74 consecutive patients with hypertensive basal ganglionic-thalamic intracerebral hemorrhage and were admitted to the Department of Neurosurgery. Konkuk University Hospital, from Jan. 1991 to Dec. 1993. A variety of prognostic factors that influence mortality were observed. The locaton of hematoma was at the basal ganglia in 47 cases and at the thalamus in 27 cases. The prognosis gets poorer as the hematoma extended wider and deeper. The prognosis was unfavorable when the hematoma was over 30cc(P<0.001). The mortality rate was higher in cases with IVH than in cases without IVH(P<0.005). In cases with IVH, 19 cases(26%) showed dilated 4th ventricular hemorrage and higher mortality rate(P<0.001). Cases in which the GCS were less than 9 on admission showed higher mortality rate(P<0.0001). The mortality rate was also higher if the midline shift was more than 10mm on the initial brain CT scan(P<0.005). THe group where the unilateral or bilateral pupillary light reflex was unreactive(35cases) showed poorer prognosis than the group where the bilateral pupillary light reflex was reactive(P<0.0001). The ventriculocranial ratio(VCR), hydrocephalus, surrounding edema edema around the heamtoam, and treatment modality were not related to the prognosis. The significant prognostic factors in patients with hypertensive basal ganglionic-thalamic intracerebral hemorrhage were location and type of hematoma, whether or not the volume of hematoma is more than 30cc, IVH, dilated 4th ventricular hemorrhage, Graeb's score of more than 7, GCS of less than 9, midline shift of more than 10mm, and reactivity of pupillary light reflex.

Factors Affecting the Prognosis in Hypertensive Thalamic Hemorrhage

The authors reviewed 114 patients with hypertensive thalamic hemorrhage diagnosed by CT scan, and analyzed the factors affecting the prognosis in acute stage of 76 patients who were selected by our criteria. The overall mortality was 26.3%. The isolated hemorrhage within thalamus represented 22.8% and showed 100% survivability of ADL(ability in daily life) 3 or above. The mortality of the other that were extended to internal capsule or midbrain, was 35.7%. The factors affecting poor prognosis were as follows : 1) poor conscious level on admission ; 2) the hematoma on left side in location ; 3) hemorrhagic groups that were extended to internal capsule with intraventricular hemorrhage, midbrain, or both ; 4) the presence of ventricular penetration or dilatation ; 5) the hematoma volume of 10cc or above ; 6) the maximum diameter of 33mm or above ; 7) the maximum height of 40mm or above. The prognosis had no significant relationship with the age.

A Clinical Analysis of Hypertensive Intracerebral Hematoma

Hypertensive intracerebral hematoma is a serious and potentially lethal condition. The indication of surgery in this hematoma is still controversial. Authors have treated 335 cases of hypertensive intracerebral hematomas which were confirmed by computerized tomography between July 1, 1982 and June 30, 1986. The hematomas have been classified according to their modes of extension on computerized tomography. The outcome was assessed on their basis of activity daily living. According to our study, moderate and severe types of putaminal hematoma cases have shown better results with surgery than conservative management. Mortality was 23.7 percent in surgery and 35.3 percent in conservative management.

Classification of Spontaneous Thalamic Hemorrhagy for Management and Prediction of Prognosis

65 patients with spontaneous thalamic hemorrhage(TH) diagnosed by CT scan were treated in Catholic Medical Center. Of total 340 patients with spontaneous intracerebral hemorrhage from 1980 to 1983, TH occured in 19.1%. In order to analyse prognosis and guideline of management we classified TH into 4 types with the topographic involvement of thalamus : Type I-the anteromedial TH in 3 cases(4.8%) showed no specific correlation between symptoms and site of hematoma. The prognosis was good with medical treatment alone. Type II-the posterolateral TH in 23 cases(35.2%), mainly spreaded into the internal capsule and the midbrain. Aphasia was one of the main clinical features and the prognosis was worse with both conservative and surgical treatment than those of type I and III. Type III-the dorsal TH in 26 cases(40%), often extended to the lateral ventricle and were localizing in the thalamic area. Emotional change was more occasionally indicated. Type IV-the massive TH in 13 cases(20%), was extensively involved in the thalamus and spreaded to all direction. Symptoms and signs were various and surgery was not indicated because the prognosis was poor. Aphasia was noted in the left TH, but right-hemisphere cortical dysfunction were found mainly in the right TH. The prognoses of the patients with aphaia and/or right hemisphere cortical dysfunction were poorer than those of the patients without. We consider that the patients in type II or III with aphasia and/or right-hemisphere cortical dysfunction should be managed with EVD or stereotaxic urokinase therapy for better neurological outcome.