Application of ocular vestibular evoked myogenic potentials in acute brainstem infarctions / 中华物理医学与康复杂志

Objective To explore the value of ocular vestibular evoked myogenic potential in treating brainstem infarctions through comparing the characteristics ocular vestibular evoked myogenic potential (oVEMP) and brainstem auditory evoked potential (BAEP) in patients with brainstem infarctions.Methods A total of 60 patients with brainstem infarctions were enrolled in a brainstem infarction (BI) group, while another sixty healthy volunteers were selected as the control group.All patients underwent oVEMP and BAEP tests via air-conducted stimuli.Results The oVEMPs were elicited reliably and stably in 58 of the control group, and 42 of the BI group, with the bilateral N1 and P1 latencies of oVEMP significantly prolonged [N1 (left) : 11.85 ± 0.82 ms, N1 (right) : 11.91 ± 0.86 ms, P1 (left) : 15.52 ± 1.61 ms, P1 (right) : 15.63 ± 1.64 ms respectively] and the bilateral N1-P1 amplitudes of oVEMP significantly reduced [1.23 ±0.42 μV (left) and 1.58 ± 0.70 μV (right) respectively].Moreover, no recordable oVEMPs was elicited in the other 18 patients, among which found 13 prolonged N1 latencies, 10 prolonged P1 latencies, 6 prolonged N1 and P1 latencies and 8 reduced N1-P1 amplitudes of oVEMP.Altogether, 45 abnormal oVEMPs were found, with an abnormal rate of 75％.The average peak latencies of Ⅴ waves [(5.98 ± 0.37) ms] and interpeak latencies of Ⅲ-Ⅴ and Ⅰ-Ⅴ waves [2.93 ± 0.34 ms and 4.96 ± 0.39 ms respectively] in the BI group were significantly prolonged compared to the controls (P＜ 0.01).The amplitude ratio of Ⅴ/Ⅰ (0.48 ± 0.10) in the BI group was significantly reduced compared to the controls (P ＜ 0.05).Forty-two abnormal BAEPs were found, with an abnormal rate of 75％ , including 17 prolonged latency of Ⅴ waves, 6 prolonged latency of Ⅲ waves, 15 prolonged interpeak latencies of Ⅲ-Ⅴ waves, 9 prolonged interpeak latencies of Ⅰ-Ⅴ waves, 11 cases of Ⅲ-Ⅴ interpeak latency larger than Ⅰ-Ⅲ interpeak latencies, 13 cases of the amplitude ratio of Ⅴ / Ⅰ smaller than 0.5 and 3 case of unclear waves.There were no significant differences in abnormal rate when using the oVEMP (42/60 and 75％) and BAEP (45/60 and 70％) testing However, the abnormal rate was 91.7％ when combining oVEMP with BAEP testing, significantly higher than that when only conducting BAEP testing.Conclusion Patients with brainstem infarctions have abnormalities in oVEMP.Combined with MRI and other electrophysiological testing, oVEMP may contribute to the diagnosis of brainstem infarctions.

Risk factors for posterior circulation stroke and imaging features:a retrospective case series study / 国际脑血管病杂志

Objective To investigate the major risk factors for posterior circulation stroke and the clinical and imaging features of posterior circulation stroke patients with diabetes.Methods The patients with acute cerebral infarction were enrolled.The clinical data of patients with posterior circulation and anterior circulation stroke were compared.The patients with posterior circulation stroke were further divided into either a diabetic group or a non-diabetic group,and the vascular risk factors and imaging features of both groups were compared.The patients with posterior circulation stroke were divided into proximal segment,middle segment and distal segment and mixed groups according to the distribution of vascular lesions.The correlations between diabetes and each group and the imaging features were analyzed.Results A total of 328 patients with posterior circulation stroke (male 194,the diabetic group 108) and 336 patients with anterior circulation stroke (male 214,the diabetes group 59)were enrolled.The proportions of patients with diabetes (32.9％ vs.21.7％ ; x2 =10.501,P =0.001),hyperlipidemia (60.1％ vs.47.9％ ;x2 =9.852,P =0.002),previous stroke or transient ischemic attack (TIA) (29.0％ vs.22.0％ ;x2 =4.213,P =0.040) in the posterior circulation ischemic stroke group were significantly higher than those in the anterior circulation ischemic stroke group,and the proportion of smoking patients was significantly lower than that in the anterior circulation ischemic stroke group (18.3％ vs.26.2％ ; x2 =5.977,P =0.014).The levels of total cholesterol (4.72 ±1.07 mmol/L vs.4.56 ± 0.98 mmol/L; t =2.079,P =0.038),triglycerides (1.54 ± 1.07 mmol/L vs.1.33±0.71 mmol/L; t=3.085,P=0.002) and low-density lipoprotein cholesterol (2.91±0.90 mmol/L vs.2.75 ±0.80 mmol/L; t =2.373,P =0.018) were significantly higher than those in the anterior circulation ischemic stroke group,and the level of high-density lipoprotein cholesterol was significantly lower than that in the anterior circulation ischemic stroke group (1.13 ± 0.31 mmol/L vs.1.18 ±0.32 mmol/L; t =2.045,P=0.041).Multivariate logistic regression analysis showed that diabetes (odds ratio [OR] 1.560,95％ confidence interval [CI] 1.086-2.239; P =0.016) and previous stroke or TIA history (OR 1.455,95％ CI 1.013-2.090; P =0.042) were the independent risk factors for posterior circulation ischemic stroke.In patients with posterior circulation ischemic stroke,the patient's proportions of hyperllpidemia (66.7％ vs.55.5％ ;x2 =5.069,P =0.024) and drinking (13.0％ vs.4.5％;x2 =7.568,P=0.006) in the diabetic group (n =108) were significantly higher than those in the non-diabetic group (n =220); the proportion of atrial fibrillation patients was significantly lower than that in the non-diabetic group (3.7％ vs.11.4％ ;x2 =5.274,P =0.022).The levels of triglycerides (1.70 ± 0.93 rnmol/L vs.1.45 ± 1.11 mmol/L; t =1.989,P =0.048),fasting glucose (8.46 ± 2.96) mmol/L vs.5.30± 0.96 mmol/L; t=10.706,P=0.000) and glycosylated hemoglobin (8.36％ ± 1.94％ vs.6.07％ ± 0.55％ ; t =10.576,P =0.000) in the diabetic group were significantly higher than those in the non-diabetic group.The proportion of patients with large artery atherosclerosis stroke in the diabetic group was significantly higher than that in the non-diabetic group (73.1％ vs.60.0％; x2=5.457,P=0.019); the proportion of the patients with cardioembolism was significantly lower than that of the non-diabetic group (2.8％ vs.9.1％;x2 =4.428,P =0.035).The proportion of patients with posterior circulation middle segment infarction in the diabetic group was significantly higher than that of the non-diabetic group (49.1％ vs.31.4％ ;x2 =9.726,P =0.002).The proportions of the patients with brainstem infarction (60.2％ vs.48.2％ ;x2 =4.182,P =0.041) and single brainstem infarction (55.6％ vs.30.5％ ;x2 =19.235,P =0.000) in the diabetic group were significantly higher than those in the non-diabetic group.In patients with single brainstem infarction,the proportions of the patients with pontine infarction (43.5％ vs.25.9％ ;x2 =10.374,P =0.001) and medulla oblongata infarction (7.4％ vs.1.8％ ; P =0.023) in the diabetic group were significantly higher than those in the non-diabetic group.Conclusions Diabetes and previous stroke or TIA history are the independent risk factor for posterior circulation stroke.Diabetes is closely associated with brainstem infarction,and it is more likely to result in pontine infarction.

Effect of Continual Rehabilitation on Brainstem Infarction / 中国康复理论与实践

@#Objective To observe the effect of continual rehabilitation on patients with brainstem infarction. Methods 52 stroke patientswith brainstem infarction were divided into early rehabilitation group (n=26) and continual rehabilitation group (n=26). 2 groups receivedearly rehabilitation for 1 month. Then the continual rehabilitation group continued rehabilitation in the rehabilitation unit, while the early rehabilitationgroup just received the medical guide after discharge. Fugl-Meyer Assessment (FMA), the Balance subscale of the Fugl-Meyertest (FM-B), and modified Barthel Index (MBI) were applied to assess the motor function, balance function and the activities of daily living(ADL) in two groups respectively before and 1 month and 3 months after training. Results The motor function, balance function, the performanceof activities of daily living improved in the continual rehabilitation group (P<0.05). Compared with the early rehabilitation group, thecontinual rehabilitation group significantly improved in FMA, FMA-B and MBI 3 months after the rehabilitation (P<0.05). There was a positivecorrelation in the scores among FMA and FMA-B and MBI. Conclusion The continual rehabilitation is benefit to the motor functionand balance function and ADL of the patients with brainstem infarction.

Brainstem Infarction Complicated by Pneumococcal Ventriculitis / 대한뇌졸중학회지

We report an adult case of pontine infarct complicated by a community-acquired pneumococcal ventriculitis. An 85-year-old woman was referred to the hospital with left-sided weakness and persistent fever despite antibiotics therapy. Diffusion weight magnetic resonance image revealed high signal intensity on the right paramedian pontine and the occipital horn of the lateral ventricle. In the cerebrospinal fluid (CSF) examination, white blood cell count was 2,720 /mm3, glucose level was 4 mg/dL (simultaneous blood glucose level was 135 mg/dL), and CSF protein level was 2,025.4 mg/dL. On admission day 4, CSF culture showed Streptococcus pneumoniae. Despite continuous antibiotics treatment, she expired on admission day 7. In patients with pneumococcal ventriculitis, despite high mortality as in this case, early detection and treatment improve clinical outcome. Also aggressive treatment (intraventricular antibiotics injection, and pus drainage) should be considered.

Basilar Artery Occlusion With Initial Manifestation as Convulsive-Like Movement

Brainstem infarction secondary to basilar artery occlusion often causes very-severe and life-threatening neurological conditions. For better recovery, early diagnosis is essential; however, this is not always easy because of ambiguous symptoms and limited information in some cases. We experienced two patients with basilar artery occlusion who presented with convulsive-like movements as an initial manifestation.

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).

Sudden Hearing Loss Caused by Acute Pontine Infarction: Reports of Two Cases / 대한이비인후과학회지

In most cases, sudden deafness results from viral infection, vascular occlusion or cochlear membrane rupture, but occasionally, its central origin can not be excluded. Although a number of signs are theoretically plausible in patients with pontine infarction such as facial weakness, lateral gaze palsy, Horner syndrome, limb dysmetria, crossed sensory loss or vertigo, isolated sudden deafness is a very rare manifestation. When pontine infarction occurs, it is usually identified on T2-weighted and diffusion-weighted magnetic resonance imaging (MRI). Early treatment with anticoagulant and antiplatelet agents leads to a more rapid resolution of symptoms and preservation of existing brain function. Recently, the authors have experienced two cases of sudden hearing loss caused by acute pontine infarction. Hence, we report two cases with a review of literature.

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.

Ondine's Curse in a Patient with Right Medullary and Bilateral Cerebellar Infarctions: A Case Report

Failure of automatic control of ventilation (Ondine's curse syndrome) is a rare syndrome that sometimes occurs following localized brainstem dysfunction. In this report, we present a case of a 52-year-old male who was admitted to the hospital with sudden-onset nausea. On examination, no lateralization signs were presented. After one hour, his consciousness was altered and he became apneic. After endotracheal intubation and mechanical ventilation, his mentality improved and he was able to ventilate spontaneously. Cranial magnetic resonance imaging demonstrated acute infarction in both cerebellar inferior aspects involving the right side of the medulla. Eleven hours later, the patient's consciousness altered again. Computed tomography demonstrated newly developed hydrocephalus and emergent craniotomy, and extraventricular drainage were performed. The patient improved in both consciousness and respiratory status but complained of mild ataxia and left arm weakness. We recommend cautious examination and early diagnosis and therapeutic decisions in cases of patients with atypical presentation of stroke.

A Case of Combined Facial and Vestibulocochlear Nerve Paralysis in Brainstem Infarction / 대한이비인후과학회지

Isolated cranial nerve palsy without long tract signs such as contralateral hemiparesis, hemihypoesthesia and ataxia is often reported as brainstem infarction. But most of them are accompanied by oculomotor or abducens nerve palsy. Isolated cranial nerve palsy involving the facial nerve and vestibulocochlear nerve is very rare in brainstem infarction. We report, with a review of literature, a case of right caudal pontine infarct on the dorsolateral portion of the middle cerebellar peduncle with isolated 7th and 8th cranial nerve palsies.

Advances in Brainstem Infarction / 国际脑血管病杂志

Brainstem infarction accounts for about 9% to 21.9% of all cerebral infarctions. This article reviews the etiology of brainstem infarction and its pathogenesis,clinical manifestation,diagnosis,and treatment.

Extreme Duplication-type, Nonseparated Fenestration of the Basilar Artery in a Patient with Pontine Infarction: Confirmation with Virtual Arterial Endoscopy

We present a case of a 55-year-old woman with pontine infarction and fenestration of the basilar artery that was demonstrated using virtual endoscopy. The patient had motor weakness of the right side with sudden onset. Diffusion- and T2-weighted MR images revealed high signal intensities in the left pontine regions, and an MR angiographic examination showed the double-lumen sign of the basilar artery. An extensive duplication-type, nonseparated fenestration of the basilar artery was diagnosed by virtual endoscopy and craniocaudal communications with discrete openings were observed. We report a case of a patient with basilar artery fenestration and associated brainstem infarction.

Combined Facial and Contralateral Trochlear Nerve Palsy in a Patient with Diabetes Mellitus

There is an increasing number of reports that the lesion site in isolated cranial neuropathies may be the brainstem. The authors describe a diabetic patient with peripheral type facial palsy and concurrent trochlear palsy. Magnetic resonance imaging showed only a small pontine infarction responsible for the facial palsy. Multiple cranial nerve palsies seen in this patient might be a manifestation of multiple acute small infarcts involving both the brainstem and its cranial nerve root simultaneously.

Brainstem Infarction in Patients with Basilar Artery Dolichosis

BACKGROUND: Basilar arterial dolichosis (BD) has chracteristics of tortuosity and elongation. BD can cause obstructive hydrocephalus, direct compression of brainstem and cranial nerves, and cerebral ischemia or infarction. It has been reported that brainstem infarction is usually located contralateral to the side of lateral displacement. This study was aimed to reveal the relation between the location of the infarction and the some characteristics of BD. METHODS: Among the 143 patients who had brainstem infarction from January, 2003 to July, 2004, 40 patients with BD were analyzed retrospectively. Characteristics of BD and infarct site were analysed with special respect via MRI and MRA. We surveyed the relation between the location of the infarction and the lateral displacement of BD. Subjects were divided into two groups by the degree of the lateral displacement of basilar artery (BA). We made a comparison between the two in clinical characteristics and risk factors. Height of the infarct site and the maximal point of lateral displacement from arbitrarily defined standard level (lower pons) were measured. We surveyed the lesional laterality associated with relative height of the infarct site. RESULTS: Infarct lesions located to the contralateral side of the laterally displaced BA were more prevalent (25 cases, 62.5%). There was significant correlation between the lesional laterality and the lateral displacement of the BA in group B (p=0.039) and between the lesion-height and the maximal dolichosis-height (r=0.639, p<0.001). CONCLUSIONS: Patients with BD are more likely to have brainstem infarction at the contralateral side of the laterally displaced BA.

A Cas e of Bilateral Lateral Medullary Syndrome due to Two Cons ecutive Medullary Infarcts

Lateral medullary syndrome is one of the most well known and best characterized vascular syndromes of the vertebrobasilar circulation. This syndrome is most often caused by unilateral occlusive disease of the ipsilateral vertebral artery or its posterior inferior cerebellar artery branch. Bilateral lateral medullary syndromes are rare and the prognosis of this condition is grave. A 70-year-old hypertensive, diabetic woman developed sudden dizziness and gait ataxia. On neurologic examination, she had dysarthria, hoarseness, nystagmus, absent gag reflex, sensory changes on the right hemibody, and left limb and gait ataxia. Brain MRI revealed left middle and inferior lateral medullar infarction. Brain MR angiography revealed occlusion of the right vertebral artery and mild stenosis at the origin of the left vertebral artery with distal occlusion. Seven months later, she developed right lateral medullary syndrome. Repeated brain MRI revealed right upper lateral medullar and cerebellar infarction. We report a case of bilateral lateral medullary syndromes due to two consecutive medullary infarcts.

Brainstem Infarction Following Snake Bite

Bleeding complications of central nervous system following snake bite are well known. However, nonhemorrhagic manifestations such as ischemic stroke are extremely rare. As far as we know, only four such instances involving middle cerebral artery territory have ever been reported in the literature up to now. A 53-year-old farmer noted right side motor weakness and severe dysarthria 3 hours after a snake bite on right middle finger. Magnetic resonance T2WI showed high signal intensity on left pontine region extending to basal surface and bilateral tegmentum of the pons. He had neither atherogenic risk factors nor cardiogenic embolic sources. Laboratory findings were within normal limits except for mild consumptive coagulopathy. Cerebral angiogram revealed abrupt occlusion of proximal basilar artery. We report a case of brainstem infarction caused by a Korean viper (Agkistrodon blomhoffii brevicaudus) bite and discuss possible mechanisms for cerebral infarction.