Simultaneous Occurrence of Transient Complete Heart Block With Acute Lateral Medullary Infarct.

Lateral Medullary Syndrome (LMS) poses clinical challenges, often resulting from ischemic events in the medulla oblongata. We present a unique case of LMS in a woman in her 60s with a complex medical history. Alongside neurological deficits, she experienced a transient high-grade atrioventricular block (HgAVB), a rare cardiac manifestation linked to LMS. Given the rarity of simultaneous transient HgAVB with acute lateral medullary infarct, only a handful of case reports documenting similar findings are available in the existing literature. More research and case reporting are needed to better our understanding of this area. The patient's condition, marked by a sudden onset of severe headache and left-sided weakness, revealed an acute infarct in the medulla territory. Notably, her HgAVB spontaneously resolved after 72 hours. This case emphasises the crucial need for extended cardiac surveillance in LMS patients due to their susceptibility to life-threatening arrhythmias. The intricate interplay between the brainstem and cardiovascular system highlights autonomic dysregulation as a potential mechanism for cardiac abnormalities. The report advocates for a holistic approach to managing LMS cases, stressing interdisciplinary collaboration for timely diagnosis and intervention, ultimately improving patient outcomes and reducing the risk of fatal arrhythmias.

Lateral Medullary Infarction With Atonic Bladder and Lateropulsion.

Lateral medullary infarction (LMI), or Wallenberg syndrome, can develop various symptoms, but it is rare that ipsilateral axial lateropulsion (or body lateropulsion, BL) or atonic bladder (AB) are caused by LMI. This report describes a case of LMI with both BL and AB. A 77-year-old man, with a history of hypertension and diabetes, developed acute left BL and anuresis. A neurological exam showed right gaze nystagmus, slight dysarthria and dysphagia, right dysesthesia in the trunk, and ataxia in the left limbs and trunk. Horner's syndrome and paralysis were unremarkable. Brain magnetic resonance imaging revealed hyperintensity in the lateral medulla oblongata. Cystometry revealed AB, although the patient had the urge to urinate. Owing to acute therapy, although trunk ataxia was presented for several months, BL and anuresis were recovered on day 15 and day 35, respectively. Here, we describe the potential mechanisms of BL and AB caused by LMI.

Topographic Consideration on the Occurrence of Ipsilesional Facial Paresis in Lateral Medullary Infarction.

INTRODUCTION: The purpose of this study was to identify course of the corticobulbar tract and factors associated with the occurrence of facial paresis (FP) in lateral medullary infarction (LMI). METHODS: Patients diagnosed with LMI who were admitted to tertiary hospital were retrospectively investigated and divided into two groups based on the presence of FP. FP was defined as grade 2 or more by the House-Brackmann scale. Differences between the two groups were analyzed with respect to anatomical location of the lesions, demographic data (age, sex), risk factors (diabetes, hypertension, smoking, prior stroke, atrial fibrillation, and other cardiac risk factors for stroke), large vessel involvement on magnetic resonance angiography, other symptoms and signs (sensory symptoms, gait ataxia, limb ataxia, dizziness, Horner syndrome, hoarseness, dysphagia, dysarthria, nystagmus, nausea/vomiting, headache, neck pain, diplopia, and hiccup). RESULTS: Among 44 LMI patients, 15 patients (34%) had FP, and all of them had ipsilesional central-type FP. The FP group tended to involve upper (p < 0.0001) and relative ventral (p = 0.019) part of the lateral medulla. Horizontally large lesion was also related to the presence of FP (p = 0.044). Dysphagia (p = 0.001), dysarthria (p = 0.003), and hiccups (p = 0.034) were more likely to be accompanied by FP. Otherwise, there were no significant differences. CONCLUSION: The results of present study indicate that the corticobulbar fibers innervating the lower face decussate at the upper level of the medulla and ascend through the dorsolateral medulla, where the concentration of the fibers is densest near the nucleus ambiguus.

Parálisis bilateral de las cuerdas vocales con obstrucción aguda de la vía aérea y traqueotomía urgente en una paciente con ictus vertebrobasilar agudo / Bilateral vocal cord paralysis with acute airway obstruction and urgent tracheotomy in a patient with an acute vertebrobasilar stroke

Introducción El ictus vertebrobasilar puede suponer un reto diagnóstico. La parálisis bilateral de las cuerdas vocales como manifestación de ictus agudo es muy rara, pero potencialmente mortal, por la posibilidad de obstrucción aguda de la vía aérea. No hay casos descritos de parálisis bilateral de las cuerdas vocales como presentación de ictus agudo de etiología neurológica mixta central y periférica. Caso clínico Mujer de 88 años con disfonía secuelar a parálisis de la cuerda vocal derecha postiroidectomía que presentó un cuadro brusco de vértigo, dismetría y disartria leve (National Institutes of Health Stroke Scale: 2) asociado a hipertensión arterial. La tomografía computarizada cerebral urgente demostró trombosis distal oclusiva de la arteria vertebral izquierda sin isquemia establecida. Por mejoría sintomática con control tensional, no se realizó terapia de revascularización. Cuatro horas después, la paciente desarrolló de forma brusca estridor inspiratorio e insuficiencia respiratoria grave por parálisis bilateral de las cuerdas vocales con obstrucción completa de la vía aérea. Se realizó una traqueotomía urgente con mejoría respiratoria. Una tomografía computarizada cerebral de control a las 24 horas mostró un infarto establecido en el hemicerebelo izquierdo y la región bulbar lateral, congruente con territorio de la arteria cerebelosa posterior inferior izquierda. Conclusión Nuestro caso ilustra la posibilidad de la rara aparición de una parálisis bilateral aguda de las cuerdas vocales en el contexto de un ictus agudo junto con una afectación periférica crónica del nervio recurrente laríngeo. Aunque es excepcional, ejemplifica el potencial riesgo asociado a los ictus vertebrobasilares. Un tratamiento más agresivo de reperfusión podría ser adecuado en estos casos, pese a un déficit inicialmente leve, por la posibilidad de progresar a complicaciones vitales. (AU)

INTRODUCTION Vertebrobasilar stroke can be a diagnostic challenge. Bilateral vocal cord paralysis is very rare as a manifestation of acute stroke, yet it is potentially life-threatening because of the possibility of acute airway obstruction. No cases of bilateral vocal cord paralysis have been reported as a presenting symptom of acute stroke of mixed central and peripheral neurological aetiology. CASE REPORT An 88-year-old woman with dysphonia resulting from paralysis of the right vocal cord following a thyroidectomy presented with sudden onset of vertigo, dysmetria and mild dysarthria (National Institutes of Health Stroke Scale: 2) associated with arterial hypertension. An urgent brain computed tomography (CT) scan evidenced distal occlusive thrombosis of the left vertebral artery without established ischaemia. Due to the improvement of symptoms achieved with control of her blood pressure, revascularisation therapy was not performed. Four hours later, the patient suddenly developed inspiratory stridor and severe respiratory failure due to bilateral vocal cord paralysis with complete airway obstruction. An urgent tracheotomy was performed, which resulted in an improvement in her breathing. A control brain CT scan performed at 24 hours showed established infarction in the left hemicerebellum and lateral medullary region, consistent with the territory of the left posterior inferior cerebellar artery. CONCLUSION. Our case illustrates the possibility of the rare occurrence of acute bilateral vocal cord paralysis in the context of acute stroke in conjunction with chronic peripheral involvement of the recurrent laryngeal nerve. Although exceptional, it exemplifies the potential risk associated with vertebrobasilar strokes. A more aggressive reperfusion therapy may be appropriate in these cases, despite an initially mild deficit, because of the possibility of progression to life-threatening complications. (AU)

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.

Midlateral medullary infarction presenting with isolated thermoanaesthesia: a case report.

BACKGROUND: A small lateral medullary lesion could produce isolated impairment of temperature sensation without concomitant impaired pain sensation. However, only one such case has ever been reported, and there are no reports on subjective symptoms and detailed somatosensory testing. CASE PRESENTATION: Herein, we report the case of a 53-year-old female patient presenting with impaired temperature sensation on the left half of her body, from the neck down, following a small infarction of the right midlateral medulla. The chronological changes in the patient's introspection regarding impairment of thermoception and the results of detailed somatosensory tests, including thermal sense, are shown in this report. CONCLUSIONS: Thorough somatosensory tests, personal descriptions of symptoms, and electrophysiological quantification of similar cases are needed to improve our understanding of the neurological separation of the sensations of pain and temperature at the medullary level.

Pain Mimicking Trigeminal Neuralgia in Patients with Acute Ischemic Stroke of the Brainstem.

Background and Purpose: Cases of pain mimicking trigeminal neuralgia (TN) induced by ischemic stroke in the brainstem have been sparsely reported. The study was to determine the characteristics of symptomatic TN in patients with acute ischemic stroke in the medulla oblongata and pons, and to determine the location of the ischemic lesion associated with the pain. Patients and Methods: A total of 6/21 (28.5%) patients with medullary ischemic stroke and 3/34 (8.8%) patients with pontine ischemic stroke who experienced pain mimicking TN between 1 week before and 2 weeks after the stroke onset were enrolled in the study. All patients accepted neuroimaging examinations to determine the location of the ischemic lesion and the etiology of ischemic stroke. The characteristics of pain were recorded and analyzed. Results: Ischemic lesions of patients who experienced pain mimicking TN were located in the lateral medulla oblongata (n=6), nerve root entry zoo (n=2), and areas involved with the spinal trigeminal tract (n=1) in the pons. Half of the instances of pain induced by medullary ischemic stroke occurred prior to the stroke onset. The branch of V1 was exclusively involved in patients with lateral medullary infarction and the branches of V2 and V3 were typically involved in patients with pontine infarction. The pain was relieved spontaneously (n=4, 44.4%) or was controlled with drugs for neuropathic pain treatment (n=5, 55.5%). Conclusion: Half of the instances of pain induced by medullary ischemic stroke occurred prior to the stroke onset. Pain mimicking TN might be a premonitory symptom of the medullary ischemic stroke. Pain mimicking TN induced by brainstem infarction has a good prognosis.

LATERAL MEDULLARY INFARCTION: A PROSPECTIVE HOSPITAL-BASED COHORT STUDY OF CLINICAL AND IMAGING FEATURES AND A CASE REPORT IN A WHITE ADULT.

OBJECTIVE: The aim: The purpose of this study is to determine clinical and imaging features of lateral medullary infarction in a prospective hospital-based cohort study, illustrated with a clinical case presentation in a white adult. PATIENTS AND METHODS: Materials and methods: We prospectively recruited 120 acute posterior circulation stroke patients, admitted to the Neurological Center of the University Hospital (Oleksandrivska Clinical Hospital) in Kyiv, Ukraine, within 6 to 24 hours from the onset of the stroke symptoms. Comprehensive neurological, clinical, laboratory, ultrasound, and imaging examination was performed on all patients. RESULTS: Results: Out of 120 adult patients (68 men, 52 women aged 28 to 89 years; average age 60.7 ± 12.1 years) with an acute ischemic MRI/CT-proven posterior circulation stroke, 22 (18.3%) patients have acute medulla oblongata infarctions.We provided a complex clinical, neurological, laboratory, and instrumental analysis of lateral medullary infarction illustrated with a clinical case presentation. CONCLUSION: Conclusions: Specific clinical and imaging features of lateral medullary infarction were determined, analyzed, compared, and described.

Clinical characteristics of patients with lateral medullary infarction who had fatal respiratory failure.

INTRODUCTION: Respiratory failure is a fatal complication of lateral medullary infarction (LMI). However, the clinical characteristics associated with respiratory failure in patients with LMI have not been fully elucidated. We aimed to evaluate the clinical characteristics associated with respiratory failure in patients with LMI. METHODS: Among the 6365 consecutive patients who were admitted to our institute within 7 days of onset of acute ischemic stroke between January 2007 and December 2019, we identified those with acute LMI as verified by magnetic resonance imaging. We evaluated the associations between clinical characteristics and fatal respiratory failure that occurred within 10 days of stroke onset. RESULTS: Of 102 patients with acute LMI, eight had fatal respiratory failure within 10 days of stroke onset. Patients with fatal respiratory failure had a higher premorbid modified Rankin Scale score than did those without (3 vs. 0, p < 0.001), as well as a higher frequency of pulmonary disease (37.5% vs. 2.1%, p = 0.003). Severe dysphagia (100% vs. 30.9%, p < 0.001), dysarthria (100% vs. 56.4%, p = 0.020), ipsilateral hemiparesis (50.0% vs. 5.3%, p = 0.002), and urinary retention (50.0% vs. 2.1%, p < 0.001) were also significantly more common in patients with fatal respiratory failure than in those without. There were no significant differences in infarct locations between patients with fatal respiratory failure and those without. CONCLUSIONS: Assessment of pre-stroke history and monitoring of neurological symptoms that occur during the first 10 days post-stroke onset would be useful for predicting the risk of respiratory failure in patients with acute LMI.

Characteristics and Prognostic Factors of Swallowing Dysfunction in Patients with Lateral Medullary Infarction.

OBJECTIVES: Lateral medullary infarction mainly impairs the pharyngeal phase of swallowing. We aimed to investigate the utility of the assessment tools of swallowing function in patients with lateral medullary infarction and to determine the factors that could predict the outcomes of swallowing function. MATERIALS AND METHODS: 15 patients with lateral medullary infarction who were admitted to Suiseikai Kajikawa Hospital between August 1, 2016, and March 31, 2020 (age 62.7 ± 14.8 years, 5 women) were enrolled in this prospective study. The diagnosis was made using brain magnetic resonance imaging. We analyzed the factors associated with severe swallowing dysfunction, which was defined as the necessity for tube feeding on the 90th day from admission, with multiple logistic regression analysis. RESULTS: Multivariate analyses identified the repetitive saliva swallowing test, modified water swallowing test, and vertical spread of stroke lesions as independent significant factors affecting severe swallowing dysfunction (p = 0.002, 0.016, and 0.011, respectively). The sub-scores of the pharyngeal phase of the Mann Assessment of Swallowing Ability were also significantly associated with severe swallowing dysfunction (p < 0.001). However, tongue pressure, severe passage pattern abnormality on videofluoroscopic examination, and vertebral artery dissection were not significantly associated with swallowing dysfunction. CONCLUSIONS: Since lateral medullary infarction presents with swallowing dysfunction mainly in the pharyngeal phase, tools that can be used to evaluate the pharyngeal phase of swallowing, such as repetitive saliva swallowing test and modified water swallowing test, are moreuseful than tongue pressure measurement.

The course of facial corticobulbar tract fibers in the dorsolateral medulla oblongata.

BACKGROUND: The course of the corticobulbar tract (CBT) to the facial nucleus has been investigated by some previous studies. However, there are some unclear points of the course of the CBT to the facial nucleus. This study aimed to elucidate the detailed course of the CBT to the facial nucleus through the analysis of lateral medullary infarction (LMI) cases. METHODS: The neurological characteristics and magnetic resonance imaging findings of 33 consecutive patients with LMI were evaluated. The location of the lesions was classified rostro-caudally (upper, middle, or lower) and horizontally. Further, we compared the neurological characteristics between the groups with and without central facial paresis (FP). RESULTS: Eight (24%) patients with central FP ipsilateral to the lesion were identified. Dysphagia and hiccups were more frequently observed in the group with central FP than in the group without central FP. In patients with central FP, middle medullary lesions and those including the ventral part of the dorsolateral medulla were more frequently observed. Contrastingly, patients with lesions restricted to the lateral and dorsal regions of the dorsolateral medulla did not present with central FP. CONCLUSION: The results of this study indicate that the CBT to the facial nucleus descends with the corticospinal tract at least to the middle portion of the medulla, and then ascends to the facial nucleus through the medial and ventral areas of the dorsolateral medulla after decussation.

Dysphagia prognosis prediction via corticobulbar tract assessment in lateral medullary infarction: a diffusion tensor tractography study.

We investigated the capacity for dysphagia prognosis prediction using diffusion tensor tractography (DTT) to assess the state of the corticobulbar tract (CBT) during the initial period following lateral medullary infarction (LMI). Twenty patients with LMI and 20 control subjects were recruited for this study. The patients were classified into two subgroups: subgroup A (16 patients with nasogastric tube required for six months or less after LMI onset) and subgroup B (4 patients with nasogastric tube required for more than six months after onset). DTT was used to reconstruct the CBTs of each patient and control subject, and the fractional anisotropy (FA) and tract volume (TV) measurements were obtained. In the affected hemisphere, the FA value of the CBT was significantly lower in subgroup B than in subgroup A and the control group (p < 0.05), with no significant difference between subgroup A and the control group. In the affected and unaffected hemispheres, the TV values of CBT in subgroups A and B were lower than those of the control group (p < 0.05), with no significant difference between subgroups A and B. In addition, among the four patients of subgroup B, reconstruction of the CBT was not possible in three patients, and the remaining patients exhibited on old lesion in the corona radiate involving descending pathway of the CBT in the affected hemisphere. We found that the injury severity of the CBT in the affected hemisphere appeared to be related to a poor dysphagia prognosis following LMI. Our results suggest that evaluation of the CBT state during the early post-LMI could be useful for dysphagia prognosis prediction.

Neural Correlates of Hiccups in Patients with Lateral Medullary Infarction.

Background: Hiccups is a known presentation of lateral medullary infarction. However, the region in the medulla associated with this finding is not clearly known. In this study, we aimed to study the neural correlates of hiccups in patients with lateral medullary infarction (LMI). Methods: This retrospective study included all patients who presented with lateral medullary infarction between January 2008 and May 2018. Patients with hiccups following LMI were identified as cases and those with no hiccups but who had LMI were taken as controls. The magnetic resonance imaging of the brain was done viewed and individual lesions were mapped manually to the template brain. Voxel-based lesion-symptom mapping employing nonparametric permutation testing was performed using MRIcron. Results: There were a total of 31 patients with LMI who presented to the hospital during the study period. There were 11 (35.5%) patients with hiccups. Using the voxel-based lesion-symptom mapping analysis, the dorso-lateral region of the middle medulla showed significant association with hiccups. Conclusion: In patients with LMI, we postulate that damage to the dorsolateral aspect on the middle medulla could result in hiccups.

Patient characteristics with negative diffusion-weighted imaging findings in acute lateral medullary infarction.

BACKGROUND: Diffusion-weighted imaging (DWI) on magnetic resonance imaging (MRI) shows limited sensitivity in the acute-phase brainstem infarctions, including lateral medullary infarction (LMI), and the detailed characteristics of acute LMI patients with initially negative DWI-MRI findings have not been reported previously. Therefore, we aimed to investigate the differences in the backgrounds or symptoms of acute LMI patients with initially negative findings in standard axial DWI-MRI and those with positive findings. METHODS: In this retrospective cohort study, we collected the data for 35 consecutive acute LMI patients who were hospitalized in our hospital from January 2011 to December 2018. Initial standard axial DWI-MRI was assessed, and the patients were divided into positive and negative groups. The characteristics of the two groups were compared, and the usefulness of additional thin-slice coronal DWI-MRI was also investigated. RESULTS: Nine (26%) acute LMI patients were initially negative on standard axial DWI-MRI. The patients were independently associated with smoking history (78% vs. 23%, p = 0.021) and headache (78% vs. 31%, p = 0.046). Thin-slice coronal DWI-MRI showed positive findings in 50% of the patients with negative findings in standard axial DWI-MRI. All four patients with negative findings in both standard axial and thin-slice coronal DWI-MRI had smoking history and headache. CONCLUSION: Smoking history and headache were associated with initial negative results in standard axial DWI-MRI in acute LMI. Additional thin-slice coronal DWI-MRI was sometimes useful in detecting acute LMI. Follow-up MRI is important for patients showing negative findings in initial DWI-MRI.

Network Localization of Central Hypoventilation Syndrome in Lateral Medullary Infarction.

BACKGROUND AND PURPOSE: The brainstem plays a key role in the control of respiration. Strokes involving the lateral medulla can rarely produce a central hypoventilation syndrome (CHS) characterized by loss of automatic respiration called Ondine's curse. In this study, we investigated the neuroanatomical correlates of CHS in patients with lateral medullary infarction (LMI). METHODS: Cases of CHS following LMI were identified from searching our medical records and literature. Voxel-based lesion-symptom mapping and lesion network-symptom-mapping (LNSM) analysis was performed to identify the regions connected to the lesion sites based on normative functional connectome data. RESULTS: Sixteen patients with CHS and 32 controls were included. The ventro-lateral region of the rostral medulla showed a significant association with CHS. LNSM analysis showed connections of this region to the rostral ventro-lateral medulla and caudal pons. CONCLUSIONS: In patients with LMI, disruption of the respiratory control network, at the level of ventro-lateral region of the rostral medulla, could result in CHS.

Neural Correlates of Urinary Retention in Lateral Medullary Infarction.

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. CONCLUSION: 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.