[The use of the osteopathic correction for the combined treatment and rehabilitation of the patients presenting with the vertebral artery syndrome]. / Osteopaticheskaia korrektsiia v kompleksnoi terapii i reabilitatsii patsientov s sindromom pozvonochnoi arterii.

BACKGROUND: The pathological changes in the cervical spine frequently result in the disturbances of the blood supply in the vertebral-basiliar system. The degenerative-dystrophic processes in the cervical spine occupy the leading place in the pathogenesis of the vertebral artery syndrome (VAS) causing disorders of the microcirculation and innervation, as well as the restriction of mobility and the development of somatic dysfunctions. It can be assumed that the manual methods applied to manage this condition can be effective in the removal the functional abnormalities in the blood flow. AIMS: The objective of the present study was to evaluate the effectiveness of the osteopathic treatment as a component of combined therapy of the patients presenting with the vertebral artery syndrome. MATERIAL AND METHODS: This experimental prospective controlled randomized study was conducted during the period from January 2015 till January 2017. A total of 106 patients with VAS, aged from 20 to 60 (the average age was 43.1±1.0 years) took part in the study. The patients were divided into three groups. The experimental group was comprised of 40 patients who received the medicamentous and osteopathic treatment. The control group consisted of 40 patients given the medicamentous treatment alone. The group of comparison contained 26 patients treated with the use of pharmacotherapy and massage. The methods finding application in clinical neurology, clinical osteopathy, and ultrasonic diagnostics of the brachiocephalic vessels were employed to evaluate the health status of the patients and evaluate the effectiveness of their treatment. RESULTS: The combined treatment of the patients comprising the experimental group with the use of osteopathic correction and pharmacotherapy produced the positive effect and resulted in the normalization of the neurological status of the patients; specifically, the incidence of both subjective and objective (neurological) symptoms was reduced. Simultaneously, the incidence of somatic dysfunctions at all levels of their manifestation decreased as compared with their frequency in the patients of the control and comparison groups. The results of the ultrasound examination of the great vessels of the neck and the brain in the experimental group made possible the evaluation of the dynamics in the incidence of the major pathological changes in the vessels of the vertebral-basiliar basin (VBB). It was shown that the occurrence of such serious changes as venous dishemia, reduction of the vasoconstriction and vasodilation reserves in VBB, in the patients of the experimental group vessels fell down by 32.1% (p<0.001), in comparison with only 12% (p<0.05), in the control group and 6,27% in the group of comparison (p>0.05). CONCLUSION: The osteopathic manipulative treatment included in the combined therapy of patients with VAS based on the personified approach to the management of individual cases, detection and correction of each clinically significant functional disorder accompanying the pathological process greatly contributes to the regression of the neurological symptoms, elimination of somatic dysfunctions at different levels of the body, normalization of the blood flow in the vessels of the vertebral-basilar system. Taken together, these effects prolong the beneficial results of the combined rehabilitative treatment of the patients with the vertebral artery syndrome based on the application of standard pharmacotherapy and correction of the functional disorders with the use of the osteopathic methods.

Lateral Medullary Infarction with or without Extra-Lateral Medullary Lesions: What Is the Difference?

BACKGROUND: Lateral medullary infarction (LMI) is not an uncommon disease. Although lesions are usually restricted to the lateral medullary area, some patients have additional infarcts in other parts of the brain. The clinical features and prognosis of isolated LMI (pure LMI, LMIpr) have been investigated. However, it remains unclear whether clinical characteristics, prognosis and factors associated with prognosis differ between patients with LMIpr and those with additional lesions (LMI plus, LMIpl). METHODS: Patients with LMI identified by MRI were enrolled. The demographic and clinical characteristics, in-hospital outcome (intensive care unit [ICU] admission, pneumonia and modified Rankin scale [mRS] at discharge), and long-term residual symptoms (vertigo/dizziness, sensory disturbances, dysphagia) and outcomes (occurrence of stroke, acute coronary syndrome [ACS], death, and mRS at follow-up) were compared between LMIpr and LMIpl patients. Factors associated with poor functional outcome (mRS 2-6) at the follow-up were analyzed. RESULTS: Among 248 LMI patients, 161 (64.9%) had LMIpr and 87 (35.1%) had LMIpl. During admission, patients with LMIpl more frequently experienced ICU care, pneumonia and had a higher discharge mRS (3 vs. 2; p < 0.001) than LMIpr patients. The occurrence of stroke, ACS, frequency of death and functional outcome was not different during follow-up. However, residual neurologic symptoms such as dizziness (p = 0.002), dysphagia (p = 0.04) and sensory symptoms (p < 0.001) were more frequent in LMIpr than in LMIpl patients. In LMIpr patients, the rostral location of LMI was associated with poor functional outcome (p = 0.041), whereas in LMIpl patients, the presence of medial posterior-inferior cerebellar artery lesion was associated with good functional outcome (p = 0.030). CONCLUSION: Although the short-term outcome is poorer in LMIpl than LMIpr patients, long-term residual symptoms are more common in LMIpr patients. The location of the LMI and extra-medullary lesion affects the long-term functional outcome of LMIpr and LMIpl patients respectively.

High-Resolution Magnetic Resonance Imaging Evidence for Intracranial Vessel Wall Inflammation Following Endovascular Thrombectomy.

Intracranial high-resolution vessel wall magnetic resonance imaging evidence of vessel wall inflammation is present following stent retriever manipulation but absent following aspiration thrombectomy. This is presented in a case of rotatory vertebral artery compression causing multiple posterior circulation infarctions requiring multiple separate aspiration and stent retriever thrombectomies.

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

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

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

Successful endovascular treatment of a dissecting aneurysm of vertebral artery associated with double origin of the posterior inferior cerebellar artery.

BACKGROUND: Double origin of the posterior inferior cerebellar artery (DOPICA) has been rarely reported in the literature, with a reported incidence of 1.45%. In contrast, a high concurrence rate of DOPICA and vertebral artery dissecting aneurysm has been reported. CLINICAL PRESENTATION: A 61-year old woman presented with vomiting and diplopia with preceding headache. Magnetic resonance imaging (MRI) showed fresh infarction of the left lateral medulla and a vertebral artery dissecting aneurysm of the left vertebral artery. The next day, she exhibited transient loss of consciousness and worsening of headache, and MRI depicted subarachnoid hemorrhage. Four-vessel digital subtraction angiography showed a posterior inferior cerebellar artery (PICA) arising both intracranially and extracranially from the left vertebral artery. Although the dissecting lesion involved the V3 and V4 portion, it did not involve an extracranially originating PICA. Internal trapping of the V3 and V4 portion was chosen as the extracranial channel was expected to supply the PICA territory. This procedure was safely performed. CONCLUSION: Early endovascular intervention should be considered in the treatment of dissecting aneurysm of vertebral artery associated with DOPICA for patients with relatively long lesions even in unruptured cases.

Clinical study of 46 patients with lateral medullary infarction.

BACKGROUND: Lateral medullary infarction (LMI) exhibits a variety of clinical features. Various bulbar symptoms can occur in LMI. METHODS: Neuroradiologic findings of 46 LMI patients were examined. Their infarcts were categorized into the rostral, middle, and caudal groups and were further subdivided into the anteromedial, anterolateral, lateral (L), and posterior regions. RESULTS: The middle medulla was the most common site (27 patients). Most lesions affected the L region alone (25 patients). Dysarthria and facial palsy occurred significantly more frequently in the rostral group than those in the caudal group. Severe truncal ataxia was significantly more common in the caudal group than that in the rostral group. Twenty-five of the 28 patients with severe truncal ataxia displayed vestibular symptoms; otherwise, the other 3 patients showed absence of vestibular symptoms. Soft palate paralysis occurred at a significantly high frequency in the patients with dysphagia and hoarseness compared with the patients without these 2 symptoms. Segmental sensory disturbance occurred in 5 patients, 4 of whom exhibited atypical patterns. CONCLUSIONS: The results of our comparisons between the rostral and caudal groups were consistent with those of previous studies. The presence of severe truncal ataxia without vestibular symptoms in LMI was atypical. An analysis of the bulbar symptoms indicated that the extent to which soft palate paralysis contributed to dysphagia was associated with the severity of ischemia in the nucleus ambiguus. The present study showed variability in clinical features of LMI, which was related to differences in the severity and the extent of ischemia in the lateral medulla.

Long-term observation of lateral medullary infarction due to vertebral artery dissection assessed with multimodal neuroimaging.

A 33-year-old man presented with a lateral medullary infarction, vertigo, and nausea. At the time of hospital admission, he had Wallenberg syndrome. Although initial magnetic resonance imaging showed no abnormalities, subsequent diffusion-weighted magnetic resonance imaging showed a high-intensity area in the right lateral medulla oblongata. The right vertebral artery was shown to be dilated on basi-parallel anatomical scanning but to be stenosed on magnetic resonance angiography (MRA). Cerebral angiography 7 days after onset showed the "pearl and string sign" in the right vertebral artery. Follow-up MRA showed gradual improvement of the stenosis in the right vertebral artery. Multiple neuroimaging studies, such as MRA, basi-parallel anatomical scanning, 3-dimensional computed tomographic angiography, and cerebral angiography, should be performed soon after onset in suspected cases of cerebral artery dissection. In addition, serial imaging examinations increase diagnostic accuracy, and the medical history and neurological examination are important.

Treatment of dissecting aneurysms of the PICA: anatomical considerations and clinical outcome.

BACKGROUND AND PURPOSE: Posterior inferior cerebellar artery (PICA) dissecting aneurysms require rapid and aggressive treatment by sacrificing the parent vessel of the aneurysm-bearing dissected vessel. We assessed the clinical consequences of PICA occlusion in view of the local vascular anatomy. MATERIALS AND METHODS: We performed a retrospective search of our neurovascular database in the period 2007-2012. Patient characteristics, including clinical presentation, WFNS (World Federation of Neurosurgical Societies) grading and Glasgow Outcome Scale (GOS), were recorded. CT and CT angiographic findings as well as the detailed vascular anatomy including collateral circulation were assessed. RESULTS: We identified 10 patients (5 male; mean age 50 years). Eight patients presented with WFNS grade I and II, one with grade IV and one with grade V. All patients were treated with parent vessel occlusion (PVO). An extradural PICA origin was seen in three patients. Collateral circulation was visible before PVO in two and after PVO in seven additional patients. Despite the presence of collaterals, mild cerebellar ischemia occurred in three patients, without development of a Wallenberg syndrome. Outcome was favorable in 9 patients (8 patients GOS 5, one patient GOS 4). One patient died due to the mass effect of the initial cerebellar hematoma. CONCLUSION: PVO to treat PICA dissecting aneurysms was well tolerated with a 90% favorable outcome. Regional collateral circulation and vascular variations permitted relative safe vessel occlusion with only minor cerebellar symptoms in this small group of patients.

[Successful treatment of dysphagia due to Wallenberg syndrome using intermittent air stretching method with balloon catheter: a case report].

A 69-year-old woman presented with dysphagia due to Wallenberg syndrome. Videofluorography revealed unilateral dysfunction of the cricopharyngeal muscle, which caused stenosis of the esophageal entrance on the affected side. Pharyngeal fiberscopy indicated that glottal function and the cough reflex were preserved and that the pharyngeal reflex was lost. The stenosis of the esophageal entrance due to dysfunction of the cricopharyngeal muscle on the affected side and the loss of the pharyngeal reflex were considered to cause the patient's dysphagia. Based on above mentioned findings, the intermittent air stretching method with balloon catheter(IASM)was performed. As a result, dysphagia showed rapid improvement without any complications such as aspiration or bleeding. Thus, the IASM may be effective in some cases of dysphagia due to Wallenberg syndrome.

Stroke syndromes and clinical management.

The knowledge of brain syndromes is essential for stroke physicians and neurologists, particularly those that can be extremely difficult and challenging to diagnose due to the great variability of symptom presentation and yet of clinical significance in terms of potential devastating effect with poor outcome. The diagnosis and understanding of stroke syndromes has improved dramatically over the years with the advent of modern imaging, while the management is similar to general care as recommended by various guidelines in addition to care of such patients on specialized units with facilities for continuous monitoring of vital signs and dedicated stroke therapy. Such critical care can be provided either in the acute stroke unit, the medical intensive care unit or the neurological intensive care unit. There may be no definitive treatment at reversing stroke syndromes, but it is important to identify the signs and symptoms for an early diagnosis to prompt quick treatment, which can prevent further devastating complications following stroke. The aim of this article is to discuss some of the important clinical stroke syndromes encountered in clinical practice and discuss their management.

Lateral medullary syndrome in a boy with hereditary dysfibrinogenemia.

A 9-year-old boy presented with sudden onset of nausea, vomiting and unsteady gait after a bread-eating game, which possibly caused neck hyperextension. Neurological examination revealed hemisensory loss of pain and temperature sensation in the right trunk and limbs along with left Horner's syndrome, suggesting lateral medullary syndrome (LMS). Magnetic resonance (MR) imaging of the brain revealed infarction at the left lateral medulla. MR angiography showed no sign of arterial dissection and no occlusion or stenosis of the intracranial, basilar or vertebral arteries or their branches. No evidence of cardioemboli or systemic inflammation was apparent. Repeated blood examination revealed low activity of fibrinogen. Genetic testing confirmed the presence of hereditary dysfibrinogenemia with a mutation in the FGB gene (BßGly15Cys). This fibrinogen variant has previously been found in Japanese patients with atherosclerosis obliterans or no symptoms. Under conservative treatment without anticoagulation and aspirin, the patient made a good recovery within a few months. We presume that microthrombosis may have been deposited within the vertebral system as a result of extension and rotation of the neck during sports activity, with a contribution from hereditary dysfibrinogenemia.

Hyoid bone and larynx movements during electrical stimulation of motor points in laryngeal elevation muscles: a preliminary study.

OBJECTIVES: This study aimed to determine the laryngeal elevation muscle motor points, evaluate the movement of hyoid bone and larynx during stimulation of the motor points, and examine the potential for treating severe dysphagia by functional electrical stimulation. METHODS: The motor points of the laryngeal elevation muscles were anatomically determined from four cadavers. Those motor points in two healthy subjects and one lateral medullary syndrome patient were electrically stimulated by surface or implanted electrodes. RESULTS: The movements elicited by electrical stimulation of the motor points were greater in implanted than in surface electrodes. Elevation of the hyoid bone and the larynx in a lateral medullary syndrome patient were achieved with the implanted electrodes, but the upper esophageal sphincter opening was not obtained unless an additional cricopharyngeus muscle block was provided. CONCLUSION: The hyoid bone and larynx were elevated by electrically stimulating the motor points of the laryngeal elevation muscles.

Therapeutic role of rTMS on recovery of dysphagia in patients with lateral medullary syndrome and brainstem infarction.

BACKGROUND: There is some evidence for a therapeutic effect of repetitive transcranial magnetic stimulation (rTMS) on dysphagia in hemispheric stroke. AIM: To compare the effect of active or sham rTMS applied to the motor area of both hemispheres in patients with acute lateral medullary infarction (LMI) or other brainstem infarctions. MATERIAL AND METHOD: The study included 22 patients with acute ischaemic stroke who had severe bulbar manifestation. 11 patients had LMI, and 11 had another brainstem infarction. They were randomly allocated to receive active (n=11) or sham (n=11) rTMS of the oesophageal motor cortex. Each patient received 300 rTMS pulses at 3 Hz and an intensity of 130% resting motor threshold to each hemisphere for five consecutive days. Clinical ratings of dysphagia and motor disability were assessed before and immediately after the last session, and then again after 1 and 2 months. RESULTS: There were no significant differences in baseline clinical assessment of swallowing between active and sham groups. Active rTMS improved dysphagia compared with sham rTMS in both groups of patients, (p=0.001 for both); the LMI group also improved the scores in the Barthel Index. All improvements were maintained over 2 months of follow-up (p=0.001). CONCLUSION: These findings suggest that rTMS could be a useful adjuvant strategy in neurorehabilitation of dysphagia due to LMI or other brainstem infarction, although further assessment is necessary in multicentre clinical trials.

Development of unusual collateral channel from the posterior meningeal artery after endovascular proximal occlusion of the posterior inferior cerebellar artery.

A 38-year-old man presented with a dissecting aneurysm of the left proximal posterior inferior cerebellar artery (PICA) manifesting as Wallenberg's syndrome. The patient was treated by endovascular occlusion of the aneurysm and parent artery. Immediately after the treatment, the PICA territory was supplied by collateral circulation via the ipsilateral anterior inferior cerebellar artery. Seven days later, endogenous revascularization of the distal PICA territory had occurred via collateral circulation from the posterior meningeal artery (PMA). This unusual collateral circulation was thought to occur through a pre-existing anastomotic channel between the primitive vessels of the PICA and the PMA during subclinical hypoperfusion of the distal PICA territory. This unusual case demonstrates the potential for delayed development of collateral circulation from the PMA to the PICA territory.

Lateral medullary ischaemic events in young adults with hypoplastic vertebral artery.

OBJECTIVE: To present three cases of young adults with lateral medullary ischaemic events associated with a hypoplastic vertebral artery (VA). All three patients had two additional atherosclerotic or non-atherosclerotic risk factors for stroke. PATIENTS AND METHODS: One female, aged 40 years, and two males, aged 38 and 37 years, each with two risk factors for stroke, presented to the emergency department with acute onset of symptoms and findings consistent with lateral medullary syndrome. All three patients underwent emergency CT scan of the brain followed by MRI and magnetic resonance angiography (MRA). RESULTS: The CT scans were negative in all patients. MRI revealed a lateral medullary lesion in only one patient. All three patients had a hypoplastic VA ipsilateral to the clinical ischaemic event on MRA. CONCLUSIONS: Hypoplasia of VA is not considered a risk factor for stroke as it is a common variant in up to 75% of the general population. However, in our patients, hypoplastic VA coexisted with two risk factors and resulted in stroke. Thus although a hypoplastic VA may not be an uncommon asymptomatic finding, it may contribute to stroke if additional risk factors are present.

[New aspects of Wallenberg syndrome and other brain stem infarctions]. / Nya aspekter på Wallenbergs syndrom och andra hjärnstamsinfarkter.

Studies with MRI and non-invasive vascular imaging have modified previous conceptions on clinical spectrum and causes of different types of brain stem infarcts. Wallenberg's syndrome caused by lateral medullary infarction (LMI) often presents with patterns of sensory loss different from the "classical" crossed type. LMI carries a risk for respiratory and cardiovascular complications in the acute phase, warranting close patient monitoring. Medial medullary infarcts often present with a lacunar syndrome mimicking capsular or pontine small vessel disease. Cerebellar infarcts are most often caused by cardiac embolism. Isolated vertigo may be the only presenting symptom. Neurosurgical intervention of expansive cerebellar infarcts may be life-saving. Clinical features of progressive multifocal brain-stem symptoms are often suggestive of basilar artery occlusion. CT-angiography is a useful initial diagnostic tool. Based on observational studies, intraarterial thrombolysis is used in selected patients with basilar artery occlusion, but further studies are needed to define treatment criteria more precisely.

Traumatic arteriovenous fistula of the posterior inferior cerebellar artery treated with endovascular coil embolization: case report.

BACKGROUND: High-flow intracranial arteriovenous (AV) fistulas associated with giant varices are rare lesions. These varices can present with symptoms from mass effect, spontaneous hemorrhage, and seizures to cardiac failure. Direct AV fistulas of the posterior inferior cerebellar artery (PICA) are extremely rare lesions, with only two cases reported in the literature. CASE DESCRIPTION: The authors present an unusual case of a 25-year-old male with a direct AV fistula of the PICA that resulted from a fracture of the occipital condyle. This high-flow AV fistula drained into a giant varix of the vein of the lateral recess that compressed the brainstem, resulting in a Wallenberg syndrome. The patient underwent embolization of the proximal PICA feeding the fistula with a Guglielmi detachable coil (GDC), which resulted in thrombosis of the varix. A postembolization angiogram showed occlusion of the PICA AV fistula and draining varix. A computed tomography (CT) scan performed at a 10-month follow-up visit showed dramatic decompression of the brainstem. Although the patient continued to have some sensory changes secondary to Wallenberg syndrome, he was otherwise doing well neurologically. CONCLUSION: The treatment of this lesion is difficult because of its location near the brainstem. Postocclusion edema or hemorrhage can result in mass effect and life-threatening brainstem compression. Our patient, whose AV fistula was caused by trauma, was treated effectively with GDC embolization.

[Lateral medullary infraction due to left atrial myxoma--a case report]. / Sluzak lewego przedsionka przyczyna zespolu bocznego opuszki--opis przypadku.

A case of 53 year old women with Wallenberg syndrome due to atrial myxoma is reported. She was operated. Atrial myxoma on 7 x 8 cm was removed. After few months she can walk independently, she needs only a little help in everyday activities.

Chronic motor cortex stimulation for central deafferentation pain: experience with bulbar pain secondary to Wallenberg syndrome.

Six patients with bulbar pain caused by lateral medullary infarct were treated by stimulation therapy. Dysesthesia on the opposite side of the body was subjected to stimulation therapy in these patients. Of the subjects, 4 underwent thalamic stimulation and 3 were treated by motor cortex stimulation; the effects of both thalamic and motor cortex stimulation were investigated in 1 patient. No satisfactory pain control was obtained by thalamic stimulation in any of the patients in this series. In contrast, 2 of the 3 patients treated by motor cortex stimulation reported satisfactory pain control. The pain inhibition usually occurred at intensities below the threshold for the production of muscle contraction (pulse duration, 0.1-0.5 ms; intensity, 3-8 V). This finding was consistent with our previous observations made in a series of patients with thalamic pain, indicating that motor cortex stimulation is significantly more useful than thalamic stimulation for controlling deafferentation pain secondary to central nervous system lesions. We discuss the possibility that better control of deafferentation pain may be provided by stimulation at a level more rostral to the site of deafferentation.