SEARCH · Search PubMed
Search indexed PubMed citations on genomics, clinical trials, systematic reviews and public health. Explore titles, authors and supplied subject terms, then open the PubMed record.
Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.
A case of suspected brain stem infarction (modified Wallenberg syndrome) due to vertebral artery injury in a bow hunter is presented. An anatomical review is presented to explain the neurological involvement, and recommendations are given for avoiding this syndrome.
The authors report a patient who sustained delayed occlusion of the basilar artery (BA) after an automobile accident. This report illustrates the clinical temporal profile of angiographically verified thromboembolic occlusion of the BA. Further propagation of thrombosis and/or late embolization in the proximal BA and distal vertebral artery resulted in fatal brain stem infarction.
We report the clinical features, radiological studies, operative management, and follow-up data in a series of 27 patients with tentorial meningiomas. Headache and extremity or gait ataxia were the most common presenting symptoms. Signs of elevated intracranial pressure and cranial nerve, pyramidal, or cerebellar deficits were the most common findings on neurological examination. Computed tomography was the single most important diagnostic tool. Cerebral arteriography was considered important to define arterial and venous relationships to the tumor. Two patients in the series underwent cerebrospinal fluid shunting only. The others underwent an operation on the tumor, with or without a shunt. There were 2 postoperative deaths early in the series, 1 due to cerebellar swelling and the other due to brain stem infarction. With an average follow-up of 5.5 years, 19 patients are independent and have resumed their premorbid level of activity. The pathological anatomy of these lesions is described. The different operative approaches to this tumor are discussed.
The authors discuss three patients with biopsy-proven giant cell arteritis (GCA) who experienced significant auditory and vestibular symptoms. Two of the patients who presented with audiovestibular symptomatology died as a direct result of GCA affecting the vertebral arteries. Postmortem findings are reported. This report illustrates the importance of maintaining a high index of suspicion of GCA in elderly patients who present with the acute onset of audio-vestibular symptoms. These symptoms can be a herald of brain stem infarction if giant cell arteritis is the underlying cause. High-dose prednisone and rheumatologic/neurologic consultation is required.
The authors report a case of bilateral ptosis with miosis, paralysis of upward gaze and of smooth pursuit movements to the right, as well as a slowly regressive state of lassitude. This syndrome followed a haemorrhagic brain stem infarction. After a review of the pathophysiology of ptosis and of vertical eye movements, together with analysis of data provided by computerized tomography studies--since the case was not fatal--explanations are offered for each clinical sign and it is proposed that the lesion, a paramedian, slightly deviated to the right haemorrhagic focus in the midbrain, with a diameter of 15 mm, might have involved several structures, namely the rostral interstitial nucleus of the medial longitudinal fasciculus, the mesencephalic reticular formation, as well as cortico-nuclear and sympathetic pathways.
A 45-year-old man presented with enlargement of basilar artery dissecting aneurysm 10 months after suffering brain stem infarction. Combined stenting and placement of Guglielmi detachable coils (GDCs) was planned to obliterate the aneurysm sac. Stent deployment was performed but the procedure was halted to avoid overdosing with contrast material. Cerebral angiography 10 days later showed thrombosis of the aneurysm sac and normalization of the blood flow in the basilar artery. The patient has been followed up for 2 years and showed good clinical and angiographic outcome. Stenting results in obliteration of the aneurysm sac, so a two-stage procedure is recommended.
The inner ears of 167 patients with vertigo and/or abnormal findings at vestibular testing were studied using magnetic resonance (MR). Pathology potentially explaining vertigo was found in 54 patients, and was detected in the posterior fossa (28%), the internal auditory canal (28%) and the membranous labyrinth (44%). The overall percentage of pathology and the percentage of pathology found in the membranous labyrinth was high and was probably influenced by the referral pattern in our hospital where high resolution MR of the inner ear (three dimensional Fourier transformation-constructive interference in steady state sequence; 3DFT-CISS sequence) is available. Unenhanced, and especially gadolinium (Gd)-enhanced T1-weighted spin-echo images, are needed to detect most of the pathology inside the internal auditory canal, and some of the lesions inside the membranous labyrinth. 3DFT-CISS images are the only images that can show fibrous obliteration of the intralabyrinthine fluid spaces, and are therefore necessary to recognise most of the intralabyrinthine pathology. Finally, T2-weighted spin-echo images are best suited to demonstrate cerebellar or brain stem infarction. An additional MR-angiography sequence (three dimensional Fourier transformation-fast imaging with steady precession; 3DFT-FISP) is used when vascular compression of the cochleovestibular nerve is suspected. MR is the method of choice to look for pathology in patients with vertigo, and allows detection of pathology that remains invisible with other imaging techniques. However, well adapted sequences are needed to detect these lesions.
Twenty-seven patients with pain of central origin following cerebral hemisphere or brain stem infarction underwent stereotactic mesencephalic tractotomy. Twenty-one (77.8%) were pain free or significantly improved at discharge. Twenty-four were available for later review and 1p (66.7%) reported relief up to 5 years later. The target site was revised after the first 14 patients, reducing the number obtaining long term relief (lesion I, at the level of the superior colliculus--75%; lesion II, at the level of the inferior colliculus--58.3%), but substantially decreasing the incidence of disorders of ocular function from 83.3% to 16.7%.
Five autopsied cases of dissecting aneurysms of the intracranial vertebral artery are reported and the literature is reviewed to clarify the clinicopathological correlations. In an autopsy series of 110 patients with subarachnoid hemorrhage (SAH), the incidence of this entity was 4.5%, with all five cases progressing rapidly to death from massive SAH. Cases of intracranial vertebral dissection can be divided clearly into two groups based on the clinical and pathological features. In the first group, the dissection is confined to the vertebral artery and a massive SAH develops caused by the rupture of the arterial wall. The plane of dissection is mainly subadventitial. In the second group, brain-stem infarction develops resulting from luminal occlusion by intramural hematoma. The plane of dissection is mainly subintimal, with the dissection extending to the basilar artery. The condition in the second group affects patients at a younger age. If the lesion is localized within the vertebral artery and does not extend to the basilar artery, the disease seems not to be fatal. The clinical features of the vertebral dissection are largely determined by the plane and extension of dissection. Vertebral artery dissection is due to many causative factors including hypertension, congenital or degenerative changes in the arterial wall, and anatomical and pathological characteristics of the vertebral artery.
Neurologic complications associated with inferior petrosal sinus sampling for adrenocorticotropic hormone in the diagnosis of Cushing syndrome are rare. Previously reported complications include brain stem infarction and pontine hemorrhage. We report a case of venous subarachnoid hemorrhage with subsequent acute obstructive hydrocephalus occurring during inferior petrosal sinus sampling for Cushing syndrome.
Dissecting aneurysms of the intracranial arteries are exceedingly rare vascular lesions that can produce acute cerebral or brain stem infarction in young healthy adults. They carry a high mortality rate. Two cases of dissecting vertebral artery aneurysms that presented with bleed, were successfully operated by trapping and excision of the dissecting segment. Both dissecting aneurysms were located distal to PICA origin. Both the patients developed post operative lower cranial nerve paresis and one developed lateral medullary syndrome, which improved subsequently. Dissecting aneurysms presenting with bleed should be surgically managed by trapping and excising the involved segment sparing the PICA origin or by interventional radiological techniques. Revascularisation procedures should be considered in addition to trapping of the main vertebral segment if PICA is involved in the trapped segment. The diagnostic and therapeutic difficulties associated with dissecting vertebral artery aneurysms and the controversies regarding their management have been reviewed.
Two patients having significant coronary artery disease with innominate artery near-total occlusion presented neurological deficit of syncope events or cerebellar and brain stem infarct. Both of them were successfully treated with one-stage reconstruction combined with aorto-carotid-subclavian bypass and coronary artery bypass grafting (CABG). While it could not be over-emphasized how to protect both myocardium and cerebrum during CABG, cerebral perfusion through the reconstructed carotid bypass graft is the key maneuver during cardiac arrest and moderate hypothermia. Hypoperfused cerebral hemispheres were both improved extensively in the follow-up angiography. The absence of cerebral deficit and the free from coronary angina suggested that surgical technique to combine innominate with coronary artery surgery is feasible with acceptable mortality and morbidity rate.
A 53 year old male was admitted with the diagnosis of brain stem infarction. Severe stenosis of the bilateral internal carotid arteries was revealed by cerebral angiography. During the angiography, he complained of acute abdominal pain and was referred to abdominal surgical department. He was diagnosed as thrombo-embolism of the superior mesenteric artery and treated conservatively. The symptoms improved, but renal function became worse and the toe was found to be blue. Cholesterol embolism was suspected by nephrologists and thrombolytic therapy was discontinued. Steroid was administrated and LDL-apheresis was performed. The renal function was aggravating and hemodialysis was required. Emergency neurosurgical operations are sometimes performed immediately after cerebral angiography and the neuroanesthesiologists should be aware of the pathology of cholesterol embolism in perioperative management.
BACKGROUND AND PURPOSE: Several approaches to the treatment of dissecting aneurysms of the vertebrobasilar system have been used. We evaluated our endovascular experience, which includes trapping and proximal occlusion. METHODS: Thirty-five patients with intradural vertebrobasilar dissecting aneurysms presented to our institution between 1992 and 2002. Twenty-six were treated by endovascular means and two with surgery. In the endovascular group, 14 were in a supra-posterior inferior cerebellar artery (PICA) location, and three of these extended to the vertebrobasilar junction on the initial angiogram. Ten were located in an infra-PICA location, or no antegrade flow was seen in the PICA or anterior spinal artery. Two were located at the PICA with antegrade flow preserved in the branch. Twelve lesions were treated with trapping; another 14 were initially treated with proximal occlusion techniques, two of which eventually required trapping procedures. Follow-up images were obtained within 1 year of initial treatment in 24 patients. Mean follow-up for these patients was 3.5 years. RESULTS: Initial treatments were technically successful and without complication in all 26 patients. Follow-up examinations showed complete cure in 19 of 24 patients. One patient died of global ischemia after presenting as Hunt and Hess grade 5 with subarachanoid hemorrhage. Two recurrent hemorrhages occurred in patients in the proximal occlusion group; one died, and the other underwent a trapping procedure. One patient developed contralateral vertebral dissection 24 hours after occlusion of a dissecting aneurysm of the dominant vertebral artery and died of a brain stem infarct. Another died of probable vasospasm, and the last died of an unknown cause 1 month after treatment. Two patients had recanalization despite an initial trapping procedure, both underwent further treatment. Mortality rate was 20% in the treated group (including the two patients treated surgically), with four of five deaths occurring during the initial hospital course. Mortality rate was 50% in the six patients in the untreated group who were available for follow-up. CONCLUSION: Dissecting aneurysms of the vertebrobasilar system remain high-risk lesions because of their natural history. They can be managed by endovascular methods according to aneurysm location, configuration, collateral circulation, and time of presentation. Trapping results in better prevention of rehemorrhage. Proximal occlusion can achieve occlusion without manipulation of the affected segment when more direct endovascular occlusion or stent placement cannot be performed.
We report a 30-year-old man presenting with medial longitudinal fasciculus (MLF) syndrome after an afternoon nap. Magnetic resonance imaging revealed a right medial pontine tegmental infarction and right cerebellar infarctions. This patient was complicated with basilar impression detected on cervical X-ray and MRI. Three-dimensional CT angiography disclosed that the odontoid process migrated into the posterior fossa, thrusting the bilateral vertebral arteries postero-laterally. The mechanical stress on the bilateral vertebral arteries may have caused infarctions in the territories of the posterior circulation of this patient with basilar impression.
Dizziness and vertigo--like headache--are the most common complaints which leads patients to visit the doctor. In spite of the headache--which may be primary (e.g. migraine) or symptomatic--dizziness and vertigo do not appear to be a separate nosologic entity but rather the symptoms of several neurological disorders. For differential diagnosis, interdisciplinary thinking and activity is needed because the vestibular, neurological and psychiatric disorders might have a common role in the development of symptoms and further overlapping can also occur. The vascular disorders of the vertebrobasilar system are discussed in detail in this review. The importance, occurrence and causes of vertigo as a warning symptom is in the focus. The author draws attention to life-threatening conditions with acute onset in cases of the posterior scale ischemia and emphasizes the importance of the correct and early diagnosis. The author tries to clear up the nihilistic aspect in treating of stroke and stresses the necessity of thrombolysis and interventional radiological procedures which may be the only chance for the recovery of the patients. The pharmacological prevention of recurrent vascular events is also important and obligatory for the clinicians.
Fusiform aneurysms (FA) and dissecting aneurysms (DA) of the vertebro-basilar systems have been thought to be rare, but recently reports of these aneurysms have increased. The differential diagnosis between FA and DA is requisite for deciding therapy or for prognosis, but it is often difficult to distinguish these aneurysms even if angiographies are conducted. The authors have treated 6 cases with FA and 5 cases with DA during the past 17 years. As the initial symptom, subarachnoid hemorrhage (SAH) was noted in all 6 cases with FA. On the other hand, 2 cases of SAH, 2 cases of brain stem infarction, and 1 case of ischemic attack were noted in DA cases. The aneurysmal locations of FA were at the vertebral artery (VA) in all 6 cases, and those of DA were at the VA in 3 cases and at the basilar artery (BA) in 2 cases. As angiographic findings of DA, pearl & string signs were demonstrated in 3 cases, and retention of contrast medium was noted in 3 cases. Diagnosis of FA is comparatively easy on angiography but when angiospasm exists, it is difficult to differentiate DA from FA. Consequently, repeated angiography is recommended. MR imaging findings of 2 cases with FA were compared with those of 3 cases with DA. No abnormal findings, excepting a dilatation of the signal-void area corresponding to the arterial blood flow were shown in FA, but various abnormalities were detected in all of the 3 cases with DA. Namely, an intimal flap and a double lumen in 1 case, intra-mural hematoma in 1 case, and a hematoma adjacent to the parent artery in 2 cases were demonstrated. Thus, MR imaging was thought to be a useful means for distinguishing between FA and DA.