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PubMed1990

Fractures of the clivus: classification and clinical features.

Fractures of the clival complex were diagnosed in a series of 17 patients admitted to the Maryland Institute for Emergency Medical Services System and the University of Maryland Medical System over a 30-month period. These fractures were divided pathologically into three types based upon their appearance on computed tomography: longitudinal, transverse, and oblique. The mechanisms of injury were similar in all groups, and the Glasgow Coma Scale scores at admission were comparable, regardless of fracture type, in survivors and nonsurvivors. Longitudinal fractures were associated with severe injury to the central nervous system and with brain stem infarction, and 4 of 6 (67%) of these patients died. Transverse fractures of the clival complex were found in 6 patients, 3 of whom (50%) died. All of these patients had fractures of the petrous ridge; 2 of the 3 survivors had multiple cranial nerve deficits, and one patient developed a carotid-cavernous fistula. Of the 5 patients with oblique clival fractures, 2 survived (40%), both of whom had multiple cranial nerve palsies; in addition, one of these patients developed a carotid-cavernous fistula. Using the present generation of computed tomographic scanners, fractures of the clival complex can be reliably diagnosed; they are probably more common than previously believed and can be separated into three groups based on the characteristics on computed tomographic scans and clinical findings.

Accidents, Traffic↗
PubMed1988

[Revascularization of vertebro-basilar occlusive disease].

Various surgical techniques have been reported for vascular reconstruction in cases of vertebro-basilar occlusive disease, but sufficient study has not been made on the question of which technique should be applied in various pathological conditions. Based on our experience, we have examined the advantages and disadvantages of these techniques. In 34 patients with clinically and angiographically diagnosed vertebro-basilar insufficiency, the reconstructive vascular surgery to the posterior circulation was performed. Preoperatively, 24 had vertebro-basilar TIAs, 2 had RIND, 3 had progressing symptoms and 5 had brain stem infarctions verified by persistent deficits. In the 18 patients with intracranial vertebro-basilar occlusive lesions, the bypass were done to the proximal posterior inferior cerebellar artery in 7 cases, proximal superior cerebellar artery in 9 cases, posterior cerebral artery in one and anterior inferior cerebellar artery in one. In the 16 patients with extracranial occlusive lesions of vertebral artery, endarterectomy or subclavian-vertebral transposition was performed. With the exception of one of the progressing stroke cases, in which the surgery was ultimately too late, there were no cases in which neurological symptoms become aggravated following operation. Patency was 94% (32/34). In light of these findings, the following conclusions concerning the operative indication and the selection of the technique have been drawn. In cases with occlusive lesions of basilar artery, the first choice should be bypass to the proximal superior cerebellar artery. In cases with occlusive lesions of vertebral artery, bypass to the posterior inferior cerebellar or superior cerebellar or anterior inferior cerebellar artery should be performed.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1985

Group B streptococcal infective endocarditis.

From 1970 to 1983, five patients with group B streptococcal endocarditis were treated at the Mayo Clinic, Rochester, Minn. The minimal inhibitory concentration and the minimal bactericidal concentration of penicillin were 0.09 microgram/mL or less and 1.56 micrograms/mL or less, respectively. The in vitro activity of cefazolin against group B streptococci was similar to that of penicillin. In three of the five cases, penicillin and streptomycin acted synergistically in vitro against group B streptococci. Four of the five patients were cured, three by use of an aminoglycoside combined with penicillin, ampicillin, or vancomycin. Three of the five patients had multiple large systemic emboli, and one of the three died of brain-stem infarct. Penicillin alone or in combination with an aminoglycoside is effective therapy for group B streptococcal endocarditis. Patients unable to tolerate penicillin may be treated with cefazolin or vancomycin. Clindamycin therapy should be avoided in patients with endocarditis caused by strains that are tolerant in vitro to clindamycin.

Adolescent↗
PubMed1985

Pyogenic hepatic abscess and diabetes mellitus--a probable association.

Four patients with pyogenic hepatic abscesses are reported. There were three females and one male with an age range of 36-75 years. In all the cases, diabetes mellitus was associated. Confirmation of the abscesses was obtained by liver scanning or ultrasonography, or both. In one patient, the clinical course was complicated by sympathetic pericardial effusion with right heart failure. Two patients had percutaneous transhepatic drainage of the abscesses under fluoroscopy. All four patients eventually required laparotomy and open drainage of the abscesses. Diabetic control was achieved with insulin therapy. The common causative organism in all instances was the Klebsiella species. Three patients recovered. The remaining one developed hypotension post-operatively and died of brain-stem infarction and the hepato-renal syndrome.

Adult↗
PubMed1995

[A case of growing up aneurysms with occlusion of basilar artery].

This is a report of unruptured aneurysms with occlusion of the basilar artery. A 61-year-old female was admitted to our hospital because of dysarthria and numbness of her left face. Angiography revealed occlusion of the basilar artery and severe arteriosclerosis of the bilateral cerebral carotid arteries. Pcom was not visualized on bilateral carotid angiogram. These neurological signs were considered to be derived from vertebrobasilar insufficiency by occlusion of the basilar artery. Right STA-SCA anatomosis was performed to prevent brain stem infarction. Postoperative angiography showed a good filling of both PCA and SCA by collateral circulation via a right STA and an unruptured basilar top aneurysm. Seven months after the bypass surgery, angiography disclosed that the basilar top aneurysm was visualized clearly, and its size was unchanged. The fact that there was no thrombus formation in the aneurysm was considered to be due to ticlopidine, and the hemodynamic changes after the bypass surgery were suspected to have increased the intraaneurysmal pressure. Therefore we performed neck clipping of the basilar top aneurysm by using a right pterional approach. Two years after the second operation, the patient complained of severe headache and vomiting. CT scan showed subarachnoid hemorrhage, and angiography demonstrated a newly developed aneurysm which might have ruptured on left internal carotid anterior choroidal artery bifurcation. Emergency neck clipping of the second aneurysm was performed, and the patient showed a good postoperative course. The newly developed second aneurysm might have been caused by severe arteriosclerosis and hypertension in addition to hemodynamic stress.

Arterial Occlusive Diseases↗
PubMedDate not supplied

Severe complications following a "barium swallow" investigation for dysphagia.

OBJECTIVE: To highlight the risks of investigation of patients with swallowing disorders by "barium swallow", when the disorders may arise from dysfunction of the upper swallowing tract. CLINICAL FEATURES: An 81-year-old Italian woman presented to her local doctor with a history of dysphagia of five days' duration. A barium swallow resulted in aspiration of a large amount of barium into the right main bronchus, causing severe problems. After a period of intensive respiratory care including intubation and continuous positive airway pressure, she recovered sufficiently to be referred to a rehabilitation unit. She had mild hemiplegia but severe dysphagia, secondary to a brain stem infarct. INTERVENTION AND OUTCOME: Persisting severe dysphagia was confirmed, with extreme risk of aspiration. The patient underwent percutaneous endoscopic gastrostomy and was discharged to live independently, but requiring long-term gastrostomy feeding. CONCLUSION: When a patient presents with dysphagia, great care should be taken to exclude upper tract dysfunction with its attendant risk of aspiration, generally by referral to a centre or consultant with expertise in this area, before ordering or carrying out investigations appropriate to disorders of the lower tract.

Aged↗
PubMed1993

The anatomy and physiology of cortical mechanisms of cardiac control.

For nearly fifty years, attention has repeatedly been drawn to electrocardiographic changes accompanying acute stroke. The mechanism was unknown. These alterations, which are more frequent after hemisphere than brain stem infarction, are not solely due to concomitant myocardial ischemia. Recently, cardiac chronotropic organization has been shown within the posterior rat insular cortex. Stimulation of that site mimics both the electrocardiographic changes and the cardiac pathology accompanying acute stroke. These effects are attended by increased sympathetic activity. In addition, stimulation of the human right insula increases sympathetic cardiovascular tone, whereas parasympathetic increases are more frequent during left insula stimulation. It is suggested that right middle cerebral artery infarction disinhibits insular function, resulting in increased sympathetic cardiovascular tone and the cardiac consequences of stroke.

Animals↗
PubMed1977

External carotid-vertebral artery anastomosis for vertebrobasilar insufficiency.

Two patients with previous brain stem infarction and current symptoms of vascular insufficiency in the basilar circulation had evidence of vertebral artery occlusive disease. Angiography demonstrated ostial stenosis of the dominant right vertebral artery and retrograde flow down the left vertebral artery to the level of the transverse process of C2 in the first case and to the level of a severely stenosed origin in the second case. Carotid circulation was patent in both cases. The blood flow in the posterior circulation was patent in both cases. The blood flow in the posterior circulation was augumented by extracranial anastomosis of the external carotid artery to the vertebral artery in the foramen transversarium at the level of C1-2 by a lateral approach in Case 1 and at the level of C4-5 by an anterior approach in Case 2. Postoperative improvement in neurologic status occurred in both cases.

Adult↗
PubMed1997

[Direct surgical management of giant and large intracerebral aneurysms, associated with intraluminal thrombus and/or atherosclerotic thickening of aneurysmal neck].

Direct surgical management of giant or large cerebral aneurysms remains one of the most challenging topics in the neurosurgical field. Surgical results have remained unsatisfactory. We review 22 cases of large or giant aneurysms with intraluminal thrombus and/or atherosclerotic thickening of the aneurysmal neck that have received direct surgical management in our department during the period from 1984 to 1996. As initial symptoms, ten patients presented with mass effect, five with ischemic attack, and three with subarachnoid hemorrhage. Sixteen aneurysms were supratentorial and six were in the posterior fossa. Direct neck clipping was attempted in sixteen cases. Two giant basilar aneurysms among them were clipped under deep hypothermia with cardiac arrest. Simple trapping of the parent artery was performed in three aneurysms and trapping with bypass graft was also carried out in three aneurysms. Ten patients made an excellent clinical recovery. Eleven patients suffered mild to severe disability. One death resulted from brain stem infarction, not directly related with surgical management. Appropriate preoperative assessment and intraoperative management of the associated thrombus and atherosclerotic change of the aneurysmal neck are essential for obtaining acceptable surgical results of large or giant cerebral aneurysms.

Adult↗
PubMed1976

Ischaemic infarct of the brain stem combined with bisymptomatic Klippel-Trénaunay-Weber syndrome and cutis laxa.

The combination of Klippel-Trénaunay-Weber syndrome (KTWS) with intracranial vascular malformations is documented by angiography in a 25 year old man with the classical features of KTWS: systematized naevi, hypertrophy of the right side, and varicosis. In addition, the syndrome was associated with "cuts laxa", a coincidence of somar rarity. The patient suffered from an ischaemic infarct of the brain stem with several neurological deficits.

Adult↗
PubMed1986

[Ultrastructural aspects of the secondary brain stem syndrome in hemorrhages and infarcts in the cerebral hemispheres].

Ultrastructural aspects of the secondary brain stem syndrome in patients with hemorrhages and infarcts in the brain hemispheres are considered. The secondary brain stem syndrome is manifested by diverse clinical symptomatology suggestive of dysfunction of different levels of the brain stem: a diminished level of awakening, oculomotor disturbances, changes in the muscle tone and reflexes, cardiorespiratory and other vegetative disorders. Examining the reticular formation of the brain stem under the electron microscope the authors revealed changes in neurons in the form of chromatolysis, an increase in the cellular cytoplasm of the number of lipid inclusions and lysosomes, swelling of mitochondria and (less frequently) the appearance of cells with an elevated osmiophilia of the cytoplasm. Also observed was a systemic increase in lysosomes and lipid granules in capillary structures, and in glial and nervous cells. The pathogenetic factors of secondary brain stem syndrome are discussed.

Brain Stem↗
PubMedDate not supplied

Monitoring therapeutic efficacy of decompressive craniotomy in space occupying cerebellar infarcts using brain-stem auditory evoked potentials.

Brain-stem auditory evoked potentials (BAEPs) have been used to gauge effects of brain-stem dysfunction in humans and animal models. The purpose of this study was to evaluate the usefulness of BAEP in monitoring patients undergoing decompressive surgery of the posterior fossa for space occupying cerebellar infarcts. We report on serial BAEP recordings in 11 comatose patients with space occupying cerebellar infarcts undergoing decompressive craniotomy. BAEP studies were performed within 12 h after admission, 24 h following surgery and prior to extubation. BAEP signals were analyzed using latency determination and cross-correlation. Following surgery, 9 patients regained consciousness; 2 patients persisted in a comatose state and died subsequently. BAEP interpeak latency (IPL) I-V assessed prior to surgery exceeded normal values in all patients in whom it could be reliably measured (N = 9). Following decompressive surgery BAEP wave I-V IPL normalized in 5 patients, but remained prolonged despite dramatic clinical improvement in 4 patients. We prospectively computed the coefficient of cross-correlation (MCC) of combined ipsilateral BAEP trials after right and left ear stimulation. In all patients increasing MCC was associated with clinical improvement. Unchanging or decreasing MCC indicated poor outcome. We conclude that serial BAEP studies are an appropriate perioperative monitoring modality in patients with space occupying cerebellar infarcts undergoing decompressive surgery of the posterior fossa. Our study suggests advantages of cross-correlation analysis as an objective signal processing strategy; relevant information can be extracted even if BAEP wave discrimination is impossible due to severe brain-stem dysfunction.

Acoustic Stimulation↗
PubMed1993

[Atrial septum aneurysm as the cause of a thromboembolic infarction of the brain stem and cerebellum?].

A 32-year-old woman with migraine for several years again had a migraine attack with headache, nausea, vomiting and eye-muscle disorder, 14 days after an uncomplicated delivery. Within 24 hours a left-dominant hemiparesis developed, followed 12 hours later by tonic-clonic seizure and deep unconsciousness (Glasgow score: 3); the patient could not be aroused. Cranial computed tomography revealed extensive infarction of the brainstem and cerebellum. Angiography demonstrated occlusion of the basilar artery but not other abnormalities of other vessels. There was no evidence for vascular anomalies and the clotting tests were normal. Transoesophageal echocardiography demonstrated an atrial septal aneurysm. But any interatrial shunt (e.g. through a patent foramen ovale) was excluded by colour Doppler sonography, making it highly unlikely that a paradoxical embolus was the cause of the infarction. The brainstem infarction resulting from the basilar artery occlusion did not respond to treatment and the patient died 10 days after the initial seizure.

Adult↗
PubMedDate not supplied

[Comparative clinico-radiological study of lacunar infarcts of the cerebral hemispheres and brain stem in 110 cases].

INTRODUCTION: Lacunar infarcts (LI) are small deep infarcts due to occlusion of perforating branches. OBJECTIVE: Our objective was to outline the clinical and epidemiological characteristics which differentiate hemispherical lacunar infarcts (HLI) from those of the brain stem (SLI). PATIENTS AND METHODS: We present 110 cases of LI (80 HLI, 30 SLI) analysing risk factors, clinical syndromes, findings on neurological examination (dysarthria, gravity, distribution and proportional paresia), form of clinical presentation, evolution whilst in hospital, site and results of carotid duplex. Diagnosis was made in 72 patients using magnetic resonance (MR) and in 38 patients using computerized axial tomography (CT). RESULTS: The commonest characteristics of SLI, as compared with HLI, with statistical significance (p < 0.05) was the appearance of supranuclear facial paresia (OR = 2.68), severe motor involvement (OR = 4.23), form of presentation with previous TIA (OR = 6.33), fluctuating evolution of the symptoms (OR = 5.78) and progression of the paresia (OR = 6.41). Also, in the pontine LI there was significant correlation between site and gravity: the lower the site of the lesion, the more serious was the paresia. Patients with multiple LI presented with no previous risk factors significantly more frequently than those with a single LI. CONCLUSION: The different clinical profiles may help to establish the subgroups of IL, according to where they occur.

Brain Stem↗
PubMed2006

Cerebral microbleeds are associated with lacunar stroke defined clinically and radiologically, independently of white matter lesions.

BACKGROUND AND PURPOSE: Associations among microbleeds, white matter lesions (WMLs), and small deep infarcts on imaging have been reported. Because many of these imaging infarcts were asymptomatic, the relationship of microbleeds to clinical lacunar stroke is unclear. An association between microbleeds and clinically defined lacunar stroke might suggest a common causal microangiopathy. METHODS: Patients with lacunar, partial anterior circulation or posterior circulation stroke syndromes and older healthy subjects underwent MRI. Microhemorrhages, infarcts, hemorrhages, and WMLs were coded blind to clinical details. A final clinicoradiologic stroke subtype diagnosis was assigned. RESULTS: Among 308 subjects (67 older healthy and 241 with stroke), 54 patients had microbleeds (17%). Microbleeds were twice as frequent in lacunar than cortical strokes (26% versus 13%, P=0.03) or healthy older subjects (9%) and associated with increasing WML scores (P<0.0001). Lacunar and cortical stroke subtypes and healthy older subjects had similar WML scores. CONCLUSIONS: Microbleeds are associated with lacunar stroke defined clinicoradiologically more than other stroke subtypes but not simply by association with WMLs. This suggests that microbleeds and lacunar stroke have a similar microvascular abnormality.

Aged↗
PubMed1999

Remote regional cerebral blood flow consequences of focused infarcts of the medulla, pons and cerebellum.

UNLABELLED: The aim of this study was to evaluate regional and remote diaschisis of inferior brain stem or cerebellar infarcts in 25 patients presenting with relatively limited lesions. Patients presented with medullary, pontine or cerebellar infarction. METHODS: Lesions were evaluated on MRI (0.5 T). Regional cerebral blood flow (rCBF) was assessed by means of SPECT, after injection of 9rmTc-hexamethyl propyleneamine oxime (HMPAO) and, when possible, inhalation of 133Xe in the same session. For each method, asymmetry indices (Als), comparing contralateral to ipsilateral rCBF values, were calculated in four areas of each cerebral hemisphere and in the cerebellum and later compared with values obtained in healthy subjects (P = 0.05). RESULTS: Higher rCBF values were observed in the contralateral cerebellum in 2 of 7 patients with selective lateral medullary lesions, and cerebellar Als were significantly increased. When a cerebellar infarct was associated with a lateral medullary lesion, the cerebellar and contralateral hemispheric asymmetries were more severe. Unilateral paramedian pontine infarcts had more frequent consequences on the cerebellum (2 of 3 cases), with rCBF or tracer uptake being reduced in the ipsilateral or the contralateral lobe. Inverse cerebral hemispheric asymmetry could then be observed. Bilateral pontine lesions were difficult to evaluate. Using 99mTc-HMPAO, discrete cerebellar asymmetry was observed in 3 of 6 cases. Pure cerebellar infarcts in the posterior inferior cerebellar artery territory were always associated with a severe ipsilateral flow drop in the cerebellum, and contralateral hemispheric diaschisis was frequent (3 of 4 patients), predominating in the frontotemporal cortex and subcortical structures. This was also more obvious using 99mTC-HMPAO than 133Xe. Variance analysis showed that hemispheric diaschisis was more severe in mixed brain stem and cerebellar infarcts than in pure cerebellar or brain stem lesions. Furthermore, cerebellar and hemispheric AI values were not correlated with measurements of clinical deficits, disability or handicap. CONCLUSION: Unilateral and limited inferior brain stem lesions can have ipsi- or contralateral consequences on the cerebellum and cerebral hemispheres rCBF. These remote effects are related to lesions of the main pathways joining these structures, resulting in deactivation and, in some cases, overactivation. Contrary to what has been suggested, consequences on cerebral hemispheres are more severe in mixed cerebellar and brain stem infarcts than in pure cerebellar lesions.

Adult↗
PubMed1991

[Cerebellar infarction].

Cerebellar infarcts have long been underrecognized both clinically and neuroradiologically. In approximately a quarter of cases, they are oedematous and may require, unlike other cerebral infarcts, a sometimes life saving surgery when there are signs of brain stem compression. Benign infarcts are more frequent, but inaugural symptoms are identical: vertigo, headache, vomiting, unsteadiness, and dysarthria of sudden onset. Brain stem and occipital symptoms can be associated and are sometimes prominent. The infarct can be shown by CT but MRI is the method of choice for early recognition, precise delineation, and detection of associated brain stem infarcts. Prognosis is good when the infarct is restricted to the cerebellum, and poor when the brain stem is involved, a fact which should be taken into account in the surgical decision making. Cardiac emboli are the leading cause followed by atherothrombotic occlusions. These are usually located in the intracranial part of the vertebral artery and less frequently in the lower basilar artery, and are therefore inaccessible to prophylactic vascular surgery.

Age Factors↗