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PubMed1980

"Top of the basilar" syndrome.

Infarction of rostral brainstem and cerebral hemispheral regions fed by the distal basilar artery causes a clinically recognizable syndrome characterized by visual, oculomotor, and behavioral abnormalities, often without significant motor dysfunction. Rostral brainstem infarction produces oculomotor and pupillary signs that are identical to those in thalamic hemorrhage. Somnolence, vivid hallucinations and dreamlike behavior may also accompany rostral brainstem infarction. Temporal and occipital infarctions are frequently accompanied by hemianopia with distinctive characteristics, fragments of the Balint syndrome, amnestic dysfunction, and agitated behavior. The "top of the basilar" syndrome is most often due to an embolus.

Aged↗
PubMed1987

Bilateral internuclear ophthalmoplegia in systemic lupus erythematosus.

Internuclear ophthalmoplegia has been infrequently described in patients with systemic lupus erythematosus. We report a 23-year-old woman with lupus who presented with bilateral internuclear ophthalmoplegia and skew deviation. Additional neurologic findings included dysarthria, hemifacial weakness, hemiparesis, and dysmetria. Computed tomography of the patient's brainstem was unremarkable while magnetic resonance scanning demonstrated two areas of infarction. Magnetic resonance imaging is superior to computed tomography in both neuroradiographic study of the brainstem as well as evaluation of patients with neurologic complications of lupus.

Adult↗
PubMed1999

Effects of hyperglycemia on small cerebral infarctions in awake rabbits.

This study concerns the effects of hyperglycemia on small infarctions in the rabbit brain. Small ischemic foci were produced in both normoglycemic (6 mM) and hyperglycemic (25 mM) rabbits, by injecting small plastic beads into the left heart ventricle under short-acting anaesthesia. 2-deoxy-D-[14C]glucose (2-DG) autoradiography was used to trace ischemic regions in which glucose uptake was increased, either shortly after, or six hours after, the embolization (in awake rabbits). A lesion was characterized by a 2-DG activity > 120%. The obtained freeze-dried sections were inspected for infarcts (with lost tissue structure and increased transparency to light). In the short experiments (< 1 hour), lesions could be detected throughout the brains, indicating hypoxic regions with enhanced glycolysis. In some foci, mostly located in the basal ganglia (the region containing the largest lesions), a central dip could be seen in the 2-DG accumulation, suggesting a poor glucose supply to the ischemic core. The lesions in the basal ganglia of rabbits that were made hyperglycemic were smaller and did not show such dips. No infarcts could be found in the tissue sections. In the long experiments (6 hours), both infarcts and lesions could be found. The impact of hyperglycemia on the infarction process in different brain regions was evaluated by measuring the infarct volumes, and by evaluating the fraction of infarcts--number of infarcts found in freeze-dried sections/number of foci (both lesions and infarcts) found in the 2-DG autoradiograms. Hyperglycemia reduced the fraction of infarcts in the cortex, and reduced the size of infarcted areas in the brain stem. In summary, this study shows that the impact of hyperglycemia on the ischemic outcome depends on where in the brain the ischemic focus is located. This adds interesting information as to what is known about the general effects of glucose on cerebral ischemia.

Animals↗
PubMedDate not supplied

Evaluation of brainstem stroke using brainstem auditory evoked responses.

Brainstem stroke syndromes are primarily determined by clinical criteria. There are few diagnostic procedures which are of benefit for the evaluation of brainstem ischemic events. Brainstem auditory evoked responses (BAERs) are a new electrophysiologic technique for assessing brainstem function. To evaluate the use of BAERs in patients with brainstem ischemic events, 35 individuals with recent brainstem strokes, selected by strict clinical criteria, were evaluated with BAERs. The initial BAER was abnormal in 22 of 35 patients (63%). When the clinical course and site of the lesion are correlated with the BAER results, several trends emerge. An unstable course, characterized by progression or remission and relapse, was present in 19/35 (54%) of patients, and 15/19 (79%) of these individuals had an initially abnormal BAER. The other 16 brainstem stroke patients with a stable clinical course had an initially abnormal BAER in 7 instances (44%). This difference is statistically significant at the p = 0.04 level. The principal sites of ischemia were mesencephalic in 11/35, pontine in 13/35, and medullary in 11/35. The association of an abnormal BAER with an unstable clinical course seemed independent of the site of the lesion, However, of the 9 deaths that occurred, all were in patients with mesencephalic or pontine lesions, and 8 of these individuals had an initially abnormal BAER. Abnormal BAERs in patients with brainstem ischemic lesions correlate with an unstable clinical course. Furthermore, individuals with pontomesencephalic infarction and abnormal BAERs have an especially poor prognosis. The BAER may be of prognostic value in the early evaluation of patients with brainstem ischemic strokes.

Brain Ischemia↗
PubMed1995

[Infantile brainstem infarction due to vertebral artery fenestration: a case report].

The patient was a 10-year-old boy. He had a sudden onset of generalized tonic-clonic convulsion. On admission, he presented with mild disturbance of consciousness and right hemiparesis. The electroencephalogram showed diffuse spike and slow wave complex. Three days later, magnetic resonance imaging (MRI) showed high signal intensity areas in the left cerebellar hemisphere and pons. On cerebral angiograms, coiling of the bilateral carotid arteries, occlusion of the basilar artery at the distal site, and fenestration of the left vertebral artery at the atlanto-axis level were shown. According to these findings, the patient was diagnosed with brainstem and cerebellar infarction. On the follow-up angiograms, recanalization of the basilar artery on the right vertebral angiogram, occlusion of the left vertebral artery at the distal site of the posterior inferior cerebellar artery origin, and occlusion of one of the duplicated vertebral arteries were recognized. Fenestration of the vertebral artery is presented in about 1-2% at angiography and autopsy and the clinical significance is controversial. In this case, the fenestration may have played a role as an embolic source because there was no probable cause of the cerebral infarction, and the vascular occlusion and recanalization occurred near the distal site of the fenestration. These findings suggest the clinical significance of vertebral artery fenestration as an embolic source.

Brain Stem↗
PubMed1995

[A study of skin surface temperature in patients with unilateral cerebral infarction--with special reference to central autonomic regulation of skin vasomotor response].

Skin surface temperature was examined using thermography in 26 patients with unilateral ischemic cerebrovascular disease (5 with pontine lesions, 5 with lateral medullary lesions and 16 with hemispheric lesions). Three of the 5 patients with pontine lesions and 4 of the 5 with medullary lesions showed hemihyperthermia on the ipsilateral body surface. However, the face showed no impairment with pontine lesions, whereas it appeared as a hyperthermic area with medullary lesions. Ten of 11 patients with lesions of the internal capsule or putamen had hypothermia on the contralateral body surface except for the face. All the patients with thalamic lesions showed no skin temperature asymmetry. These observations suggest the following: (1) sympathetic skin vasomotor fibers descend through the ipsilateral side of the brainstem; (2) at the level of the medulla, skin vasomotor fibers innervating the body trunk and limbs and those innervating the face descend contiguously, while at the level of the pons the two fiber groups descend separately; (3) hypothermia in patients with cerebral infarction could be explained by interruption of the inhibitory neural pathway that controls vasomotor function on the contralateral side of the body; (4) these inhibitory pathways descend in the vicinity of the pyramidal tract.

Adult↗
PubMed1983

Inability to deactivate sympathetic nervous system in brainstem infarct patients.

Catecholamine urinary excretion under basal conditions and after head down tilting (4 degrees) was studied in normo- and hypertensive controls and in patients with hemisphere and brainstem infarction, respectively. Both the normo- and hypertensive controls and patients with hemisphere infarction displayed a conspicuous decrease (about 40%) in noradrenaline (NA) urinary excretion after head down tilting. In contrast the patients with brainstem infarction increased NA urinary excretion after the manoeuvre, suggesting activation instead of deactivation of the sympathetic nervous system (SNS). In normo- and hypertensive controls the values of night NA excretion were lower than those of day NA excretion, whereas in brainstem infarct patients the night NA excretion was close to the day NA excretion. This finding also supports the view that the brainstem infarct patients are not able to deactivate their SNS during night recumbency. The SNS reactivity disorder of such patients if associated with impairment of autoregulation of cerebral circulation might generate an abnormal increase in cerebral circulation during night recumbency.

Blood Pressure↗
PubMed1978

Vertebral artery occlusion following manipulation of the neck.

A 23-year-old woman developed brainstem infarction following cervical manipulation. Vertebral angiography showed total occlusion of the left vertebral artery with a thrombus extending into the basilar artery. The literature dealing with this rare but serious complication of cervical manipulation is reviewed.

Adult↗
PubMed1998

[Clinical application of multi-shot diffusion EPI in neurological disease].

Using the multi-shot EPI method we investigated the clinical application of diffusion weighted imaging (DWI) in the diagnosis of neurological disease. The multi-shot method provided better susceptibility artifact-free DWI than the single-shot method particularly in the region of the posterior cranial fossa. DWI using the multi-shot EPI method readily shows the pyramidal tract extending from the internal capsule to the brainstems which is inaccessible by the conventional single-shot EPI method, and providing three-dimensional and distinct images of pyramidal tract changes in amyotrophic lateral sclerosis or cerebral infarction with pyramidal tract disturbance. Our findings suggest that the use of DWI with the multi-shot EPI method would provide a technique for the easy diagnosis and evaluation of various neurological diseases.

Amyotrophic Lateral Sclerosis↗
PubMed1990

The hemimedullary syndrome: case report and review of the literature.

Hemi-infarction of the medulla causes the clinical constellation of symptoms and signs of both the lateral and medial medullary syndromes and nearly always results from occlusion of an intracranial vertebral artery. In the case reported here, with a clinical diagnosis of hemimedullary syndrome, the expected infarction was imaged by magnetic resonance. A review of the literature confirms that the hemimedullary syndrome, in which both medial and lateral syndromes occur simultaneously, is extremely rare, since it yielded only two previous cases with adequate anatomical confirmation.

Adult↗
PubMed1991

Magnetic resonance imaging in brainstem ischemic stroke.

To evaluate the efficacy of magnetic resonance imaging in brainstem stroke, we studied 21 cases of clinically definite brainstem ischemic stroke with brain magnetic resonance imaging (MRI) and conventional computed tomography (CT). MRI demonstrated brainstem lesions in 79% of the cases (16.5 out of 21), while CT revealed 33% (7 out of 21) when cases with suspicious lesions counted as 0.5. Although MRI was done a few days later than CT in most cases, MRI was superior to CT in detecting the number and the size of ischemic lesions, with clear delineation of anatomy and visualization of the status of the blood flow in the vertebral-basilar artery. Disappearance of the flow signal void in the basilar artery can be an important clue in diagnosing occlusion or thrombus of the basilar artery. By delineating the extent and the location of the infarction, MRI findings allowed an interpretation of whether the ischemic vessel is a small basilar branch or a large vessel vertebral or basilar artery.

Adult↗
PubMed1995

Sympathetic skin responses (SSRs) in monofocal brain lesions: topographical aspects of central sympathetic pathways.

Lesions of the central sympathetic pathways are likely to be of clinical relevance. In patients with acute stroke, in particular, they may be responsible for the partially deleterious cardiac arrhythmia. There is little knowledge of the central organization of sympathetic pathways above the brainstem level for both cardio-efferent and sudomotor fibers. We studied the sympathetic skin response (SSR) in 29 patients with brainstem stroke or infarction in the territory of the middle cerebral artery (MCA) in order to evaluate the pathways mediating emotional sweating. In 24 patients (82.8%) the SSR was pathological. These abnormalities were bilateral with no clear asymmetry in 10 patients (34.5%), bilateral with marked contralateral pathology in 8 patients (27.6%), purely contralateral in 5 patients (17.2%) and purely ipsilateral in one patient (3.5%). Bilateral abnormalities were more frequent and more marked in brainstem than in MCA stroke. This is probably indicative of a more generalized sympathetic dysfunction. In contrast, contralateral abnormalities were more pronounced in MCA than in brainstem infarcts. Our results show that sympathetic skin responses are suppressed in the majority of stroke patients. Asymmetric responses may indicate that sudomotor fibers mediating emotional sweating have their origin or receive input from the contralateral MCA territory.

Adult↗
PubMed2000

Clinical lacunar syndromes as predictors of lacunar infarcts. A comparison of acute clinical lacunar syndromes and findings on diffusion-weighted MRI.

OBJECTIVES: To evaluate if patients with acute lacunar syndromes have acute lacunar infarcts or other types of cerebral lesions on diffusion-weighted MRI. METHODS: Patients with acute lacunar syndromes underwent echo-planar diffusion MRI of the brain within 3 days after stroke onset. Localization and size of lesions with hyperintense signal were determined, compared with clinical characteristics and with findings on follow-up T2-weighted MRI. RESULTS: Twenty-three patients participated in the study. Thirteen patients had pure motor stroke, 1 pure sensory stroke, 8 sensorimotor stroke, and 1 ataxic hemiparesis. Twenty-two patients had at least one lesion with increased signal on diffusion-weighted MR images. These acute lesions were in the internal capsule/ basal ganglia/thalamus in 13 patients, subcortical white matter in 5 patients, brainstem in 2 patients, cortex (multiple small lesions) in 1 patient, and cortex + basal ganglia in 1 patient. The median volume of the lesions was 0.6 ml on the initial examination and on follow-up, of 17 patients after 1 to 5 months, 0.5 ml. CONCLUSIONS: Almost all patients with acute ischemic lacunar syndromes have acute lesions on echo-planar diffusion-weighted MRI within 3 days after stroke onset. These lesions are mostly small and subcortical, compatible with lacunar infarcts caused by single penetrating artery occlusion, but in a minor proportion of patients (2 of 23 in our study) a cortical involvement is found.

Acute Disease↗
PubMed1991

Triphasic waves in coma from brainstem infarction.

There have been reports on patients in stupor or coma from a variety of disorders that affect the brain diffusely, notably hepatic failure, whose EEGs showed triphasic waves. We describe a patient in coma with neurologic signs localizing to the brainstem who had triphasic waves on EEG. This case further confirms the nonspecific nature of triphasic waves.

Aged↗
PubMed1984

Occlusion of the basilar artery. A clinical and pathological study of thirteen autopsied cases.

The present report dealt with thirteen autopsied cases of basilar artery occlusion. The age of the patients ranged from fifty one to seventy six years with a mean age of fifty six years, and there were eleven males and two females. Basilar artery occlusion was found in one in every 160 autopsies. The average length of the clinical course of the disease was five months. Many patients had a history of hypertension, diabetes mellitus, and cerebrovascular attacks. The neurological signs and symptoms of basilar artery occlusion extremely varied and were complicated. In our series, occular bobbing, palatal myoclonus, Foville syndrome, and Millard - Gubler syndrome are significant. Arteriosclerotic thrombosis is the most important etiologic factor. The site of occlusion was most frequently encountered in the lower third of the basilar artery. Areas of softening were prominent in the midbrain and the pons. In the cerebellum, softenings were present particularly in the areas supplied by the superior cerebellar artery. Infarcts in the thalamus and the temporo-occipital lobes supplied by the posterior cerebral artery were observed very frequently. The distribution of softening was related to the site of occlusion of the basilar artery and the collateral circulation through the Willis ring.

Aged↗
PubMed1984

[Palpebral nystagmus].

A case of palpebral nystagmus is reported. Two infarcts were present in the rostral pons, caudal midbrain and in the periaqueductal gray matter between the red nuclei, ventrally to the posterior commissure. The relationships between the palpebral nystagmus and the retraction of the upper lid together with the clinico-pathological significance of the two signs is discussed.

Brain Stem↗
PubMedDate not supplied

[Unusual bulbar infarct and occlusion of the vertebral artery].

INTRODUCTION: Isolated bulbar infarcts are infrequent. Because of the vascular anatomy the lateral region is the most commonly affected, and in this clinical disorder the various signs and symptoms are grouped together as the so-called Wallenberg's syndrome. Since the introduction of magnetic resonance (MR) it has been possible to correlate the extent and site of the laterobulbar area involved with the most probable vascular topography and etiopathogenesis. CLINICAL CASE: We describe the case of a 69 year old female patient with all the symptoms of Wallenberg's syndrome and two potential causes of stroke (emboliogenic cardiopathy and atherothrombotic vascular occlusion), in whom MR showed the presence of an isolated bulbar lesion of unusual morphology which had previously been described as being of thrombotic origin. CONCLUSIONS: In spite of the small area of the brain involved, in laterobulbar infarcts MR permits definition of different topographic patterns of ischemic lesions. Some of these patterns have been correlated with the specific aetiology of an infarct. Therefore there is twice the importance of cerebral MR in cases of suspicion of lateral bulbar ischaemia, since it not only assists in diagnosis and its clinicopathological correlations, but also, as in our case, helps to have a clinical suspicion of the most likely etiopathogenesis of the stroke.

Aged↗