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PubMed1992

Persistent trigeminal artery associated with brainstem infarct--case report.

A 47-year-old male presented with a sudden onset of right hemiparesis and numbness of the left face. Magnetic resonance imaging demonstrated a lacunar infarct in the ventral pons. Cerebral angiography demonstrated a persistent trigeminal artery (PTA) anastomosing the left internal carotid artery to the distal basilar artery. Bilateral vertebral arteries and the basilar artery below the PTA junction were extremely hypoplastic. The bilateral posterior communicating arteries were embryonic. The posterior fossa circulation was almost independent from the circle of Willis. The poor vascular supply to the posterior fossa probably caused the brainstem infarct.

Brain Stem↗
PubMedDate not supplied

The natural history of hemispheric and brainstem infarction in Rochester, Minnesota.

All cases of first episodes of brain infarction occurring in the population of Rochester, Minnesota, from 1960 through 1979 were categorized as hemispheric or brainstem (including cerebellar) on the basis of clinical criteria, autopsy evidence, and the results of computed tomography (from 1973 on). Hemispheric infarction was 5 times more frequent than infarction of the brainstem and/or cerebellum. The magnitude of the decline in incidence was the same in each group during the 20-year period of the study. Thirty-day case fatality was similar in each group, but patients with brainstem infarction had a better long-term survival. Functional outcome among survivors of brainstem infarction was also better, 35% having returned to independent living by 1 year after onset compared with 22% of survivors of hemispheric infarction. This may have been a consequence of the higher proportion of residual cognitive and sensory impairments present in survivors of hemispheric infarction.

Activities of Daily Living↗
PubMed2006

Sudden cardiac arrest in an intubated premature infant with cerebellar and brainstem injury: is there a link?

The ventilated premature infant frequently exhibits unprovoked desaturation episodes accompanied by bradycardia. In most instances, these episodes are short-lived and recover spontaneously or with minimal interventions. However, in some infants these episodes may be more profound and require substantial interventions to restore cardiorespiratory status. Here we present the case of a ventilated premature infant who had experienced prolonged, multiple daily desaturation episodes accompanied by bradycardia that required significant interventions. Postoperatively, after placement of a tracheotomy and despite a patent airway, the infant developed acute bradycardia that progressed rapidly to sudden death. At autopsy, significant cerebellar and brainstem injury was noted. We hypothesize that the specific cerebellum and brainstem injury may have contributed to autonomic dysfunction and sudden death.

Autonomic Nervous System↗
PubMed2002

Contributions of other brain pathologies in dementia with lewy bodies.

The clinical picture with its pathological correlate was analysed in 16 patients fulfilling consensus criteria for dementia with Lewy bodies (DLB). The cases were part of a larger cohort (n = 200) of patients within a prospective longitudinal study of dementing disorders. Six cases exhibited not only Lewy bodies (LBs) but also other brain pathologies such as Alzheimer changes, multiple infarcts or complete and incomplete white matter infarcts. Degeneration of the nucleus basalis of Meynert and substantia nigra was also seen. The 10 cases without LBs all had Alzheimer changes. In 7 cases, these changes were combined with mainly incomplete frontal white matter infarcts. However, the degeneration of brain stem nuclei was less pronounced in these cases. Symptoms such as fluctuations in cognition, falls and episodic confusion appeared in association with arterial hypotension, which developed during the course of dementia in almost all the 16 cases. The majority of the cases were treated with neuroleptics and other potentially hypotensive medication. This study shows that multiple and different pathological features may contribute to a clinical symptom constellation as in DLB. The case study approach reveals the complexity of the clinico-pathological relationships in dementia that might otherwise be lost in the analysis of larger group data.

Aged↗
PubMed1987

Tangled masses of central axons (central axonomas) in the brain stem: anatomical evidence for the regenerative growth of human central axons.

Eight additional cases of tangled masses of unmyelinated fine axons occurring in the brain stem in association with cystic infarcts or traumatic cysts are described. Because they are solely composed of bare axons and because of their consistent association with old, destructive lesions, they are called axonomas in lieu of the previous designation as non-myelinated neuromas. Axonomas were located at the border of the associated lesions exclusively in or near the central tegmental tract of the midbrain, pons or medulla. Their occurrence in the restricted region is considered as the reason for their rarity and for the failure to observe them in the past. The discrete, compact, mass formation, the occurrence of a large number in groups, the exclusive occurrence in specific regions of the central nervous system (CNS), and the consistent association with old axonal injury are presented as circumstantial evidence that axonomas represent regenerative growths of central axons. Based on the restricted site of predilection, it is inferred that axonomas originate from a special group or groups of CNS neurons which may have an exceptionally high capacity to regenerate. In other words, certain central neurons in man are not only capable of abundant regenerative sprouting but also are able to sustain the newly formed sprouts in the form of axonomas for years or perhaps permanently, but the specific neurons are not yet identified.

Adult↗
PubMed1997

Pure or predominant sensory stroke due to brain stem lesion.

BACKGROUND AND PURPOSE: Pure or predominant hemisensory symptoms can be seen in patients with brain stem stroke. However, there have been no reports in which sufficient numbers of patients were studied with detailed descriptions on the sensory patterns and imaging findings. METHODS: We describe 17 patients presenting with pure or predominant hemisensory symptoms due to brain stem stroke in whom CT scan and/or MRI identified appropriate lesions. RESULTS: Eleven patients had an infarct and 6 had a hemorrhage. Aside from sensory deficit, the majority had dizziness and gait ataxia. Fifteen patients had paramedian dorsal pontine lesions associated with pure or predominant lemniscal sensory involvement, often in the cheiro-oral (n = 4) or leg dominance (n = 4) patterns. The lesions of the former group tended to be located more medially compared with those of other patients, which is in agreement with the sensory topography of the pontine lemniscal sensory tract. Bilateral facial or perioral sensory symptoms were noted in 6 patients. One patient with a dorsolateral pontine lesion had selective spinothalamic modality impairment, while one with a lateral midbrain infarct had sensory deficit of all modalities. CONCLUSIONS: Pure or predominant brain stem sensory stroke is most often produced by small infarcts or hemorrhages in the paramedian dorsal pontine area and may be differentiated from thalamic pure sensory stroke by the following characteristics: frequent association of dizziness/gait ataxia, predominant lemniscal sensory symptoms, occasional leg dominance or cheiro-oral pattern, and frequent bilateral perioral involvement.

Aged↗
PubMed2000

Neuroimaging in deteriorating patients with cerebellar infarcts and mass effect.

BACKGROUND AND PURPOSE: The decision to proceed with surgery in cerebellar infarct with mass effect (CIMASS) in deteriorating patients is based on clinical features. The potential role of neuroimaging in predicting deterioration has not been systematically studied. In this study we determine the role of neuroimaging in predicting deterioration in CIMASS. METHODS: -We retrospectively reviewed the clinical and neuroimaging features in 90 patients with cerebellar infarcts. We selected for detailed analysis CIMASS in 35 patients. RESULTS: Eighteen patients remained stable and 17 deteriorated. Of these 17 patients, 8 were treated conservatively and 9 had surgery. Radiological features indicative of progression were more common in deteriorating patients compared with stable patients: fourth ventricular shift (82.3% versus 50%, P:=0.075, OR=4. 67), hydrocephalus (76.5% versus 11.1%, P:=0.0001, OR=26), brain stem deformity (47% versus 5.6%, P:=0.0065, OR=15.1), and basal cistern compression (35.3% versus 0%, P:=0.0076, OR=20.91). Differences in upward displacement of the aqueduct and pontomesencephalic junction from Twining's line, tonsillar descent on sagittal MRI, and infarct volumes between stable and deteriorating patients were not statistically significant. CONCLUSIONS: Hydrocephalus, brain stem deformity, and basal cistern compression may herald deterioration in CIMASS. Admission to a neurological-neurosurgical intensive care unit and consideration of preemptive surgery are warranted in these patients. Vertical displacement of tonsils or aqueduct, demonstrated by MR imaging, did not predict deterioration.

Brain Stem Infarctions↗
PubMed2000

A 35-year-old man with cerebral hemorrhage and pheochromocytoma: the second brain-dead organ donor in Japan.

A 35-year-old man was brought into the emergency room of Keio University Hospital by ambulance because of a sudden onset of coma. His Glasgow Coma Scale was 3 and his blood pressure 150/100 mmHg. CT scanning revealed a subcortical hemorrhage 8 cm in diameter. His respiration deteriorated rapidly, and an emergency craniotomy was performed for hematoma removal and cerebral decompression. Postoperatively the patient remained in a deep coma (GCS = 3) requiring respiratory support. The family presented an organ donor card previously signed by the patient, and brain death was confirmed in accordance with Japan's transplant law. As a result of two tests conducted six hours apart brain death was confirmed on the 5th postoperative day. With the family's consent, the donor's heart, kidneys and skin were removed for organ transplantation to be performed in other institutions. An autopsy was performed after the removal of the organs and skin. An extensive subgaleal hemorrhage was found in the left cerebral hemisphere, and microscopic examination revealed extensive necrosis with karyolysis of neuronal cells, but no viable neuronal cells were found in the cerebrum. The brain stem was marked by edema, hemorrhage, infarction necrosis and neuronal cell loss. The cerebellum was swollen and congested and showed autolysis of the granular layer. These findings suggested brain death syndrome with respirator brain. Other autopsy findings included a huge pheochromocytoma in the right adrenal gland, bilateral bronchopneumonia, liver congestion and fatty metamorphosis with four cavernous hemangiomas, and mild chronic lymphocytic thyroiditis. This patient was the second brain-dead organ donor and the first brain-dead patient to undergo postmortem examination in Japan.

Adrenal Gland Neoplasms↗
PubMed1988

Somatosensory and acoustic brain stem reflex myoclonus.

A patient with brain stem reflex myoclonus due to a massive midbrain infarct was studied electrophysiologically. Myoclonic jerks were elicited at variable latencies by tapping anywhere on the body or by acoustic stimuli, and mainly involved flexor muscles of upper extremities. The existence of convergence of somatosensory and acoustic inputs in the brain stem was suggested. This myoclonus seemed to be mediated by a mechanism similar to the spino-bulbo-spinal reflex.

Aged↗
PubMed1987

Management of Chiari II complications in infants with myelomeningocele.

Vocal cord paralysis with inspiratory stridor during infancy is a well-recognized complication of the Arnold-Chiari malformation associated with myelomeningocele. Management of these symptoms, however, remains controversial. The outcome in 19 infants with symptoms managed by us during 1978-1984 was therefore reviewed. Ten infants had stridor alone at presentation (clinical grade 1), four infants also had apnea (grade 2), and five infants also had associated cyanotic spells and dysphagia (grade 3). Of 14 ventricular shunt revisions performed, seven were associated with resolution: in five of eight infants with grade 1, two of four with grade 2, and none of two with grade 3 symptoms. Of the 10 posterior fossa decompressions performed, two were associated with clinical resolution: in one of four infants with grade 1, one of two with grade 2, and none of four with grade 3 symptoms. Mortality over 6 months following onset of symptoms was absent among infants with grade 1, one with grade 2, and three with grade 3 symptoms. We propose that differences in outcome among the three groups of infants reflect differences in pathologic processes within the brain stem. We speculate that infants with grade 2 or 3 symptoms have more extensive brain stem damage, such as hemorrhage, infarction, and necrosis. Use of our classification system may be helpful in further studies on intervention modalities in these infants.

Arnold-Chiari Malformation↗
PubMed2003

People with stroke living in the community: Attention deficits, balance, ADL ability and falls.

PURPOSE: To describe levels of attention deficits among people with stroke living in the community and explore relationships between attention, balance, function and falls. METHOD: Forty-eight mobile community-dwelling people with stroke (30 men, 18 women, mean age 68.4 +/- 11.2) were recruited to this cross-sectional investigation through General Practitioners. Twenty-six participants had a right, 21 a left hemisphere infarction and one had a brain stem lesion; mean time since stroke was 46 months (range five to 204). Participants' were interviewed about fall-events; attention, balance and function were assessed using standardised tests. RESULTS: Visual inattention was identified in five participants (10%), deficits of sustained attention in 15 (31%), auditory selective attention in nine (19%), visual selective attention in 17 (35%) and divided attention deficits in 21 participants (43%). Sustained and divided attention scores correlated with balance, ADL ability and fall-status (p < 0.01). The balance and function of subjects with normal attention were better than those with abnormal scores (p < 0.01). Analysis of variance revealed differences between repeat-fallers and non-fallers with no near-falls for divided attention, balance and ADL ability (p < 0.01). CONCLUSIONS: Attention deficits were common among this sample; sustained and divided attention deficits correlated with functional impairments and falls, highlighting that attention deficits might contribute to accident prone behaviour and falling.

Accidental Falls↗
PubMed1999

Risk factors and precipitating neck movements causing vertebrobasilar artery dissection after cervical trauma and spinal manipulation.

STUDY DESIGN: Potential precipitating events and risk factors for vertebrobasilar artery dissection were reviewed in an analysis of the English language literature published before 1993. OBJECTIVES: To assess the literature pertaining to precipitating neck movements and risk factors for vertebrobasilar artery dissection in an attempt to determine whether the incidence of these complications can be minimized. SUMMARY OF BACKGROUND DATA: Vertebrobasilar artery dissection and occlusion leading to brain stem and cerebellar ischemia and infarction are rare but often devastating complications of cervical, manipulation and neck trauma. Although various investigators have suggested potential risk factors and precipitating events, the basis for these suggestions remains unclear. METHODS: A detailed search of the literature using three computerized bibliographic databases was performed to identify English language articles from 1966 to 1993. Literature before 1966 was identified through a hand search of Index Medicus. References of articles obtained by database search were reviewed to identify additional relevant articles. Data presented in all articles meeting the inclusion criteria were summarized. RESULTS: The 367 case reports included in this study describe 160 cases of spontaneous onset, 115 cases of onset after spinal manipulation, 58 cases associated with trivial trauma, and 37 cases caused by major trauma (3 cases were classified in two categories). The nature of the precipitating trauma, neck movement, or type of manipulation that was performed was poorly defined in the literature, and it was not possible to identify a specific neck movement or trauma that would be considered the offending activity in the majority of cases. There were 208 (57%) men and 158 (43%) women (gender data not reported in one case) with an average age of 39.3 +/- 12.9 years. There was an overall prevalence of 13.4% hypertension, 6.5% migraines, 18% use of oral contraception (percent of female patients), and 4.9% smoking. In only isolated cases was specific vascular disease such as fibromuscular hyperplasia noted. CONCLUSIONS: The literature does not assist in the identification of the offending mechanical trauma, neck movement, or type of manipulation precipitating vertebrobasilar artery dissection or the identification of the patient at risk. Thus, given the current status of the literature, it is impossible to advise patients or physicians about how to avoid vertebrobasilar artery dissection when considering cervical manipulation or about specific sports or exercises that result in neck movement or trauma.

Aortic Dissection↗
PubMed1978

[Abnormal fusion of 2 primitive trigeminal arteries: apropos of an anatomo-radiological case].

Agenesis of the internal carotid artery was discovered during emergency cerebral angiography carried out on a comatose 28 year old man. The left cerebral hemisphere was supplied from the controlateral carotid artery, via a large vessel running through the sphenoid bone, between the intracavernous portions of the internal carotid arteries. Postmortem examination showed that death resulted from massive haemorrhagic infarction of the cerebellum and brain stem. Absence of the cervical and petrosal portions of the left internal carotid artery was confirmed. The anastomotic vessel was found to run through the spongiosa below the dorsum sellae. The heart, major vessels and circle of Willis were otherwise normal. An intercarotid anastomosis of this type has been reported on three previous occasions, in none of which was there anatomical confirmation.

Adult↗
PubMed1995

[A case of recanalized basilar artery following basilar artery occlusion due to spontaneous dissection].

An 85-year-old man who did not have any previous history of heart disease was admitted to our hospital with the chief complaints of disturbance of consciousness, tetraparesis, and bilateral Babinski signs. On admission, intravenous digital subtraction angiography (DSA) showed bilatral vertebral arteries without filling the basilar artery. On the second hospital day, MRI showed a septum in the basilar artery, and no infarctions were noted in the brain stem. He gradually improved with heparin therapy. On the tenth hospital day, intravenous DSA disclosed filling of the basilar artery. On the sixteenth hospital day, conventional cerebral angiography revealed filling of the basilar artery from the left vertebral artery, and string sign and linear shadow (intimal flap) was noted in the basilar artery. He was diagnosed to have the basilar artery dissection. The patient became ambulatory and was discharged independently. This is very rare case of the basilar artery dissection with a good prognosis.

Aged↗
PubMed1988

Periventricular white matter changes and dementia. Clinical, neuropsychological, radiological, and pathological correlation.

Forty-three patients with computed tomographic scan findings of decreased attenuation in the periventricular white matter (PVWM) region were studied. Clinical evaluation revealed presence of hypertension in 36 patients (84%) and cerebrovascular risk factors in 41 patients (95%). Unilateral or bilateral neurological deficits were present in 40 patients (93%). Neuropsychological evaluation in 27 of them revealed features of subcortical dementia. Magnetic resonance imaging in seven cases demonstrated high-intensity areas in the deep white matter region on T2-weighted imaging. Pathological evaluation in four patients revealed demyelination without inflammatory cells and infarctions in the PVWM region, lacunar infarctions in the basal ganglia and brain stem, and marked arteriosclerosis. The study indicated that most (95% in this series) of the patients with computed tomographic scan findings of decreased attenuation in the PVWM region had cerebrovascular risk factors and various neurological and neuropsychological features of subcortical dementia. Pathologically, these lesions represented areas of infarction and demyelination, along with diffuse arteriosclerosis.

Adult↗
PubMed2003

[The medial medullary infarction (Dejerine syndrome) following chiropractic neck manipulation].

A-38-year-old man suddenly developed nausea, vomiting and vertigo during chiropractic neck manipulation. This was followed by right hemiplegia, right deep sensory disturbance and left hypoglossal nerve palsy, consistent with the medial medullary infarction (Dejerine syndrome). The MRI revealed infarction at left medial part of the medulla. The vertebral angiogram and MRA showed marked narrowing of the left vertebral artery. X-rays of the cervical spine showed no spondylosis, dislocation nor osteolysis of the odontoid process. The serological studies, including lupus anticoagulant, protein C, and protein S gave normal results. Although vascular accidents involving the brain stem after chiropractic neck manipulation have been reported since Pratt-Thomas and Berger, previous reports are still rare. In them lateral medullary infarction (Wallenberg syndrome) is probably the most common case. On the other hand, medial medullary syndrome (Dejerine syndrome) is absolutely rare. To our knowledge, the only one report has been made by Watanabe and his colleagues before our present case. The mechanism was suggested that rotation and tilting of the neck stretches and compresses the vertebral artery at the cervical joint causing injury to the vessel, with an intimal tearing, dissection, and pseudoaneurysm formation. Consequently, the present case may be caused by injury to the left vertebral artery with an intimal tearing during neck manipulation sufficient to cause disection and subsequent infarction of the brain stem.

Adult↗
PubMed1998

Vertebrobasilar distribution stroke mimicking transtentorial herniation.

Strokes in the vertebrobasilar arterial distribution may result in a variety of physical findings and can be challenging to diagnose. We report a case of a 60-year-old woman with infarction of the left midbrain, right pons, and bilateral thalami with physical findings resembling transtentorial herniation.

Brain Stem↗