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PubMed1981

Bilateral cortical border-zone infarction. A pseudobrainstem stroke.

Acute bilateral weakness of the extremities with weakness of the tongue classically signals a medullary lesion. A patient had these signs, but at autopsy, bilateral cortical border-zone infarcts and an entirely normal brainstem were found. This case points out the importance of considering bilateral cortical border-zone infarction in the presence of bilateral motor or sensory signs, especially when there is sparing of facial motor function.

Aged↗
PubMed1975

Acute cerebellar infarction in the PICA territory.

Although old or recent infarcts of a cerebellar hemisphere in the territories of the posterior inferior (PICA), superior, or anterior inferior cerebellar arteries are commonplace autopsy findings, in no case have corresponding clinical symptoms been clearly identified. We have studied three cases, two clinocaopthologically and one clinicosurgically, in which an acute infarct involving only the cerebellum lay in the PICA territory distal to the branches to the medulla oblongata. The clinical manifestations consisted of rotatory dizziness intensified by motion, nausea, vomiting, imbalance, and nystagmus. In two cases, the clinical diagnosis had been a benign labyrinthine disorder. Recognition of a syndrome corresponding to cerebellar infarction in the PICA territory is important insofar as it assists in the differential diagnosis of dizziness. It becomes of crucial importance when cerebellar infarction is the prelude to cerebellar swelling and brain stem conpression leading to coma and death unless surgically relieved.

Acute Disease↗
PubMedDate not supplied

Embolic stroke in a child with idiopathic dilated cardiomyopathy.

An eleven year old boy presented with sudden onset right-sided hemiplegia and ipsilateral lower facial weakness. Two-dimensional echo revealed the diagnosis of idiopathic dilated cardiomyopathy with multiple intracardiac clots. MRI scan of head showed infarctions in the area of caudate nuclei, putamen, brain stem and cerebellum. On anticoagulation therapy, all thrombi, except one, disappeared. The child died 2.5 months later due to resistant cardiac failure.

Anticoagulants↗
PubMed1989

[MRI of acute cerebral infarction].

Sequential changes of magnetic resonance imaging (MRI) in sixteen patients with acute cerebral infarction are studied in comparison with the findings of computed tomography (CT). The sixteen patients were examined within 36 hours from the onset of symptoms on resistive type MRI (0.15T) using T1 weighted image (IR2000/500) and T2 weighted image (SE2000/80), and on CT. In general, large infarcted lesions of the cortex-subcortex seemed to be visualized earlier than small lesions of the basal ganglia and brainstem. In 8 patients, the infarcted lesions were detected on MRI earlier than on CT. For example, early detecting time within 12 hours were 2, 6, 7, and 10 hours after onset. In two patients of this group, lesions were detected on T2-weighted image earlier than on T1-weighted image. In two cases, small lesions of the brainstem were detected only on MRI. The size of abnormal findings gradually developed and reached a maximum on days 5 to 7 sequentially. The difference between infarction and perifocal edema was not clear even on MRI. The changes gradually subsided and assumed a stable size after about 2 months. Contrast enhancement effect was observed in four patients. In two of these cases, the signal intensity of T2-weighted imaging was decreased just at the region which was enhanced with contrast medium. MRI is useful for early diagnosis of ischemic cerebral infarction, and may elucidate some aspects of the pathophysiology of ischemic stroke.

Acute Disease↗
PubMed1990

[Listeriosis of the central nervous system].

Listeriosis of the CNS is an inflammatory disease of the central nervous system that occurs mostly sporadically or occasionally as a limited epidemic. The pathogens are generally ingested with the food. Whether or not the infection becomes manifest in an exposed person depends on the number of pathogens ingested, on the virulence of the Listeria strain and on the individual disposition. It appears to be of decisive importance for an infection that the cellular immunodefense mediated by the T cells is disturbed; however, even persons without any previous disease worth mentioning may be affected. The characteristics of the various CNS manifestations are demonstrated via the case histories of 12 own patients (acute meningitis and meningoencephalitis, brain stem encephalitis, brain abscess, meningoencephalitis with infected cerebral infarct, chronic recidivating encephalitis). Early neurological focal signs and symptoms, combined with CSF findings atypical for bacterial CNS disease, should not be taken lightly and may point to listeriosis even though they are not specific for CNS listeriosis. The decisive criterion is the proof of the pathogen in the blood or CSF or the proof of antibody titre changes in the serum. Recent CSF diagnostic methods such as CSF lactate determination and the identification of IgG-positive B lymphocytes are useful in differentiating between viral and noninflammatory CNS disease; most important for follow-up are repeat CSF examinations. High-dosage ampicillin or amoxycillin treatment combined with gentamycin is the therapy of choice in CNS listeriosis. The bactericidal effect achieved thereby is desirable especially if immunodefense is disturbed. Prognosis of CNS listeriosis depends on the underlying disease in each case. The high mortality even among persons who had been healthy before the infection, is at least in part due to delayed diagnosis.

Adolescent↗
PubMed1995

Macrovascular causes underlying otoneurological disturbances.

In the diagnostic procedure for patients with symptoms and signs indicating VIIIth nerve or brain stem disturbances, the possible presence of tumors, infarcts, bleedings or microvascular loops are taken into account. Ten patients with vertigo, balance disorders, tinnitus or unilateral hearing loss proved to have a similar cause underlying the disturbances. They ranged in age from 51 to 80 years and had a duration of their symptoms of 1-10 years. In the test battery audiology, electronystagmography, broad-frequency rotatory testing and dynamic posturography were used. No uniform pattern was present. The results showed VIIIth nerve as well as CNS signs. Trigeminal neuralgia and hemifacial spasm were observed. CT, NMR or angiography were performed. The common finding for these patients were ectatic vertebral and/or basilar arteries. The size and position of the vessels indicated that compression of the VIIIth nerve or brainstem was the cause underlying their disturbances. To exclude that macrovessels appear in patients without neurotological symptoms and signs 300 consecutive NMR investigations in patients referred for other than neurotogic indications were scrutinized. In these patients no macrovessels were found. The findings indicate that ectatic vessels may cause disturbances mimicking a pontine angle tumor, Meniere's disease and other peripheral or central conditions with inner ear symptoms, vertigo and balance disorders. Arterial loops in the pontine angle may give indications for microvascular surgery, but the big ectatic vertebral and basilar arteries may offer surgical decompression possibilities, though with large risks.

Aged↗
PubMed1993

Cerebellar infarction. Clinical and anatomic observations in 66 cases.

BACKGROUND AND PURPOSE: Cerebellar infarction displays different clinical features, depending on the vascular territory involved. We studied patients with infarcts in the territories of the posterior inferior cerebellar artery or the superior cerebellar artery to compare their clinical presentation, course, and prognosis. METHODS: We retrospectively analyzed the clinical features, laboratory data, and imaging studies of 66 patients with cerebellar infarction collected consecutively at five institutions. All the cerebellar infarcts were documented on computed tomographic scan or magnetic resonance imaging. RESULTS: Two distinct profiles emerged, depending on the vascular territory involved. In 36 patients with posterior inferior cerebellar artery territory infarcts, a triad of vertigo, headache, and gait imbalance predominated at stroke onset. Computed tomography showed severe cerebellar mass effect in 11 cases (30%), with associated hydrocephalus in seven. In these seven patients (19%), postinfarct swelling led to brain stem compression that resulted in four deaths. In 30 patients with superior cerebellar artery infarcts, gait disturbance predominated at onset; vertigo and headache were significantly less common. The clinical course was usually benign. Computed tomography showed marked cerebellar mass effect, hydrocephalus, and brain stem compression in only two instances (7%). Presumed cerebral embolism was the predominant stroke mechanism in patients with superior cerebellar artery distribution infarcts, whereas in those with posterior inferior cerebellar artery distribution infarcts, the stroke mechanism was equally divided between cardiogenic embolism and posterior circulation arterial disease. CONCLUSIONS: Cerebellar infarcts in the posterior inferior cerebellar artery and superior cerebellar artery distribution have distinct differences in clinical presentation, course, and prognosis. These differences should help in the selection of appropriate monitoring and treatment strategies.

Adolescent↗
PubMed1992

Pure motor stroke: a reappraisal.

We studied the correlations between the pattern of weakness, stroke type, topography, and etiology in 255 patients whose first stroke was manifested by isolated hemiparesis. They represented 14% of consecutively admitted stroke patients. The weakness distributions were as follows: face, upper limb, and lower limb (FUL) (50%); face and upper limb (FU) (29%); upper limb (U) (10%); and upper and lower limb (UL) (9%). Twenty-nine percent of the patients had dysarthria, which was of no localizing value. Less than one half of the patients had a deep infarct, and one third had a potential embolic source from the heart or large arteries. Logistic regression analysis showed that history of hypertension and type of weakness distribution were the main factors accounting for lesion localization: patients with FUL distribution and hypertension had a 90% probability of deep infarct; patients either with FUL distribution but no hypertension or with UL distribution and hypertension each had 70% probability of deep infarct. Pure motor monoparesis was almost never caused by a deep infarct. We suggest that the assumption of a lacunar etiology to a pure motor stroke should be applied only to patients with FUL involvement.

Brain↗
PubMedDate not supplied

[Etiology, clinical variants, diagnosis and treatment tactic of cerebellar infarction].

The article contains a review of revelant medical literature focusing on etiology, diagnosis and treatment of cerebellar infarction (CI). The above health problem occurs relatively seldom covering about 2% of all strokes. Common CI etiological factors include atherothrombotic lesions of the vertebrobasilar arteries, cardiac embolism. CI symptoms depend on localization and size of the infarction site. The infarct topography in accordance with the affected arterial region correlates with neurological disfunction. CI may bring about complications such as acute obstructive hydrocephalus and brain stem compression developing in the wake of the mass-effect. Computerized tomography and magnetoresonance topography permit making an early diagnosis and timely to make detect the development of complications. Cases of complicated CI need the neurosurgical treatment to be carried out.

Basilar Artery↗
PubMedDate not supplied

Relationship between abnormal respiratory control and perinatal brainstem and cerebellar infarctions.

Clinical and neuropathologic studies were performed in 5 infants who had brainstem or cerebellar infarction and respiratory control abnormalities during early infancy. The anatomic distribution of brainstem infarction was closely related to the failure of neural respiratory control as was unilateral cerebral hemorrhagic infarction to sudden death. Brainstem and cerebellar lesions may be important in the pathogenetic mechanism of sleep apnea and sudden infant death syndrome due to brainstem tegmental gliosis and cerebellar respiratory control disturbance.

Brain Stem↗
PubMed1982

Isolated bilateral abducens palsy.

This case illustrates the sudden onset and gradual regression of abducens palsy following an isolated brainstem infarct secondary to moderate to marked hypertension. This case also demonstrates that patients presenting with sudden diplopia need to be referred to internal medicine and/or neurology for further documentation of the etiology of this condition.

Abducens Nerve↗
PubMed1991

Excessive sweating: an uncommon sign of basilar artery occlusion.

Excessive sweating of the face and, to a lesser degree, of the thorax and limbs, occurred after basilar artery occlusion in a 15 year old Saudi boy. Magnetic resonance imaging (MRI) showed a limited bilateral paramedian infarction of the rostral ventral pons. Basilar artery occlusion in children and adolescents is a rarity. Excessive sweating following such a stroke is rare in any age group. Clinico-anatomical correlations are discussed.

Adolescent↗
PubMed1998

Diffusion-weighted MRI in acute subcortical infarction.

BACKGROUND AND PURPOSE: Conventional imaging lacks sensitivity and specificity for the detection of early subcortical cerebral infarction. The purposes of our study were (1) to determine the accuracy of diffusion-weighted (DW) MRI for early subcortical infarction and (2) to determine the efficacy of DW MRI for differentiating acute from nonacute subcortical infarctions when conventional MR demonstrates multiple infarctions. METHODS: Thirty-nine patients with clinically diagnosed acute subcortical infarction and 17 control subjects were imaged with both conventional and DW MRI from 7 hours to 4 days (mean, 2.0 days) after onset of symptoms. All images were read blinded to specific clinical findings. In all cases, the precise neuroanatomic locations of lesions were noted. These lesions were subsequently correlated by an experienced stroke neurologist to determine whether their locations correlated to the patients' symptoms. RESULTS: The accuracy of DW MRI for acute subcortical infarction was 94.6%. In 4 of 39 cases, the acute infarction was not detected on conventional MRI. In 24 of 39 cases, conventional MRI showed the acute lesion as well as multiple other subcortical lesions. In each of these 24 cases, the DW MRI showed a single lesion to be acute, and in all 24 cases, that lesion corresponded to the patients' acute symptoms. CONCLUSIONS: DW MRI has very high accuracy for acute subcortical infarction and can differentiate acute from nonacute lesions. These data have significant implications in guiding patient management and patient selection for clinical trials.

Acute Disease↗
PubMed2003

Auditory disturbance as a prodrome of anterior inferior cerebellar artery infarction.

OBJECTIVES: To investigate the clinical and radiological features of patients presenting with an acute auditory syndrome as a prodromal symptom of anterior inferior cerebellar artery (AICA) infarction. METHODS: 16 consecutive cases of AICA infarction diagnosed by brain magnetic resonance imaging completed a standardised audiovestibular questionnaire and underwent a neuro-otological evaluation by an experienced neuro-otologist. RESULTS: Five patients (31%) had an acute auditory syndrome as a prodrome of AICA infarction one to 10 days before onset of other brain stem or cerebellar symptoms. Two types of acute auditory syndrome were found: recurrent transient hearing loss with or without tinnitus (n = 3), and a single episode of prolonged hearing loss with or without tinnitus (n = 2). The episodic symptoms were brief, lasting only minutes. The tinnitus preceding the infarction was identical to the tinnitus experienced at the time of infarction. At the time of infarction, all patients developed hearing loss, tinnitus, vertigo, and ipsilateral hemiataxia. The most commonly affected site was the middle cerebellar peduncle (n = 5). Four of the five patients had incomplete hearing loss and all had absence of vestibular function to caloric stimulation on the affected side. CONCLUSIONS: Acute auditory syndrome may be a warning sign of impending pontocerebellar infarction in the distribution of the AICA. The acute auditory syndrome preceding an AICA infarct may result from ischaemia of the inner ear or the vestibulocochlear nerve.

Acute Disease↗
PubMedDate not supplied

Mini-infarct encephalopathy associated with uncommon microvessel convolute formation presenting with presenile dementia.

A female patient started to suffer from transient ischemic attacks when she was 47 years of age, followed by increasing predominantly left-side spastic tetraparesis, generalized seizures and progressive dementia over a period of 11 years. She died when she was 58 years of age. On gross examination the brain showed enlarged ventricles and arteriosclerotic changes of large extracerebral vessels of the circulus arteriosus. Microscopic examination of the atrophic brain showed innumerable incomplete microinfarcts in the white and gray matter throughout all parts of the brain. In the white matter these lesions were characterized by small foci of demyelination and loss of oligodendrocytes while occasionally some scavenger cells were seen. Axons seemed to be unaffected or displayed irregular axonal regeneratory growth. Any inflammatory reaction failed. In the cerebral cortex and subcortical nuclei the lesions showed loss of neurons and decrease in synaptophysin expression. Intracerebral arteries showed fibrosis or fibrohyalinosis of the entire intracerebral small-vessel network. In addition, numerous uncommon clusters of angioma-like telangiectatic vessels were observed. Medium-sized ischemic infarcts were found in the right putamen and adjacent internal capsule region, left-side dorsolateral brain stem and cerebellar hemisphere as well as a left-side pyramidal tract degeneration. Contralateral pseudohypertrophy of the inferior olivary nucleus was seen. The clinical and the neuropathologic observations made in this patient are compatible with small vessel disease characterized by a multicentric special and not yet described type of incomplete mini-infarcts in cerebral cortex and white matter accompanied by some larger ischemic infarcts of the common type in brain stem and cerebellum.

Alzheimer Disease↗
PubMedDate not supplied

Symmetric brainstem necrosis in an adult following hypotension: an arterial end-zone infarct?

A 44-year-old woman with prolonged coma and hypotension following drug overdosage developed bilateral hemorrhagic infarcts in the dorsolateral brainstem. The regional distribution of these paired lesions corresponds to the area of confluence of penetrating arteries in the brainstem. It is suggested that under exceptional circumstances brainstem arterial end-zones may be vulnerable to anoxic-ischemic insult.

Adult↗
PubMed1994

The role of early MR in the evaluation of the term infant with seizures.

PURPOSE: To define the role of MR in evaluating term neonates with seizures the most common clinical manifestation of cerebral injury in neonates. METHODS: Fifteen term infants with seizures underwent MR imaging. The presence and pattern of MR findings were compared with clinical markers of perinatal distress, cause of cerebral injury, and short-term neurologic outcome. RESULTS: Seizures were caused by hypoxic-ischemic encephalopathy in three patients, bacterial meningitis in three, and prenatal cocaine exposure in one. Nine patients had no identifiable risk factors. By MR, five patients had focal ischemic injury of the cerebral hemispheres and/or basal ganglia and brain stem. Six patients had diffuse cerebral edema: of these, five had basal ganglia edema; one had brain stem edema. One patient had superior sagittal sinus thrombosis with venous infarcts. Three patients had normal MR studies. There was no correlation between markers of perinatal distress, risk factors for seizures, and presence or pattern of MR findings. There was some correlation between MR findings of diffuse cerebral injury and neurologic outcome, and between MR findings of basal ganglia and brain stem abnormalities and neurologic outcome; these findings correlated with spasticity and hemiplegia at 6 to 24 months follow-up. CONCLUSION: The presence or pattern of MR findings does not appear to correlate with with clinical signs of perinatal distress or presumed causes of perinatal cerebral injury. Further investigation is needed to identify prospectively neonates with seizures who are at risk for significant neurologic morbidity.

Asphyxia Neonatorum↗