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Narrative: At times something little and insignificant can get into our minds as clinicians and give as a reason to think a little more deeply about whatever it may be. This is the case when l came to realise there is no given lineage of how upper cervical Chiropractic care came to be what it is today. There are multiple independent stories, each favourable to one person's particular recollections, but by and large they are isolated stories and disconnected from others. I have commenced this small project to build a lineage based on what I have been able to retrieve from the literature. It is a work in progress, which I present here, with the open invitation to readers with further detail they feel is relevant to please reach out to me so we can build a definitive lineage of this idea in Chiropractic. [ABSTRACT FROM AUTHOR]

Background: Central tumor location, brain stem involvement, and medulloblastoma have been implicated as risk factors for pediatric postoperative cerebellar mutism syndrome (pCMS) by most researchers. However, conflicting results have been reported for surgical factors, such as the extent of excision, surgical approach, and the need for cerebrospinal fluid diversion. The role of emergency or elective surgery is also not well established. Aim: To assess the role of surgical factors as a risk for pCMS. The secondary variables assessed include patient profile, histopathology, radiological features, and the effect of pCMS on patient survival. Materials and Methods: Overall, 162 consecutively operated patients with posterior fossa tumor (PFT) from July 2012 to March 2020, younger than 16 years of age, were included in the study. The study population was divided into two cohorts: the pCMS group and the non-pCMS group for statistical analysis. A P-value of less than 0.05 was considered statistically significant. Results: In the sample size of 162 patients, 129 patients were included for analysis. There were 11 patients in the pCMS group. Emergency surgery was found to be a significant risk for pCMS (P = 0.021). There was a trend toward statistical significance for the need for preoperative cerebrospinal fluid diversion. The extent of resection and surgical approach were not found to be statistically significant factors. Central tumor location and contrast enhancement were significant radiological risk factors (P < 0.05). Conclusion: Aggressive tumor resection causing iatrogenic injury to the cerebellar circuitry and the brain stem is the most important risk factor for pCMS. Patients with pCMS have adverse survival outcomes. [ABSTRACT FROM AUTHOR]

Over the last decade advancements in computer processing have enabled the application of machine learning (ML) to complex medical problems. Convolutional neural networks (CNN), a type of ML, have been used to interrogate medical images for variety of purposes. In this study, we aimed to investigate the potential application of CNN in prognosticating patients with traumatic brain injury (TBI). Patients with moderate to severe TBI and evidence of diffuse axonal injury (DAI) were selected retrospectively. A CNN model was developed using a training subgroup and a holdout subgroup was used as a testing dataset. We reported the model characteristics including area under the receiver operating characteristic curve (AUC). We included a total of 38 patient, of which we generated 725 MRI sections. We developed a CNN model based on a modified AlexNet architecture that interpreted the brain stem injury to generate outcome predictions. The model was able to predict GOS outcomes with a specificity of 0.43 and a sensitivity of 0.997. It showed an AUC of 0.917. The utilization of machine learning MRI analysis for prognosticating patients with TBI is a valued method that require further investigation. This will require multicentre collaboration to generate large datasets. [ABSTRACT FROM AUTHOR]

Introduction: Patients may remain comatose after the resumption of spontaneous circulation with cardiopulmonary resuscitation. A primary neurologic event may precede a cardiac standstill. Case report: We present a 33-year-old patient with successful resuscitation for pulseless electrical activity and a "normal computed tomography (CT) scan." Further scrutiny showed a hyperdense basilar artery sign ('big white dot') that led to a CT angiogram confirming an embolus to the proximal basilar artery. His examination showed fixed and dilated midsize (mesencephalic) pupils and extensor posturing. Endovascular retrieval of the clot was successful, but there was a devastating ischemic injury to the brainstem. Conclusion: This case reminds us to consider neurologic causes of cardiac arrest. [ABSTRACT FROM AUTHOR]

Cricopharyngeal dysfunction, especially cricopharyngeal achalasia, is a common cause of dysphagia, while patients with brainstem stroke and medullary damage have a relatively high risk of cricopharyngeal achalasia. The aim of this article was to introduce an improved method of CT-guided method of injecting botulinum toxin A into the cricopharyngeus muscle using esophageal balloon radiography, and to assess the effect of the botulinum toxin A injection on swallowing performance. Seventeen patients with cricopharyngeal dysphagia were treated with botulinum toxin A injection using esophageal balloon radiography combined with CT guidance to the cricopharyngeal muscle. Primary outcome measures, including Functional Oral Intake Scale and Deglutition Handicap Index, were performed at baseline, 1 week, and 1 month after treatment. The Levene method was used to test the homogeneity of variance, and the Kruskal-Wallis test was used to compare the scores between the timepoints. Botulinum toxin A injection resulted in obvious improvement in 15 patients (88.2%) and no improvement in two patients (11.8%). Compared with the scores prior to treatment, the Functional Oral Intake Scale and Deglutition Handicap Index scores were significantly improved at 1 week (P < 0.001 and P = 0.008, respectively) and 1 month after the treatment (P = 0.001 and P < 0.001, respectively). Thus, CT-guided percutaneous injection of botulinum toxin A is probably a relatively safe, well-tolerated, and viable technique for the treatment of cricopharyngeal dysphagia caused by brainstem injury. Localization with a balloon radiography made the needle guidance easier to visualize. [ABSTRACT FROM AUTHOR]

Background: The brainstem mesopontine tegmental anesthesia area is a key node in circuitry responsible for anesthetic induction and maintenance. Microinjecting the γ-aminobutyric acid-mediated (GABAergic) anesthetic pentobarbital in this nucleus rapidly and reversibly induces general anesthesia, whereas lesioning it renders the animal relatively insensitive to pentobarbital administered systemically. This study investigated whether effects of lesioning the mesopontine tegmental anesthesia area generalize to other anesthetic agents.Methods: Cell-selective lesions were made using ibotenic acid, and rats were later tested for changes in the dose-response relation to etomidate, propofol, alfaxalone/alfadolone, ketamine, and medetomidine delivered intravenously using a programmable infusion pump. Anesthetic induction for each agent was tracked using five behavioral endpoints: loss of righting reflex, criterion for anesthesia (score of 11 or higher), criterion for surgical anesthesia (score of 14 or higher), antinociception (loss of pinch response), and deep surgical anesthesia (score of 16).Results: As reported previously for pentobarbital, on-target mesopontine tegmental anesthesia area lesions reduced sensitivity to the GABAergic anesthetics etomidate and propofol. The dose to achieve a score of 16 increased to 147 ± 50% of baseline in control animals ± SD (P = 0.0007; 7 lesioned rats and 18 controls) and 136 ± 58% of baseline (P = 0.010; 6 lesioned rats and 21 controls), respectively. In contrast, responsiveness to the neurosteroids alfaxalone and alfadolone remained unchanged compared with baseline (94 ± 24%; P = 0.519; 6 lesioned rats and 18 controls) and with ketamine increased slightly (90 ± 11%; P = 0.039; 6 lesioned rats and 19 controls). The non-GABAergic anesthetic medetomidine did not induce criterion anesthesia even at the maximal dose tested. The dose to reach the maximal anesthesia score actually obtained was unaffected by the lesion (112 ± 8%; P = 0.063; 5 lesioned rats and 18 controls).Conclusions: Inability to induce anesthesia in lesioned animals using normally effective doses of etomidate, propofol, and pentobarbital suggests that the mesopontine tegmental anesthesia area is the effective target of these, but not necessarily all, GABAergic anesthetics upon systemic administration. Cortical and spinal functions are likely suppressed by recruitment of dedicated ascending and descending pathways rather than by direct, distributed drug action. [ABSTRACT FROM AUTHOR]

Due to the poor tolerance of the brainstem to injury and the high risk of surgery, there may be important neurological dysfunction in any part of the brainstem. How to improve the success rate and prognosis of microsurgery remains to be further explored. The purpose of this article is to observe and analyze the application of micro-instruments in brain stem tumor treatment surgery, analyze the actual role of micro-instruments in clinical practice, and to compare the before and after micro-instruments in brain stem tumor surgery, The Clinical Path of Microdevices in Brain Stem Tumor Therapy. Using the method in this article, through the analysis of experimental data, we understand the role of microscopy equipment in the treatment of brainstem tumors, and found that different parts of brainstem space occupying lesions have different characteristics. Different surgical approaches should be adopted, and the application of microscopic instruments is closely related. The research results show that the application of micro-instruments in the treatment of brain stem tumors has a great effect on improving the surgical treatment of brain stem tumors. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Constipation is prevalent in individuals after stroke. However, the pathophysiological mechanisms of poststroke constipation remain unclear. This study was designed (i) to investigate the difference in anorectal motility and rectal sensation among stroke patients with constipation, stroke patients without constipation, and healthy controls (HC), (ii) to evaluate the impact of stroke sites on constipation and rectal sensation, (iii) to explore the role of autonomic functions, and (iv) to determine the independent risk factors for poststroke constipation. METHODS: Seventy-one stroke patients and 24 HC were recruited. General information, clinical characteristics, and relevant questionnaires were collected. Meanwhile, an anorectal manometry test was performed to assess functions of anorectal motility and rectal sensation, and an electrocardiogram was recorded to evaluate autonomic functions. RESULTS: (i) Constipation patients exhibited increased rectal sensation thresholds, compared with patients without constipation or HC (P < 0.001). Almost no difference was detected in anorectal motility parameters among 3 groups. Constipation-associated clinical characteristics, such as spontaneous bowel movements, were weakly or moderately correlated with rectal sensation thresholds (P < 0.05 to P < 0.001 for various parameters). (ii) Patients with brainstem lesions had increased prevalence of constipation and first sensation threshold, compared with patients without brainstem lesions (P = 0.045, P = 0.025, respectively). (iii) There was a weak positive correlation between sympathetic activity and stroke severity and a weak negative one between vagal activity and stroke severity. Rectal sensation thresholds were positively and weakly correlated with sympathetic activity but negatively with vagal activity. (iv) The desire of defecation threshold and the physical activity were independent risk factors for poststroke constipation (P = 0.043, P = 0.025, respectively). DISCUSSION: Poststroke constipation is characterized by elevated thresholds for rectal sensation, rather than altered anorectal motility. Patients with brainstem lesions are predisposed to constipation possibly because of the disruption of afferent pathway from the rectum to the brain. Moreover, the desire of defecation threshold and the physical activity level are factors independently associated with poststroke constipation. [ABSTRACT FROM AUTHOR]

Objective: Loss of consciousness is an indicator of the severity of traumatic brain injury and the ascending reticular activating system has been considered as a main structure for consciousness. However, no study on the relation between loss of consciousness and ascending reticular activating system injury in traumatic brain injury has been reported. We investigated the relation between loss of consciousness, severity of traumatic brain injury, and ascending reticular activating system injury using diffusion tensor tractography. Design: One hundred twenty patients were recruited. Three components of ascending reticular activating system, fractional anisotropy, and tract volume were measured. Results: In lower dorsal and ventral ascending reticular activating system, fractional anisotropy and tract volume value in mild group were higher than those of moderate and severe groups, and there was no difference between moderate and severe groups. In upper ascending reticular activating system, fractional anisotropy value in mild group was higher than in moderate group, and it was higher than in moderate group than in severe group. Tract volume value in mild group was higher than in severe group. Loss of consciousness showed moderate negative correlations with tract volume value of lower dorsal ascending reticular activating system (r = −0.348), fractional anisotropy value of lower ventral ascending reticular activating system (r = −0.343), and fractional anisotropy value of upper ascending reticular activating system (r = −0.416). Conclusions: Injury severity was different among the three traumatic brain injury groups in upper ascending reticular activating system but did not differ between moderate and severe groups in lower dorsal and ventral ascending reticular activating system. [ABSTRACT FROM AUTHOR]

Substantia nigra (SN) hyper-echogenicity (SN+) describes an enlargement (>90th percentile) of the area of echogenicity at the anatomic site of the SN in the midbrain detected by transcranial sonography. This ultrasound sign has proven to be a valuable marker supporting the clinical diagnosis of Parkinson's disease (PD). Although there is considerable variation in the extent of echogenic signals at the anatomic site of the SN among PD patients, previous work suggests that SN+ is a stable marker throughout the course of the disease. The present study focused on two aspects: (i) determining whether SN+ values differ between the sides, mirroring the asymmetric character of the disease; and (ii) determining whether age has an influence on SN echogenicity. This cross-sectional study included 300 PD patients and 200 healthy controls. SN+ was measured planimetrically by transcranial sonography. Echogenicity was analyzed separately for onset and non-onset sides, with onset side defined as the SN contralateral to the side of the body that first manifested PD-related motor impairment. Age of the patients and healthy controls at study time was used for correlation. We found that the onset SN+ contralateral to the side of initial motor symptoms was on average 17.6% larger than its counterpart. However, we also found that contrary to the control group, where an increase in age was associated with an increase in size of SN+, age of PD patients was associated with a decline in size of the onset SN+. Furthermore, SN measured at the onset side of PD patients correlated significantly with patient age and Hoehn and Yahr stage, a scale that grades PD severity, although this was not the case for the non-onset side. The present study indicates that changes in SN echogenicity have a different dynamic depending on the onset side of the disease. The age at study time had a significantly negative effect on the size of onset SN+, the effect on the non-onset side was non-significant. We conclude that for appropriate PD analysis, onset SN+ is a more important marker than the average of both sides of SN. Furthermore, we found that among healthy controls, the size of SN+ increases with age. [ABSTRACT FROM AUTHOR]

Background: Neurologic manifestations of craniovertebral junction (CVJ) disease may generate dramatic brainstem damage, which could evolve to paralysis. In most cases, patients are referred with advanced neurological symptoms such as tetraplegia/paresis. The aim of this study was to identify predictive factors of favorable neurological evolution after non-traumatic brainstem compression.Methods: A prospective study evaluated 143 consecutive patients who had undergone CVJ anterior brainstem decompression. The mean age was 45.1 ± 19.1 years. The study analyzed clinical, surgical, and imagery characters to determine predictive factors of neurological improvement.Results: The mean follow-up of our series was 10.2 years (range 0.5-23.9). Seventy-one (49.6%) presented initial tetrapalsies resulting from spinal cord compression. Multivariable analysis revealed that Frankel score [odds ratio (OR) 5.7, CI 95% 1.01-31.8; p < 0.04] and preoperative symptoms < 6 months [OR 0.33, CI 95% 0.125-0.9; p < 0.025] were independently associated with partial neurological improvement, while the only independent factor associated with total neurologic recovery was the preoperative symptom evolution <6 months [odd ratio (OR) 4.3, CI 95% 1.6-11.4; p < 0.003]. None of the following were identified as predictive factors: demographic characteristics, medical history, the etiology of compression, or initial spinal cord MRI.Conclusion: The earlier the decompression is performed, the better the neurological improvement. Whatever the initial Frankel score, if neurological palsy or disorders evolved for less than 6 months, complete recovery is possible. [ABSTRACT FROM AUTHOR]

Purpose: Proton therapy can allow for superior avoidance of normal tissues. A widespread consensus has been reached that proton therapy should be used for patients with curable pediatric brain tumor to avoid critical central nervous system structures. Brainstem necrosis is a potentially devastating, but rare, complication of radiation. Recent reports of brainstem necrosis after proton therapy have raised concerns over the potential biological differences among radiation modalities. We have summarized findings from the National Cancer Institute Workshop on Proton Therapy for Children convened in May 2016 to examine brainstem injury.Methods and Materials: Twenty-seven physicians, physicists, and researchers from 17 institutions with expertise met to discuss this issue. The definition of brainstem injury, imaging of this entity, clinical experience with photons and photons, and potential biological differences among these radiation modalities were thoroughly discussed and reviewed. The 3 largest US pediatric proton therapy centers collectively summarized the incidence of symptomatic brainstem injury and physics details (planning, dosimetry, delivery) for 671 children with focal posterior fossa tumors treated with protons from 2006 to 2016.Results: The average rate of symptomatic brainstem toxicity from the 3 largest US pediatric proton centers was 2.38%. The actuarial rate of grade ≥2 brainstem toxicity was successfully reduced from 12.7% to 0% at 1 center after adopting modified radiation guidelines. Guidelines for treatment planning and current consensus brainstem constraints for proton therapy are presented. The current knowledge regarding linear energy transfer (LET) and its relationship to relative biological effectiveness (RBE) are defined. We review the current state of LET-based planning.Conclusions: Brainstem injury is a rare complication of radiation therapy for both photons and protons. Substantial dosimetric data have been collected for brainstem injury after proton therapy, and established guidelines to allow for safe delivery of proton radiation have been defined. Increased capability exists to incorporate LET optimization; however, further research is needed to fully explore the capabilities of LET- and RBE-based planning. [ABSTRACT FROM AUTHOR]

The aim of this study was to investigate how traumatic axonal injury (TAI) lesions in the thalamus, basal ganglia, and brainstem on clinical brain magnetic resonance imaging (MRI) are associated with level of consciousness in the acute phase in patients with moderate to severe traumatic brain injury (TBI). There were 158 patients with moderate to severe TBI (7-70 years) with early 1.5T MRI (median 7 days, range 0-35) without mass lesion included prospectively. Glasgow Coma Scale (GCS) scores were registered before intubation or at admission. The TAI lesions were identified in T2*gradient echo, fluid attenuated inversion recovery, and diffusion weighted imaging scans. In addition to registering TAI lesions in hemispheric white matter and the corpus callosum, TAI lesions in the thalamus, basal ganglia, and brainstem were classified as uni- or bilateral. Twenty percent of patients had TAI lesions in the thalamus (7% bilateral), 18% in basal ganglia (2% bilateral), and 29% in the brainstem (9% bilateral). One of 26 bilateral lesions in the thalamus or brainstem was found on computed tomography. The GCS scores were lower in patients with bilateral lesions in the thalamus (median four) and brainstem (median five) than in those with corresponding unilateral lesions (median six and eight, p = 0.002 and 0.022). The TAI locations most associated with low GCS scores in univariable ordinal regression analyses were bilateral TAI lesions in the thalamus (odds ratio [OR] 35.8; confidence interval [CI: 10.5-121.8], p < 0.001), followed by bilateral lesions in basal ganglia (OR 13.1 [CI: 2.0-88.2], p = 0.008) and bilateral lesions in the brainstem (OR 11.4 [CI: 4.0-32.2], p < 0.001). This Trondheim TBI study showed that patients with bilateral TAI lesions in the thalamus, basal ganglia, or brainstem had particularly low consciousness at admission. We suggest these bilateral lesions should be evaluated further as possible biomarkers in a new TAI-MRI classification as a worst grade, because they could explain low consciousness in patients without mass lesions. [ABSTRACT FROM AUTHOR]

Purpose: Proton radiation therapy is commonly used in young children with brain tumors for its potential to reduce late effects. However, some proton series report higher rates of brainstem injury (0%-16%) than most photon series (2.2%-8.6%). We report the incidence of brainstem injury and a risk factor analysis in pediatric patients with posterior fossa primary tumors treated with proton radiation therapy at our institution.Methods and Materials: The study included 216 consecutive patients treated between 2000 and 2015. Dosimetry was available for all but 4 patients. Grade 2 to 5 late brainstem toxicity was assessed by the National Cancer Institute Common Terminology Criteria for Adverse Events version 4.0.Results: The histologies include medulloblastoma (n=154, 71.3%), ependymoma (n=56, 25.9%), and atypical teratoid rhabdoid tumor (n=6, 2.8%). The median age at irradiation was 6.6 years (range, 0.5-23.1 years); median dose, 54 gray relative biological effectiveness (Gy RBE) (range, 46.8-59.4 Gy RBE); and median follow-up period, 4.2 years (range, 0.1-15.3 years) among 198 survivors. Of the patients, 83.3% received chemotherapy; 70.4% achieved gross total resection. The crude rate of injury was 2.3% in all patients, 1.9% in those with medulloblastoma, 3.6% in those with ependymoma, and 0% in those with atypical teratoid rhabdoid tumor. The 5-year cumulative incidence of injury was 2.0% (95% confidence interval, 0.7%-4.8%). The median brainstem dose (minimum dose received by 50% of brainstem) in the whole cohort was 53.6 Gy RBE (range, 16.5-56.8 Gy RBE); maximum point dose within the brainstem (Dmax), 55.2 Gy RBE (range, 48.4-60.5 Gy RBE); and mean dose, 50.4 Gy RBE (range, 21.1-56.7 Gy RBE). In the 5 patients with injury, the median minimum dose received by 50% of the brainstem was 54.6 Gy RBE (range, 50.2-55.1 Gy RBE); Dmax, 56.2 Gy RBE (range, 55.0-57.1 Gy RBE); mean dose, 51.3 Gy RBE (range, 45.4-54.4 Gy RBE); and median volume of the brainstem receiving ≥55 Gy RBE (V55), 27.4% (range, 0%-59.4%). Of the 5 patients with injury, 4 had a brainstem Dmax in the highest quartile (≥55.8 Gy RBE, P = .016) and a V55 in the highest tertile (>6.0%) of the cohort distribution (P = .047). Of the 5 patients with injury, 3 were aged >6 years (age range, 4.1-22.8 years), and 4 of 5 patients received chemotherapy and achieved gross total resection.Conclusions: The incidence of injury in pediatric patients with posterior fossa tumors is consistent with previous reports in the photon setting. Our data suggest that when Dmax and V55 are kept <55.8 Gy RBE and ≤6.0%, respectively, the 5-year rate of radiation brainstem injury would be <2%. [ABSTRACT FROM AUTHOR]

Background: Holmes tremor is a rare symptomatic movement disorder, characterized by a combination of resting, postural, and intention tremor. It is usually caused by lesions in the brainstem, thalamus, and cerebellum. Despite pharmacological advances, its treatment remains a challenge; many medications have been used with various degrees of effectiveness. Stereotactic thalamotomy and deep brain stimulation in the ventralis intermedius nucleus have been effective surgical procedures in cases refractory to medical treatment. Case Report: Here we report a young woman with topiramate-responsive Holmes tremor secondary to a brainstem cavernoma. Discussion: Herein we report a Holmes tremor responsive to Topiramate. [ABSTRACT FROM AUTHOR]

Objective: This is a descriptive study of the frequency and risk for brainstem injury by crash type, belt use, and crash severity (delta-V). NASS-CDS electronic cases were reviewed to see whether the transition from vehicles without advanced airbags and seat belts and side airbags and curtains to vehicles with the safety technologies has influenced the risk for brainstem injury.Methods: 1994-2013 NASS-CDS was analyzed to determine the number of brainstem injuries in nonejected adults (15+ years old) in vehicle crashes. Crashes were grouped by front, side, rear, and rollover. The effect of belt use was investigated. Light vehicles were included with model year (MY) 1994+. Occupants with severe head injury (Abbreviated Injury Scale [AIS] 4+) and Maximum Abbreviated Injury Scale (MAIS) 4+F injury were also determined. The risk for injury with standard errors was determined using the MAIS 0+F exposure by belt use and crash type. NASS-CDS electronic cases were studied with brainstem injury in 2001-2013 MY vehicles.Results: NASS-CDS indicates there are 872 ± 133 cases of brainstem injury per year. About 16.0% of AIS 4+ head injury involves the brainstem. For belted occupants, the highest risk for brainstem injury was in side impacts at 0.065 ± 0.010%. In contrast, the highest risk for brainstem injury was 0.310 ± 0.291% in rear impacts and 0.310 ± 0.170% in rollovers for unbelted occupants. The risk for brainstem injury increased with crash severity. The highest risk for brainstem injury was 3.54 ± 1.45% in crashes with >72 km/h (>45 mph) delta-V. Exponential functions fit the change in risk with delta-V. Eighteen NASS-CDS electronic cases showed that brainstem injury occurred in very severe collisions where the occupant experienced multiple injuries from intrusion or impact on vehicle structures stiffened by deformation.Conclusions: The risk for brainstem injury in belted occupants has remained essentially constant over 20 years, whereas the risk for MAIS 4+F injury has declined 38.3%. The prevention of brainstem injuries must address the extreme speed of collisions and weight mismatches that overwhelm structures, seat belts, frontal airbags, side airbags, and curtains in modern vehicles. [ABSTRACT FROM AUTHOR]

Cervical spine injuries are common in pediatric population and usually seen in craniocervical junction due to the anatomical and physiological differences. Combination of rapid hyperextension/hyperflexion traumas due to highspeed motor vehicle accident are known to be the reason of ligamentous injury and retroclival epidural hematoma. Our aim is to describe a rare combination injury of the the apical ligament, retroclival epidural hematoma and the suspicion of brain stem slits, due to rapid hyperextension/hyperflexion and rotational trauma with high-speed motor vehicle accident in a 3 year 8 month old girl. The cervical spine was immobilized with a Philadelphia collar. She is still under treatment in the pediatric intensive care unit with a Glascow Coma Scale of 8 for six months. [ABSTRACT FROM AUTHOR]

Progressive supranuclear palsy (PSP) is a neurodegenerative disorder showing predominant brainstem involvement, characterized by marked slowing of rapid eye movements (saccades), particularly along the vertical plane. While the contribution of the brainstem damage for the saccadic disturbance in PSP has been extensively studied, much less is known about its cortical and subcortical pathomechanisms. We measured reflexive (prosaccades) and voluntary (antisaccades) saccades in the vertical and horizontal plane in PSP patients (n = 8) and controls (n = 10) in an eye tracking study, followed by the measurement of blood oxygenation-level dependent (BOLD) activation (PSP, n = 6; controls, n = 10) during similar saccade paradigms. Behaviorally, PSP patients evidenced slower and lower amplitude prosaccades (horizontal and vertical) and lower amplitude antisaccades (vertical) than controls. Functionally, patients showed decreased frontostriatal BOLD activation during prosaccades (horizontal and vertical) and antisaccades (vertical), relative to controls. Additionally, PSP patients showed less default mode network (DMN) deactivation than controls for all types of saccades. Within groups, controls showed no BOLD differences between horizontal and vertical prosaccades while PSP patients demonstrated greater DMN deactivation during vertical prosaccades. Both groups evidenced greater DMN deactivation during vertical antisaccades when compared to their horizontal counterpart and patients further showed relative frontostriatal BOLD hypoactivity during vertical antisaccades. We found fMRI evidence of frontostriatal hypoactivity in PSP patients relative to controls, especially during vertical saccades. These new findings highlight the impact of cortical impairment in saccadic disturbance of PSP. [ABSTRACT FROM AUTHOR]

Patients with severe traumatic brain injury or large intracranial space-occupying lesions (spontaneous cerebral hemorrhage, infarction, or tumor) commonly present to the neurocritical care unit with an altered mental status. Many experience progressive stupor and coma from mass effects and transtentorial brain herniation compromising the ascending arousal (reticular activating) system. Yet, little progress has been made in the practicality of bedside, noninvasive, real-time, automated, neurophysiological brainstem, or cerebral hemispheric monitoring. In this critical review, we discuss the ascending arousal system, brain herniation, and shortcomings of our current management including the neurological exam, intracranial pressure monitoring, and neuroimaging. We present a rationale for the development of nurse-friendly-continuous, automated, and alarmed-evoked potential monitoring, based upon the clinical and experimental literature, advances in the prognostication of cerebral anoxia, and intraoperative neurophysiological monitoring. [ABSTRACT FROM AUTHOR]

Objectives: No study on injury of the inferior cerebellar peduncle (ICP) in patients with mild traumatic brain injury (mTBI) has been reported. This study, using diffusion tensor tractography (DTT), attempted to demonstrate injury of the ICP in patients with mTBI. Methods: Three patients with mTBI resulting from a car accident and 18 normal healthy control subjects were enrolled in this study. Diffusion tensor imaging data were acquired at 2 months (patient 1) and 3 months (patients 2 and 3) after onset and the ICP was reconstructed. The Balance Error Scoring System was used for evaluation of balance at the same time diffusion tensor imaging scanning was performed. Results: The ICPs were discontinued at the upper portion of the vertical cerebellar branch and the transverse cerebellar branch (patient 1) and the proximal portion of the transverse cerebellar branch (patients 2 and 3) compared to the normal control subjects. Regarding DTT parameters, in the three patients, the fibre number of the ICPs was decreased by more than 2 SD compared with those of subjects in the control group. Conclusion: Evaluation of the ICP using DTT would be useful in patients with a balance problem after mTBI. [ABSTRACT FROM AUTHOR]

Background/Aims: It is crucial to detect the composition of the thrombus in isolated brainstem infarction with large artery occlusion. The aim of this study was to explore the susceptibility vessel sign (SVS) whose composition is mainly deoxidized red cells in patients with isolated brainstem infarction and posterior circulation large artery occlusion. Methods: This was a single-center retrospective study. All patients with posterior circulation large artery occlusion from January 2003 to September 2013 were included. We identified 213 patients who had posterior circulation large artery occlusion, and 81 patients met the imaging eligibility criteria. Among the 81 patients, 21 had isolated brainstem infarction. Results: Among the 21 patients, 7 (33%) had SVS and 2 (10%) had pseudo-SVS (calcified vessels without thrombosis). In the 7 patients with SVS, we found atrial fibrillation in 2 patients, dissection in 3 patients and large artery atherosclerotic disease (LAAD) in 2 patients. There were SVS in 100% (2/2) of patients with atrial fibrillation, 50% (3/6) of patients with dissection, and 20% (2/10) of patients with LAAD. Conclusions: SVS reflects pathology of deoxidized red cells composition in patients with isolated brainstem infarction. This finding may be useful to explore the different stroke mechanisms and therapy strategies. [ABSTRACT FROM AUTHOR]

Cerebellar stroke is a rare condition with very nonspecific clinical features. The symptoms in the acute phase could imitate acute peripheral vestibular disorders or a brainstem lesion. The aim of this study was to assess the usefulness of the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification in cerebellar stroke and the impact of clinical features on the prognosis. We retrospectively analyzed 107 patients with diagnosed ischemic cerebellar infarction. We studied the clinical features and compared them based on the location of the ischemic lesion and its distribution in the posterior interior cerebellar artery (PICA), superior cerebellar artery (SCA), and anterior inferior cerebellar artery (AICA) territories. According to the TOAST classification, stroke was more prevalent in atrial fibrillation (26/107) and when the lesion was in the PICA territory (39/107). Pyramidal signs occurred in 29/107 of patients and were more prevalent when the lesion was distributed in more than two vascular regions ( p = 0.00640). Mortality was higher among patients with ischemic lesion caused by cardiac sources ( p = 0.00094) and with pyramidal signs ( p = 0.00640). The TOAST classification is less useful in assessing supratentorial ischemic infarcts. Cardioembolic etiology, location of the ischemic lesion, and pyramidal signs support a negative prognosis. [ABSTRACT FROM AUTHOR]

Background Currently-used cerebellomedullary cistern puncture method for collecting cerebrospinal fluid (CSF) from monkeys is simple, inexpensive, and practical, but with high risk for brainstem injury and CSF blood contamination. An improved technique was thus developed and characterized. Method Magnetic resonance imaging was used to identify the space and position of the cisterna magna in monkeys. Accordingly, a newly defined procedure for needle punctuation was tested in comparison with the traditional method. Blood contamination in CSF samples and brainstem injury were determined to define the superior of the improved method over the transitional method. Results The cisterna magna in monkeys was found to be a “▽” shape. The needle was punctured into the cisterna magna aiming at the wider superior gap avoided brainstem injury. The improved method showed that the rate of blood contamination in the CSF samples was reduced from 66.7% to 16.7%, the higher rate of blood contamination was associated with higher risk for brainstem injury. Comparison with existing methods: In traditional method, the needle is punctured aiming at the inferior gap with high density of blood vessels. In improved method, the needle is punctured aiming at the superior gap, pointing to the nose root while advancing the needle and avoiding injury to blood vessels. Conclusions This improved technique not only avoids blood contamination of CSF, but also prevents brainstem injury during the process of CSF collection. It is recommended for adaptation for CSF collection in monkeys. [ABSTRACT FROM AUTHOR]

Brainstem hemorrhage following evacuation of chronic subdural hematoma is extremely rare and its pathogenesis is unclear. In our case report, we present a rare case of brainstem hemorrhage following evacuation chronic subdural hematoma. Our patient was a 50-year-old man, with no comorbidities, presented with dorsal midbrain hemorrhage with ventricular extension and symptomatic progression of contralateral small chronic subdural hematoma following evacuation of chronic subdural hematoma. Contralateral subdural hematoma was evacuated and midbrain hemorrhage was managed conservatively. He was discharged with minimal neurologic deficit. Review of literature and pathogenesis of remote hemorrhage after evacuation of chronic subdural hematoma were discussed. [ABSTRACT FROM AUTHOR]

Rationale: Alterations in brainstem circuits have been proposed as a possible mechanism underlying the etiology of mood disorders. Projections from the median raphe nucleus (MnR) modulate dopaminergic activity in the forebrain and are also part of a behavioral disinhibition/inhibition system that produces phenotypes resembling behavioral variations manifested during manic and depressive phases of bipolar disorder. Objective: The aim of this study is to assess the effect of chronic lithium treatment on behavioral disinhibition induced by MnR lesions. Methods: MnR electrolytic lesions were performed in C57BL/6J mice, with sham-operated and intact animals as control groups. Following recovery, mice were chronically treated with lithium (LiCl, added in chow) followed by behavioral testing. Results: MnR lesion induced manic-like behavioral alterations including hyperactivity in the open field (OF), stereotyped circling, anxiolytic/risk taking in the elevated plus maze (EPM) and light/dark box (LDB) tests, and increased basal body temperature. Lithium was specifically effective in reducing OF hyperactivity and stereotypy but did not reverse (EPM) or had a nonspecific effect (LDB) on anxiety/risk-taking measures. Additionally, lithium decreased saccharin preference and prevented weight loss during single housing. Conclusions: Our data support electrolytic lesions of the MnR as an experimental model of a hyper-excitable/disinhibited phenotype consistent with some aspects of mania that are attenuated by the mood stabilizer lithium. Given lithium's relatively specific efficacy in treating mania, these data support the hypothesis that manic symptoms derive not only from the stimulation of excitatory systems but also from inactivation or decreased activity of inhibitory mechanisms. [ABSTRACT FROM AUTHOR]

A correction to the article "Coning Algorithms Based on a Half-Compressed Structure" that was published in a 2014 issue of the journal is presented.

Background: Infants with abusive head trauma (AHT) have diffuse brain damage with potentially fatal brain swelling. The pathogenesis of the brain damage remains unclear. We hypothesize that brain damage in AHT is due to hypoxic-ischemic injury with hypoxic-ischemic encephalopathy (HIE) rather than primary traumatic brain injury (TBI) with traumatic diffuse axonal injury (tDAI). Methods: We studied brain tissue of AHT victims. Primary outcome measure was the presence of primary traumatic versus hypoxic-ischemic brain injury. The diagnosis of tDAI followed a standardized semiquantitative diagnostic approach yielding a 4-tiered grading scheme (definite, possible, improbable, and none). In addition, results of quantitative immunohistochemical analysis in a subgroup of AHT victims with instant death were compared with matched SIDS controls. Results: In our cohort of 50 AHT victims, none had definite tDAI (no tDAI in 30, tDAI possible in 2, and tDAI improbable in 18). Instead, all AHT victims showed morphological findings indicative of HIE. Furthermore, the subgroup with instant death showed significantly higher counts of damaged axons with accumulation of amyloid precursor protein (APP) in the brainstem adjacent to the central pattern generator of respiratory activity (CPG) (odds ratio adjusted for age, sex, brain weight, and APP-count in other regions = 3.1; 95 % confidence interval = 1.2 to 7.7; p = 0.015). Conclusions: AHT victims in our cohort do not have diffuse TBI or tDAI. Instead, our findings indicate that the encephalopathy in AHT is the due to hypoxic-ischemic injury probably as the result of respiratory arrest due to local damage to parts of the CPG in the brainstem. [ABSTRACT FROM AUTHOR]

Multiple sclerosis (MS) is a demyelinating disease and is considered the most debilitating neurological disorder among young adults. Sudden deafness has been reported in MS patients. This article describes cases of sudden deafness related to acute bouts in MS patients. A survey was conducted using 405 records of MS patients attended to at a reference center in the city of Rio de Janeiro between 2011 and 2012 to identify cases of sudden deafness. Seven patients were identified, 6 with a relapsing-remitting course and 1 with progressive disease at onset. Five patients had unilateral deafness and 2 bilateral. The recovery was complete in 4 and partial in 1, and there was no recovery in 2 patients. It was not possible to establish a topographical correlation between deafness and brainstem lesions. Audiometric examinations revealed severe hearing loss during the bout and recovery of hearing in 5 cases after remission. © 2014 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

With the advent of cardiopulmonary resuscitation techniques, the cardiopulmonary definition of death lost its significance in favor of brain death. Brain death is a permanent cessation of all functions of the brain in which though individual organs may function but lack of integrating function of the brain, lack of respiratory drive, consciousness, and cognition confirms to the definition that death is an irreversible cessation of functioning of the organism as a whole. In spite of medical and legal acceptance globally, the concept of brain death and brain-stem death is still unclear to many. Brain death is not promptly declared due to lack of awareness and doubts about the legal procedure of certification. Many brain dead patients are kept on life supporting systems needlessly. In this comprehensive review, an attempt has been made to highlight the history and concept of brain death and brain-stem death; the anatomical and physiological basis of brain-stem death, and criteria to diagnose brain-stem death in India. [ABSTRACT FROM AUTHOR]

An integrated neuroreconstructive approach to stimulating the pathogenetic mechanisms of a vegetative state developed due to a severe traumatic brain injury (TBI) is suggested. It has been shown that a faster and more pronounced therapeutic effect, compared with conventional therapies, could be achieved through the application of transtimpanal chemical vestibular dereception and transcranial micropolarization. The results of neurophysiological in-depth examination in dynamics have shown that over time interregional cortical interactions become more intense, 'rigid,' and 'tight' in patients with a vegetative state, while the temporal-parietal-occipital areas begin to dominate in the organization of these interactions in the cortex of both hemispheres. It is assumed that the vestibulothalamic tract, owing to its anatomical location, appears to be the least vulnerable under the conditions of brain stem dislocation due to a severe TBI. As a result, vestibular afferentation appears to become a predominant kind of afferentation for generating interregional cortical interactions. A pathological functional system develops on the basis of this afferentation, blocking other functional systems in the damaged brain. The suggested therapies significantly reduce the amount of vestibular afferent inputs and open a possibility for restoring more effective afferent interactions. This significantly facilitates the functioning of the brain as a multimodal analyzer. [ABSTRACT FROM AUTHOR]

A 34-year-old woman presented with a history of persisting headache for years, and a newly developed dizziness, left facial palsy and right hemiparesis two days prior to this admission. Initial computed tomographic angiography of the head demonstrated an area of increased density in the left middle and posterior fossae. Multiple aneurysmally dilated venous ectasias with contrast enhancement at the left pre-pontine cistern causing a massive mass effect to the brainstem were also noted, suggesting a huge vascular abnormality. Digital subtraction angiography revealed an abnormal vascular lesion surrounding the brainstem, which indicated a left direct carotid-cavernous fistula with posterior drainage. As her consciousness deteriorated the next day, a follow-up computed tomography scan was done which revealed a pontine hemorrhage. Subsequently, endovascular closure of the fistula with sacrifice of the left ICA was performed, which successfully eliminated the imaging abnormalities. [ABSTRACT FROM AUTHOR]

Background: Macroglossia has been reported in patients undergoing posterior fossa neurosurgical procedures and is thought to be as a result of venous engorgement from intubation or mechanical positioning during these prolonged procedures. Methods: We report three patients who developed macroglossia and dysautonomia of central neurogenic origin following brainstem injury. Results: The three patients developed macroglossia and dysautonomia with wide hemodynamic fluctuations in the setting of posterior fossa injury of the lower brainstem structures, necessitating tracheostomy placement. Macroglossia was managed with dexamethasone and there was complete resolution of dysautonomia while treated with beta-blockers and gabapentin. Conclusions: Neurointensivists should be aware of macroglossia with dysautonomia complicating brainstem injury, which may have perilous consequences in the setting of cerebral edema or intracranial hypertension. [ABSTRACT FROM AUTHOR]

Parkinson's disease is a neurodegenerative disorder of the extrapyramidal system, which occurs following the slow and progressive destruction of the pigmented dopaminergic neurons in the brain stem, particularly the substantia nigra and the presence of Lewy bodies. Parkinson's disease has a progressive evolution and its signs and symptoms develop in time. The aim of this study was to analyze the potential role of rehabilitation treatment for the prevention of complications in patients with Parkinson's disease, compared to patients with drug therapy alone. The study included 30 patients aged between 50 and 82 years, divided into two groups: group A, including 15 patients who received both anti-Parkinson drug treatment and rehabilitation treatment consisting of massage, kinesiotherapy and occupational therapy, and group B, patients who received only anti-Parkinson drug treatment. The duration of treatment was two weeks. The study included patients with stages I-IV (the Hoehn and Yahr scale). The evaluation scale used was the Garden City Scale for the testing of tremor, bradykinesia, stiffness, gait, posture, facies, upper limb balance, speech, vegetative disorders and the self-care ability. At the end of the study, the study group, with rehabilitation treatment, had statistically significant improvements compared to the control group, with drug treatment alone. The highest improvements were found in the items "stiffness" and "bradykinesia", and due to these, the quality of gait was also improved. The exercises for the increase of facial mobility are extremely important, because they improve the verbal and non-verbal communication function. Our data suggest the fact that early individualized rehabilitation treatment plays an important role in the improvement of the quality of life of patients with Parkinson's disease, by the reduction of the degree of disability, the prevention of complications and the increase of the quality of life. Each patient should benefit from rehabilitation treatment that should be continued at home for better results. [ABSTRACT FROM AUTHOR]

Chronic hypoventilation due to injury to the brain stem respiratory center or high cervical cord (above the C3 level) can result in dependence to prolonged mechanical ventilation with tracheostomy, frequent nosocomial pneumonia, and prolonged hospitalization. Diaphragm pacing through electrical stimulation of the phrenic nerve is an established treatment for central hypoventilation syndrome. We performed chronic phrenic nerve stimulation for diaphragm pacing with the spinal cord stimulator for pain control in a quadriplegic patient with central apnea due to complete spinal cord injury at the level of C2 from cervical epidural hematoma. After diaphragmatic pacing, the patient who was completely dependent on the mechanical ventilator could ambulate up to three hours every day without aid of mechanical ventilation during the 12 months of follow-up. Diaphragm pacing through unilateral phrenic nerve stimulation with spinal cord stimulator was feasible in an apneic patient with complete quadriplegia who was completely dependent on mechanical ventilation. Diaphragm pacing with the spinal cord stimulator is feasible and effective for the treatment of the central hypoventilation syndrome. [ABSTRACT FROM AUTHOR]

The article discusses a study which investigated patients with multiple sclerosis in Shanghai, China. Topics discussed include the impact of lesions in the cerebrum and spinal cord on the patients' activities of daily living, the lack of association between brainstem lesions and patients' living place and the selection of multiple-sclerosis-related factors.

Abstract: Misoprostol during the first trimester of pregnancy is associated with a specific malformative pattern (Moebius sequence and limb defects) whose incidence remains unknown. Data originate mostly from illegal use for abortion and are mainly retrospective. The present prospective controlled study analyses outcomes of first trimester misoprostol exposures after medical prescriptions. Malformation rate was higher among 236 pregnancies exposed before 12 gestational weeks (4%) than in 255 controls (1.8%), although not statistically significant (OR=2.2 [95% CI=0.6–7.7]). Three malformations (2%) in the exposed group were consistent with the misoprostol malformative pattern. This is the largest prospective study on first trimester misoprostol exposure and the first one relying on prescriptions. A trend toward a doubling of the overall rate of malformations was observed and for the first time an estimation of the incidence of misoprostol specific spectrum is proposed (2%). Brainstem injuries including severe trismus might be added to this specific pattern. [Copyright &y& Elsevier]

Little is known about the effects of blast exposure on the human brain in the absence of head impact. Clinical reports, experimental animal studies, and computational modeling of blast exposure have suggested effects on the cerebellum and brainstem. In US military personnel with isolated, primary blast-related ‘mild’ traumatic brain injury and no other known insult, we found diffusion tensor MRI abnormalities consistent with cerebellar white matter injury in 3 of 4 subjects. No abnormalities in other brain regions were detected. These findings add to the evidence supporting the hypothesis that primary blast exposure contributes to brain injury in the absence of head impact and that the cerebellum may be particularly vulnerable. However, the clinical effects of these abnormalities cannot be determined with certainty; none of the subjects had ataxia or other detected evidence of cerebellar dysfunction. The details of the blast events themselves cannot be disclosed at this time, thus additional animal and computational modeling will be required to dissect the mechanisms underlying primary blast-related traumatic brain injury. Furthermore, the effects of possible subconcussive impacts and other military-related exposures cannot be determined from the data presented. Thus many aspects of topic will require further investigation. [ABSTRACT FROM AUTHOR]

Only 3%-5% of all brain metastases are located in the brainstem. We present a comprehensive review of the clinical outcomes from modern studies that treated patients with brainstem metastasis using either a Gamma Knife or a linear accelerator-based stereotactic radiosurgery. The median survival time of patients was compared to better understand what clinical or treatment factors are predictive of improved survival. This information can then be utilized to optimize patient care. The data suggests that higher prescribed marginal dose and the associated greater local control of brainstem lesions are associated with longer patient survival. Further research is necessary to better describe the most effective dose for individual brainstem lesions and to tailor optimum therapy to specific patient subgroups. [ABSTRACT FROM AUTHOR]

The article presents research that examines the conventional magnetic resonance imaging (MRI) for the prediction of future disability in early relapsing-remitting multiple sclerosis (MS). The study shows no correlation between clinical and MRI data. It notes the association of the presence or growth of new brainstem lesions with Expanded Disability Status Scale (EDSS) changes for more than five years of follow-up.

Somatosensory feedback from the larynx plays a critical role in regulation of normal upper airway functions, such as breathing, deglutition and voice production, while altered laryngeal sensory feedback is known to elicit a variety of pathological reflex responses, including persistent coughing, dysphonia and laryngospasm. Despite its clinical impact, the central mechanisms underlying the development of pathological laryngeal responses remain poorly understood. We examined the effects of persistent vocal fold (VF) inflammation and trauma, as frequent causes of long-lasting modulation of laryngeal sensory feedback, on brainstem immunoreactivity in the rat. Combined VF inflammation and trauma were induced by injection of lipopolysaccharide (LPS) solution and compared to VF trauma alone from injection of vehicle solution and to controls without any VF manipulations. Using a c-fos marker, we found significantly increased Fos-like immunoreactivity (FLI) in the bilateral intermediate/parvicellular reticular formation (IRF/PCRF) with a trend in the left solitary tract nucleus (NTS) only in animals with LPS-induced VF inflammation and trauma. Further, FLI in the right NTS was significantly correlated with the severity of LPS-induced VF changes. However, increased brainstem FLI response was not associated with FLI changes in the first-order neurons of the laryngeal afferents located in the nodose and jugular ganglia in either group. Our data indicate that complex VF alterations (i.e., inflammation/trauma vs. trauma alone) may cause prolonged excitability of the brainstem nuclei receiving a direct sensory input from the larynx, which, in turn, may lead to (mal)plastic changes within the laryngeal central sensory control. [ABSTRACT FROM AUTHOR]

It is a well-documented fact that pontomedullary lacerations (PML) occur as a result of severe craniocervical injury, but their underlying mechanism has yet to be fully clarified. The aim of this prospective study has been to give greater insight into the underlying mechanism of PML through determining the site of blunt head-impact, as well as the presence of concomitant head and neck injuries in cases of brainstem PML. A total of 56 cases with partial PML have been analysed for this study. The case group was composed of 40 men and 16 women, averaging in age 44.2 ± 19.2 years and consisting of 7 motorcyclists, 4 bicyclists, 18 car occupants, 16 pedestrians, and 10 victims of falls from a height, as well as 1 victim of a fall from standing height. The presented study has shown that there are several possible mechanisms of PML. Impact to the chin, with or without a skull base fracture, most often leads to this fatal injury, due to the impact force transmission either through the jawbone or vertebral column; most likely in combination with a fronto-posterior hyperextension of the head. Additionally, lateral head-impacts with subsequent hinge fractures and PML may also be a possible mechanism. The jawbone and other facial bones are able to act as shock absorbers, and their fracture may diminish the energy transfer towards the skull and protect the brain and brainstem from injury. The upper cervical spine can act as damper and energy absorber as well, and may prevent any occurrence of fracture to the base of the skull. [ABSTRACT FROM AUTHOR]

Summary: Objectives: Cervical vestibular evoked myogenic potentials (cVEMPs) provide assessment of lower-brainstem lesions affecting their neuronal pathways. We aimed to determine whether cVEMPs to air-conducted sound (ACS) are also abnormal in patients with early stages of amyotrophic lateral sclerosis (ALS), with or without bulbar involvement. Methods: cVEMPs were recorded in 22 ALS patients and 23 age- and sex-matched healthy volunteers. Their latencies and amplitudes were compared between the ALS patients and the control group. Results: cVEMPs were obtained in all ALS patients and controls. P13 and N23 latencies and P13–N23 amplitudes did not significantly differ between controls and ALS patients, either with or without bulbar involvement. Conclusions: We postulate that the ACS–cVEMP neural pathway is not affected in patients with early stages of ALS, even with clinical findings of bulbar involvement. Therefore, ACS–cVEMP is not a sensitive diagnostic tool for early detection of brainstem involvement in patients with ALS. [ABSTRACT FROM AUTHOR]

Background: Signs of brainstem ischemia in children may be subtle, and outcome following basilar artery occlusion is often poor. There currently are no guidelines in children regarding the best methods to diagnose and treat basilar artery occlusion. Methods: Case report and literature review. Results: We describe the presentation and management of recurrent basilar artery occlusion in a previously healthy 5-year-old boy with vertebral artery dissection. Treatment included emergent intra-arterial tPA and mechanical thrombolysis of basilar artery clot, followed by later coiling of the vertebral artery to prevent recurring episodes of basilar artery ischemia. Conclusion: Management of brainstem stroke in children requires coordination of neurology, critical care, and interventional radiology services. Delayed intra-arterial thrombolysis and vertebral artery coiling can be successfully used to treat basilar artery occlusion and prevent the recurrence of brainstem ischemia in children . [ABSTRACT FROM AUTHOR]

The article presents a study which investigates the histopathological changes in the primary brain stem injuries (PBSI) and their diagnostic impact. The study employed statistical package for the social sciences (SPSS) 11.5 software, glial fibrillary acidic protein (GFAP), and amyloid β-protien (MBP) staining. Results revealed various pathological phenomena including segmental thickening and curving, irregular swelling and wave-like processing.

Transarticular screw fixation (TASF) is technically demanding, with high risk of vertebral artery (VA) injury. How to manage intraoperative VA injury and choose optimal alternative fixation becomes a concern of spinal surgeons. In this study, the management strategy for a patient with suspected intraoperative VA injury was analyzed. A 53-year-old woman developed type II odontoid fracture and brain stem injury due to a motor vehicle accident 3 months earlier. After conservative treatments, the brain stem injury improved, but with residual ocular motility defect in the right eye. The odontoid fracture did not achieve fusion with displacement and absorption of fracture fragments. After admission, atlantoaxial fixation using bilateral C1-2 transarticular screws (TASs) combined with C1 laminar hooks was planed. The first TAS was inserted successfully. Unfortunately, suspected VA injury developed during tapping the tract for the second TAS. Considering the previous brain stem injury and that directly inserting the screw to tamponade the hemorrhage might cause VA stenosis or occlusion, we blocked the screw trajectory with bone wax. C2 laminar screw was implanted instead of intended TAS on the injured side. The management strategy for suspected VA injury should depend on intraoperative circumstances and be tailored to patients. Blocking screw trajectory with bone wax is a useful method to stop bleeding. Atlantoaxial fixation using C2 laminar screw and C1-2 TAS combined with C1 laminar hooks is an ideal alternative procedure. [ABSTRACT FROM AUTHOR]

Background: Surgical resection of brainstem lesions has a high risk of morbidity, because vital fasciculi in the brainstem can be damaged along the entry routes. Diffusion tensor imaging (DTI) is an in vivo method for mapping white matter fiber tracts in the brain. Objective: To summarize the experience of surgical treatment of brainstem lesions with the assistance of DTI and fiber tractography. Materials and Methods: A retrospective analysis clinical data of nine patients with brainstem lesions were investigated between July 2007 and September 2009. The analysis included age distribution, clinical presentation, pre- and postoperative modified Rankin score (mRS), and surgical approach. DTI and fiber tractography were used to reconstruct the corticospinal tracts and the medial lemnisci. Results: DTI and fiber tractography showed that most of the corticospinal tracts were compressed anteriorly or anterolaterally, except for one case (posteriorly). All the medial lemnisci were displaced posteriorly or posterolaterally. Individualized surgical approaches were designed according to the information provided by DTI and fiber tractography. Total resection was achieved in two patients with brainstem cavernomas and two patients with pilocytic astrocytoma. Partial resection was performed in the other patients. The neurological functional status was better than preoperative period in eight patients, one patient with medulla oblongata astrocytoma deteriorated. The preoperative average mRS score was 2.22 points. At the time of the last follow-up, the average postoperative score had improved by 0.56 to 1.66 points. Conclusions: DTI and fiber tractography can provide valuable information regarding the relationship between the principal fiber tracts and brainstem lesions, which is useful in neurosurgical planning. [ABSTRACT FROM AUTHOR]

Abstract: The aim of this study was to determine the frequency of brainstem pontomedullar lacerations among fatally injured car occupants in head-on collisions, as well as the concomitant cranial injuries, and to establish a possible underlying mechanism for brainstem laceration. Brainstem pontomedullar lacerations (PML) are often associated with fractures of the skull base (hinge, ring or pyramidal fractures) or with cervical spine fractures. Out of 705 cases of deceased car occupants involved in head-on car collisions, some form of head injury was present in 447 cases (63.4%). These cases included 353 men and 94 women with an average age of 38.2±15.8 years (range 16–89 years). The collected cases included 229 drivers, 164 front-seat and 54 rear-seat passengers. PML were present in 67 of these cases (15%), 50 men and 17 women with an average age of 42.9±15.6 years (range 15–77 years), including 32 drivers, 26 front-seat and 9 rear-seat passengers. In all of these cases the brainstem laceration was partial and the depth varied approximately from 4mm to 8mm. To understand the mechanisms by which PML occurs, we classified the head impact areas into frontal, lateral, posterior and chin area, depending on the injuries to the soft tissue of the head and scalp, as well as facial and cranial fractures. Injury impact area of the head was a good predictor of PML occurrence (χ 2 =131.112, df=3, p =0.000). Chin impact was most often associated with PML—38 cases (Wald. coeff.=5.805, df=1, p =0.016). Presence or absence of mandibular fracture was significant for PML occurrence (χ 2 =11.413, df=1, p =0.001): persons without mandibular fracture have 2.3 times greater risk for PML than those with fracture (odd ratio=7.196). Among the observed skull base fractures, the best predictor of PML was ring fracture (Wald. coeff.=30.729, df=2, p =0.000). Our study showed that PML was present in a significant number of car occupants sustaining head injuries in head-on collisions (15%). Impact to the chin with or without a ring fracture to the skull base most often led to this fatal injury, probably after collision with the dashboard. [Copyright &y& Elsevier]

The article presents an overview of locked in syndrome (LIS) which is a rare neurological disorder that can be caused several factors including a vascular or traumatic injury to the brainstem, certain types of brain tumors and prolonged hypglycemia. A discussion of the symptoms of the syndrome, which include a paralysis of most of the voluntary muscles in a patient's body and an inability to communicate, and of treatments that can be used with patients with the syndrome, is presented.

Abstract: Injury to the cerebellum and brainstem is becoming increasingly recognized in prematurely born infants. The role of infection/inflammation in mediating damage to those structures in the preterm brain is largely unknown. Preterm fetal sheep (70% gestation) received either saline-vehicle (control group; n=11) or Escherichia coli lipopolysaccharide (100 ng intravenous [i.v.]; lipopolysaccharide [LPS] group; n=9), and were allowed to recover for 3 days before sacrifice. A diffuse pattern of cerebellar white matter damage was observed in all animals exposed to LPS, while focal cerebellar white matter lesions were observed in three out of nine animals, and an intragyral white matter hemorrhage in one animal. Cerebellar white matter injury was associated with a statistically significant loss of oligodendrocyte transcription factor-2–positive oligodendrocytes and increased terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling–positive cell counts. Ionized calcium binding adapter molecule 1 (Iba1)–positive cells which had the morphology of activated microglia were commonly observed in areas of injury. There was no obvious injury to the cerebellar cortex or to cerebellar Purkinje cells, and no obvious injury in any region of the brainstem. These data provide support for a role of infection/inflammation in selective white matter injury in the immature cerebellum, and demonstrate a differential vulnerability of the brainstem and cerebellar white matter to injury at this time. [Copyright &y& Elsevier]

Abstract: Background: A different transodontoid screw fixation technique was studied in delayed type II odontoid fractures. This study presents observations on a different transodontoid fixation technique to remove and decrease the amount of sclerotic layers to accelerate the fusion process after the operation. Methods: Ten cases of chronic type II odontoid fractures were operated on via transodontoid screw fixation between 2000 and 2007 which were admitted 6 weeks or later after the trauma. Four of these 10 delayed patients were operated on using a new anterior transodontoid screw fixation technique, whereas the other 6 delayed patients were operated on using classical anterior transodontoid screw fixation. Results: Four delayed cases with type II odontoid fracture operated on via this new technique had good results throughout the minimum 38 months'' follow-up period. We did not observe nonunion, infection, and/or other complications such as vascular or brain-stem injury. Conclusion: Transodontoid screw fixation should be considered as a preferable treatment modality. This surgical intervention may be an alternative to conservative treatment even for cases with delayed type II odontoid fractures. [Copyright &y& Elsevier]