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To evaluate the alterations in brain dynamics in patients suffering from brainstem or cerebellar infarctions and their potential associations with cognitive function. In this study, 37 patients were recruited who had acute cerebellar infarction (CI), 32 patients who had acute brainstem infarction (BsI), and 40 healthy controls (HC). Every participant had their resting-state electroencephalogram (EEG) data captured, and the EEG microstates were analyzed. The cognitive function was measured by the Neuropsychological Cognitive Scale including the Mini-Mental State Examination (MMSE), the Montreal Cognitive Assessment (MoCA), the Boston Naming Test (BNT), the Digit Span Test (Digitspan), and the Symbol Digit Modalities Test (SDMT). Compared with the HC group, the transition probabilities from Microstate A(MsA) and MsD to MsC significantly decreased while the transition probabilities from MsA to MsD and from MsD to MsB significantly increased in the BsI group. By contrast, the CI group showed a significant increase in transition probabilities from MsA and MsD to MsC, whereas the transitions from MsD to MsB significantly decreased. Subgroup analysis within the CI group demonstrated that the CI patients with dizziness showed increased coverage and duration in MsB but decreased MsD occurrence than those of CI patients with vertigo. In addition, the BsI patients with pons infarction performed a decreased transition probability between MsA and MsD than those of BsI patients with medulla oblongata infarctions. Moreover, the changes in Microstate (Ms) were significantly correlated with cognitive scales in patients with CI or BsI. Altered brain dynamics in patients with CI or BsI suggested that disturbances in resting brain networks might play a functional role in the cognitive impairment of the CI or BsI patients. Through the use of microstate analysis, the dizziness or vertigo following CI could be differentiated. These findings may serve as a powerful tool in our future clinical practices. [ABSTRACT FROM AUTHOR]

Background. Lateral medullary syndrome (LMS) is a rare posterior circulation stroke caused by thrombosis or dissection of the vertebral or posterior inferior cerebellar artery (PICA). It results in neurological deficits such as ipsilateral facial pain and temperature deficits, contralateral body pain and temperature deficits, ipsilateral ataxia, vertigo, nystagmus, slurred speech, dysphagia, and hiccups. Case reports. We report the case of a 50-year-old male with uncontrolled hypertension presented with sudden severe vertigo, ataxia, swallowing difficulties, slurred speech, and sensory deficits. He had right-sided facial pain and left-sided body pain. Conclusions. Neurological examination suggested LMS, confirmed by radiological imaging

A 34-year-old patient was admitted with unclear coma and stretch synergisms. CT-imaging was strongly suspicious of basilar artery dissection, this was confirmed on subsequent DSA. The patient was lysed and a complex thrombectomy was performed. Despite sufficient recanalization, the patient unfortunately died shortly after.To the best of our knowledge, this is the first description of an acute basilar artery dissection treated by thrombectomy.

Research has demonstrated that electroacupuncture (EA) stimulation of paralyzed muscles significantly improves nerve regeneration and functional recovery. An 81-year-old man with no history of diabetes mellitus or hypertension presented with a history of brainstem infarction. Initially, the patient had medial rectus palsy in the left eye and diplopia to the right in both eyes, which almost returned to normal after six sessions of EA. The CARE guidelines informed the case study report. The patient was diagnosed with oculomotor nerve palsy (ONP) and photographed to document ONP recovery after treatment. The selected acupuncture points and surgical methods are listed in the table. Pharmacological treatment of oculomotor palsy is not ideal, and its long-term use has side effects. Although acupuncture is a promising treatment for ONP, existing treatments involve many acupuncture points and long cycles, resulting in poor patient compliance. We chose an innovative modality, electrical stimulation of paralyzed muscles, which may be an effective and safe complementary alternative therapy for ONP. [ABSTRACT FROM AUTHOR]

This report proposes a new approach to assess dysarthria in patients with brainstem infarction by involving familiar individuals. Collaboration provides valuable insights compared to subjective traditional methods. A man in his 70s presented with resolved positional vertigo. Standard neurological tests showed no abnormalities, and inquiries with the patient's friend did not reveal voice changes. While inquiring about voice changes with family, friends, and acquaintances is a common practice in clinical settings, our approach involved the patient calling out to his friend from a distance. Despite the physician detecting no abnormalities, the friend noticed a lower voice. Subsequent magnetic resonance imaging (MRI) confirmed brainstem infarction. Early and subtle symptoms of brainstem infarction pose a detection challenge and can lead to serious outcomes if overlooked. This report provides the first evidence that distance calling can detect subtle voice changes associated with brainstem infarction potentially overlooked by conventional neurological examinations, including inquiries with individuals familiar with the patient's voice. Detecting brainstem infarction in emergency department cases is often missed, but conducting MRIs on every patient is not feasible. This simple method may identify patients overlooked by conventional screening who should undergo neuroimaging such as MRI. Further research is needed, and involving non-professionals in assessments could significantly advance the diagnostic process. [ABSTRACT FROM AUTHOR]

Objectives: Magnetic resonance imaging has high sensitivity in detecting early brainstem infarction (EBI). However, MRI is not practical for all patients who present with possible stroke and would lead to delayed treatment. The detection rate of EBI on non-contrast computed tomography (NCCT) is currently very low. Thus, we aimed to develop and validate the radiomics feature-based machine learning models to detect EBI (RMEBIs) on NCCT. Methods: In this retrospective observational study, 355 participants from a multicentre multimodal database established by Huashan Hospital were randomly divided into two data sets: a training cohort (70%) and an internal validation cohort (30%). Fifty-seven participants from the Second Affiliated Hospital of Xuzhou Medical University were included as the external validation cohort. Brainstems were segmented by a radiologist committee on NCCT and 1781 radiomics features were automatically computed. After selecting the relevant features, 7 machine learning models were assessed in the training cohort to predict early brainstem infarction. Accuracy, sensitivity, specificity, positive predictive value, negative predictive value, F1-score, and the area under the receiver operating characteristic curve (AUC) were used to evaluate the performance of the prediction models. Results: The multilayer perceptron (MLP) RMEBI showed the best performance (AUC: 0.99 [95% CI: 0.96–1.00]) in the internal validation cohort. The AUC value in external validation cohort was 0.91 (95% CI: 0.82–0.98). Conclusions: RMEBIs have the potential in routine clinical practice to enable accurate computer-assisted diagnoses of early brainstem infarction in patients with NCCT, which may have important clinical value in reducing therapeutic decision-making time. Key Points: • RMEBIs have the potential to enable accurate diagnoses of early brainstem infarction in patients with NCCT. • RMEBIs are suitable for various multidetector CT scanners. • The patient treatment decision-making time is shortened. [ABSTRACT FROM AUTHOR]

Yuzhi Shi, Zhiyuan Feng, Yi Ju, Zaiqiang Zhang Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of ChinaCorrespondence: Zaiqiang Zhang; Yi Ju, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, People’s Republic of China, Tel +86 1059978000, Fax +86 59975570, Email ttyyzzq@163.com; juyi1226@vip.163.comBackground and Purpose: Cases of pain mimicking trigeminal neuralgia (TN) induced by ischemic stroke in the brainstem have been sparsely reported. The study was to determine the characteristics of symptomatic TN in patients with acute ischemic stroke in the medulla oblongata and pons, and to determine the location of the ischemic lesion associated with the pain.Patients and Methods: A total of 6/21 (28.5%) patients with medullary ischemic stroke and 3/34 (8.8%) patients with pontine ischemic stroke who experienced pain mimicking TN between 1 week before and 2 weeks after the stroke onset were enrolled in the study. All patients accepted neuroimaging examinations to determine the location of the ischemic lesion and the etiology of ischemic stroke. The characteristics of pain were recorded and analyzed.Results: Ischemic lesions of patients who experienced pain mimicking TN were located in the lateral medulla oblongata (n=6), nerve root entry zoo (n=2), and areas involved with the spinal trigeminal tract (n=1) in the pons. Half of the instances of pain induced by medullary ischemic stroke occurred prior to the stroke onset. The branch of V1 was exclusively involved in patients with lateral medullary infarction and the branches of V2 and V3 were typically involved in patients with pontine infarction. The pain was relieved spontaneously (n=4, 44.4%) or was controlled with drugs for neuropathic pain treatment (n=5, 55.5%).Conclusion: Half of the instances of pain induced by medullary ischemic stroke occurred prior to the stroke onset. Pain mimicking TN might be a premonitory symptom of the medullary ischemic stroke. Pain mimicking TN induced by brainstem infarction has a good prognosis.Keywords: trigeminal neuralgia, lateral medullary infarction, pontine infarction, brainstem infarction, ischemic stroke

This report proposes a new approach to assess dysarthria in patients with brainstem infarction by involving familiar individuals. Collaboration provides valuable insights compared to subjective traditional methods. A man in his 70s presented with resolved positional vertigo. Standard neurological tests showed no abnormalities, and inquiries with the patient’s friend did not reveal voice changes. While inquiring about voice changes with family, friends, and acquaintances is a common practice in clinical settings, our approach involved the patient calling out to his friend from a distance. Despite the physician detecting no abnormalities, the friend noticed a lower voice. Subsequent magnetic resonance imaging (MRI) confirmed brainstem infarction. Early and subtle symptoms of brainstem infarction pose a detection challenge and can lead to serious outcomes if overlooked. This report provides the first evidence that distance calling can detect subtle voice changes associated with brainstem infarction potentially overlooked by conventional neurological examinations, including inquiries with individuals familiar with the patient’s voice. Detecting brainstem infarction in emergency department cases is often missed, but conducting MRIs on every patient is not feasible. This simple method may identify patients overlooked by conventional screening who should undergo neuroimaging such as MRI. Further research is needed, and involving non-professionals in assessments could significantly advance the diagnostic process.

Background and purpose: Acute brainstem infarctions can lead to serious functional impairments. We aimed to predict functional outcomes in patients with acute brainstem infarction using deep neuroimaging features extracted by convolutional neural networks (CNNs). Methods: This nationwide multicenter stroke registry study included 1482 patients with acute brainstem infarction. We applied CNNs to automatically extract deep neuroimaging features from diffusion‐weighted imaging. Deep learning models based on clinical features, laboratory features, conventional imaging features (infarct volume, number of infarctions), and deep neuroimaging features were trained to predict functional outcomes at 3 months poststroke. Unfavorable outcome was defined as modified Rankin Scale score of 3 or higher at 3 months. The models were evaluated by comparing the area under the receiver operating characteristic curve (AUC). Results: A model based solely on 14 deep neuroimaging features from CNNs achieved an extremely high AUC of 0.975 (95% confidence interval [CI] = 0.934–0.997) and significantly outperformed the model combining clinical, laboratory, and conventional imaging features (0.772, 95% CI = 0.691–0.847, p < 0.001) in prediction of functional outcomes. The deep neuroimaging model also demonstrated significant improvement over traditional prognostic scores. In an interpretability analysis, the deep neuroimaging features displayed a significant correlation with age, National Institutes of Health Stroke Scale score, infarct volume, and inflammation factors. Conclusions: Deep learning models can successfully extract objective neuroimaging features from the routine radiological data in an automatic manner and aid in predicting the functional outcomes in patients with brainstem infarction at 3 months with very high accuracy. [ABSTRACT FROM AUTHOR]

Background: Vertebral artery dissection (VAD) is a rare but life-threatening condition characterized by tearing of the intimal layer of the vertebral artery, leading to stenosis, occlusion or rupture. The clinical presentation of VAD can be heterogeneous, with common symptoms including headache, dizziness and balance problems. Timely diagnosis and treatment are crucial for favorable outcomes; however, VAD is often missed due to its variable clinical presentation and lack of robust diagnostic guidelines. High-resolution magnetic resonance imaging (HRMRI) has emerged as a reliable diagnostic tool for VAD, providing detailed visualization of vessel wall abnormalities., Case Summary: A young male patient presented with an acute onset of severe headache, vomiting, and seizures, followed by altered consciousness. Imaging studies revealed bilateral VAD, basilar artery thrombosis, multiple brainstem and cerebellar infarcts, and subarachnoid hemorrhage. Digital subtraction angiography (DSA) revealed vertebral artery stenosis but failed to detect the dissection, potentially because intramural thrombosis obscured the VAD. In contrast, HRMRI confirmed the diagnosis by revealing specific signs of dissection. The patient was managed conservatively with antiplatelet therapy and other supportive measures, such as blood pressure control and pain management. After 5 mo of rehabilitation, the patient showed significant improvement in swallowing and limb strength., Conclusion: HR-MRI can provide precise evidence for the identification of VAD., Competing Interests: Conflict-of-interest statement: The authors declare that they have no competing interests., (©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.)

Background and Purpose: Patients with basilar artery (BA) dolichosis are at high risk of acute pontine infarction (API), but the association between BA dolichosis and long–term stroke recurrence has received little attention. We aimed to identify the effect of BA dolichosis on the risk of long–term brainstem infarction recurrence in patients with API. Methods: In this prospective cohort study, we enrolled 113 patients with API admitted to our department. BA dolichosis was diagnosed by a BA curve length >29.5 mm or bending length (BL) >10 mm on magnetic resonance angiography. The primary outcome was the occurrence of diffusion–weighted imaging (DWI)–confirmed brainstem infarction. The Cox proportional hazard model was used to detect possible predictors of brainstem infarction recurrence. Results: Among 113 patients with API, 39 (34.5%) patients had BA dolichosis, and DWI–confirmed brainstem infarction recurred in 15 (13.3%) patients with a mean follow–up time of 31.2 months; the estimated 5–year incidence of brainstem infarction recurrence was 23.1% in patients with BA dolichosis, which was significantly higher than the incidence of 8.1% in patients without BA dolichosis. Cox proportional hazard analysis showed that age ≥65 years (hazard ratio (HR) = 3.341, 95% confidence interval (CI): 1.079–10.348, P = 0.036) and BA dolichosis (HR = 3.048, 95% CI: 1.069–8.693, P = 0.037) were significantly associated with a higher risk of brainstem infarction recurrence. In a subgroup analysis stratified by age, the patients aged ≥65 years with BA dolichosis had a higher risk of brainstem infarction recurrence (HR = 7.319, 95% CI: 1.525–35.123, P = 0.013). Conclusions: This study indicates that BA dolichosis may increase the risk of long–term brainstem infarction recurrence in patients with API, especially in elderly patients, and therefore warrants more attention in clinical practice. [ABSTRACT FROM AUTHOR]

Background and Purpose: Patients with basilar artery (BA) dolichosis are at high risk of acute pontine infarction (API), but the association between BA dolichosis and long–term stroke recurrence has received little attention. We aimed to identify the effect of BA dolichosis on the risk of long–term brainstem infarction recurrence in patients with API.Methods: In this prospective cohort study, we enrolled 113 patients with API admitted to our department. BA dolichosis was diagnosed by a BA curve length >29.5 mm or bending length (BL) >10 mm on magnetic resonance angiography. The primary outcome was the occurrence of diffusion–weighted imaging (DWI)–confirmed brainstem infarction. The Cox proportional hazard model was used to detect possible predictors of brainstem infarction recurrence.Results: Among 113 patients with API, 39 (34.5%) patients had BA dolichosis, and DWI–confirmed brainstem infarction recurred in 15 (13.3%) patients with a mean follow–up time of 31.2 months; the estimated 5–year incidence of brainstem infarction recurrence was 23.1% in patients with BA dolichosis, which was significantly higher than the incidence of 8.1% in patients without BA dolichosis. Cox proportional hazard analysis showed that age ≥65 years (hazard ratio (HR) = 3.341, 95% confidence interval (CI): 1.079–10.348, P = 0.036) and BA dolichosis (HR = 3.048, 95% CI: 1.069–8.693, P = 0.037) were significantly associated with a higher risk of brainstem infarction recurrence. In a subgroup analysis stratified by age, the patients aged ≥65 years with BA dolichosis had a higher risk of brainstem infarction recurrence (HR = 7.319, 95% CI: 1.525–35.123, P = 0.013).Conclusions: This study indicates that BA dolichosis may increase the risk of long–term brainstem infarction recurrence in patients with API, especially in elderly patients, and therefore warrants more attention in clinical practice.

Background: Treating trigeminal neuralgia (TN) caused by a tortuous megadolichoectatic vertebrobasilar artery (VBA) is not uncommon, but may result in adverse events. We report a case of a brainstem infarction, triggered by obstruction of the perforators originating from the huge VBAs, owing to the sling technique. The cistern was too narrowed to pass the sling safely since it was occupied by the huge VBAs. The alternative less invasive and consistent method should be considered in such cases reported. Case description: A 57-year-old man with typical TN caused by compression of huge VBAs was treated using the sling technique by passing a tape through a fenestration near the VBA junction, because no enough space was allowed to pass the sling safely around VBA due to quite narrow superior cerebellopontine cisterns, almost completely occupied by huge VBAs. The small arteries, originating from the huge VBAs could hardly be identified during surgical maneuver. Despite complete relief of the TN, neurological deficit developed, owing to a brainstem infarction evoked by possible obstruction of the VBA perforators and it persisted for approximately 1.5 years. Conclusions: To our knowledge this is a first reported case of an adverse event triggered by the sling technique used during MVD. An incidental obstruction of perforators originating from huge VBAs may induce adverse events, because an identification of perforators from VBA is hardly possible in such cases. Despite the effectiveness of the sling technique in treating TN, surgical procedure is quite complicated, particularly when cisternal space around huge VBAs are too narrow to pass the sling safely. The alternative less invasive and consistent decompression method, such as a use of strong adhesives to mobilize and fix the VBA should be attempted instead of the sling technique to avoid adverse events.

We present a case of pontine infarction caused by subclavian steal phenomenon (SSP) due to subclavian artery stenosis (SAS) and an arteriovenous shunt in the forearm in a 74-year-old man with hemodialysis and stenting for SAS with improvement of SSP. He developed dysarthria during dialysis. He was admitted to our hospital and diagnosed with a pontine infarction. As the basilar artery appeared to be occluded on magnetic resonance angiography, an emergency diagnostic angiography was performed. Aortagram showed severe stenosis of the left subclavian artery. Right vertebral artery (VA) angiogram revealed retrograde arterial blood flow from the right VA to the left VA via the VA union, which suggested SSP. In addition, the steal was augmented by an ipsilateral hemodialysis arteriovenous shunt. Percutaneous subclavian artery stenting was performed 12 days later, and there was no recurrence of symptoms in the follow-up period. To our knowledge, this study is the first to report a patient with SSP who developed a pontine infarction due to SAS and an arteriovenous shunt during hemodialysis and who underwent subclavian artery stenting and had a good outcome., Competing Interests: The authors declare no conflict of interest., (© 2024 The Japan Neurosurgical Society.)

目的 分析血管病相关性眼肌麻痹的病因、临床特点与预后。 方法 回顾性系列病例研究。收集2012年12月-2016年7月在首都医科大学附属北京同仁医院神经内 科就诊的血管病相关性眼肌麻痹住院患者的临床资料，包括临床表现、体格检查、既往史、实验室 和影像学检查结果，随访并记录其眼肌麻痹的缓解时间，对眼肌麻痹患者的病因、临床特点与预后 进行分析。 结果 研究共入组126例患者，结果显示：①微血管缺血性（microvascular ischemic，MVI）病变为血管病 相关性眼肌麻痹最常见的病因（81.7%），其次为脑干梗死（13.5%），动脉瘤、眼肌麻痹性偏头痛、海 绵窦动静脉瘘相对少见。MVI病变和脑干梗死患者中血管危险因素常见高血压、高脂血症、吸烟、糖 尿病和酗酒。②MVI病变累及眼球运动神经比例依次为动眼神经（57.3%）、外展神经（26.2%）、滑 车神经（16.5%）；脑干梗死所致核性眼肌麻痹以动眼神经核最常受累（70.6%）、其次为内侧纵束 （17.6%）。③49.5%血管病相关性眼肌麻痹MVI病变患者可伴有头痛或眼眶周围疼痛。④88.5%血管病 相关性眼肌麻痹MVI病变症状可以缓解，其中50%约在3个月内缓解，75%在6个月内缓解。 结论 MVI病变为血管病相关性眼肌麻痹最常见病因，高血压、高脂血症、吸烟、糖尿病、酗酒是MVI 病变常见危险因素，治疗后大部分MVI病变患者可在半年内恢复。 Abstract: Objective To analyze the etiology, clinical characteristics and prognosis of ophthalmoplegia associated with vascular diseases. Methods It was a retrospective case series study. The clinical data of patients with ophthalmoplegia associated with vascular diseases who received consultation in Beijing Tongren hospital, Capital Medical University from December 2012 to July 2016 were collected, including the clinical manifestations, physical examination, past history of disease, laboratory tests and imaging examinations. The patients were followed up and the remission time of ophthalmoplegia were recorded. The etiology, clinical characteristics and prognosis of ophthalmoplegia were analyzed. Results A total of 126 patients were enrolled into this study. The results were shown as below: (1) Microvascular ischemic (MVI) disease was the most common cause of ophthalmoplegia associated with vascular diseases, accounting for 81.7 percent, followed by brainstem infarction (13.5%), and aneurysm, ophthalmoplegia migraine (OM), cavernous sinus venous fistula were rare causes. The major risk factors of MVI and brainstem infarction were hypertension, hyperlipidemia, smoking, diabetes and alcoholism. (2)The oculomotor nerve was the most common involved nerve(57.3%) by MVI disease of ocular motor nerves,followed by abducens nerve (26.2%), trochlear nerve(16.5%). The ophthalmoplegia caused by brainstem infarction involved the oculomotor nucleus most (70.6%), followed by medial longitudinal fasciculus (17.6%). (3)About 49.5% MVI patients might be associated with headache or periorbital pain. (4)The symptoms of 88.5% MVI could relieve, of which about 50% within 3 months and 75% within 6 months. Conclusion MVI disease is the most common cause of ophthalmoplegia associated with vascular diseases. Hypertension, hyperlipidemia, smoking, diabetes, alcoholism are major risk factors of MVI. Most patients of MVI disease could relieve in 6 months after treatment.

The association of internuclear ophthalmoplegia (INO) with exotropia in the contralateral eye is a rare finding, known as non-paralytic pontine exotropia (NPPE). We report a case of an 80-year-old woman with acute onset of diplopia on admission who presented with left eye exotropia with left-beating nystagmus whilst fixating with the right eye and inability to adduct the right eye on left gaze. Brain magnetic resonance imaging showed two small areas of vertebrobasilar territory ischaemic stroke, one beneath the inferior portion of the aqueduct and another in the right occipital lobe. Our case highlights an interesting clinical manifestation of brainstem infarction that, along with ocular motility examination, allowed us to review its pathophysiology, including the influence of the contralateral paramedian pontine reticular formation stimulation in the mechanism of contralateral exotropia in NPPE. The fast clinical resolution of these cases can explain the scarcity of NPPE reports. [ABSTRACT FROM AUTHOR]

Background: A 54-year-old Thai male who has suffered from multiple episodes of ischemic and hemorrhagic strokes developed facio-oculo-palatal myoclonus (FOPM) 1 month after the latest episode of the brainstem stroke. Phenomenology Shown: The patient presented with semirhythmic, involuntary, horizontal jerky, and rotatory ocular oscillation concomitant with asymmetrical palatal and perioral myoclonus consistent with FOPM. Educational value: FOPM is a useful clinical clue for diagnosing brainstem lesions, specifically in the Guillain–Mollaret triangle. The commonest etiology is cerebrovascular diseases.

Secondary trigeminal neuralgia after brainstem infarction is rare and rarely reported. A patient with secondary trigeminal neuralgia after brainstem infarction was admitted to the Department of Neurosurgery, Xiangya Hospital, Central South University. The patient was a 44 years old male who underwent motor cortex stimulation treatment after admission. The effect was satisfactory in the first week after surgery, but the effect was not satisfactory after one week. This disease is relatively rare and the choice of clinical treatment still requires long-term observation.

Introduction: Research has demonstrated that electroacupuncture (EA) stimulation of paralyzed muscles significantly improves nerve regeneration and functional recovery., Description: An 81-year-old man with no history of diabetes mellitus or hypertension presented with a history of brainstem infarction. Initially, the patient had medial rectus palsy in the left eye and diplopia to the right in both eyes, which almost returned to normal after six sessions of EA., Methods: The CARE guidelines informed the case study report. The patient was diagnosed with oculomotor nerve palsy (ONP) and photographed to document ONP recovery after treatment. The selected acupuncture points and surgical methods are listed in the table., Discussion: Pharmacological treatment of oculomotor palsy is not ideal, and its long-term use has side effects. Although acupuncture is a promising treatment for ONP, existing treatments involve many acupuncture points and long cycles, resulting in poor patient compliance. We chose an innovative modality, electrical stimulation of paralyzed muscles, which may be an effective and safe complementary alternative therapy for ONP., (Copyright © 2023. Published by Elsevier Inc.)

Background Epicrania fugax has been described as a primary headache. Nevertheless, a symptomatic form was recently found in a patient with a skull base meningioma abutting the trigeminal nerve. Here we report on a patient with facial pain with the features of epicrania fugax occurring after Wallenberg's syndrome. Case report A 53-year-old man suffered a right-sided dorsolateral medullary ischaemic stroke. Nine months later, he presented with brief electric shock-like paroxysms of pain stemming from the right eye and radiating to the ipsilateral forehead, the temple or the cheek in a zigzag trajectory. Some episodes were accompanied by ipsilateral conjunctival injection and eyelid oedema. Treatment with eslicarbazepine abolished the pain. Conclusion A pain with the features of epicrania fugax may be associated with medullary lesions. This finding suggests that the central trigeminal pathways and/or the spinal trigeminal nucleus may play an important role in the pathophysiology of this type of pain. [ABSTRACT FROM AUTHOR]

Objective: To study the brainstem auditory evoked potential (BAEP) and its correlation with posterior circulation transient ischemic attack (TIA) and brainsteminfarction. Methods: 46 patients with circulating TIA in our hospital were selected as TIA group, and 44 patients with brainstem infarction during the same period were selected as brainstem infarction group. 49 healthy subjects from the same period were enrolled as healthy group. TIA group and brainstem infarction group were examined by BAEP 1 week after the onset of symptoms, while healthy group underwent BAEP examination during physical examination. I, III, V wave latency (PL) and I-III, III-V, I-V wave latency (IPL) of the three groups were compared. Results: The abnormal rate of BAEP in TIA group, brainstem infarction group and healthy group was 71.74%, 56.82%and 24.49%, respectively. The abnormal rate of BAEP in TIA group was higher than that of the healthy group, and the differences were statistically significant (P < 0.05). The abnormal rate of BAEP in brainstem infarction group was higher than healthy group, and the differences were statistically significant (P < 0.05). The PL I, III, V levels in patients in group TIA were higher than the healthy group, and the difference was statistically significant (P < 0.05). The IPL I-III, III-V, I-V levels in patients in group TIA were higher than the healthy group, and the difference was statistically significant (P < 0.05). The PL I, III, V levels in patients in brainsteminfarction group were higher than the healthy group, and the difference was statistically significant (P < 0.05). The IPL I-III, III-V, I-V levels in patients in brainstem infarction group were higher than the healthy group, and the difference was statistically significant (P < 0.05). The IPL and PL of brainstern infarction group were all obviously higher than TIA group (P < 0.05). Conclusion: BAEP is correlated to posterior circulation TIA and brainstem infarction and are. It is sensitive and one of the best diagnostic methods. [ABSTRACT FROM AUTHOR]

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Venous hemorrhagic infarction is rare but can occur during acoustic neuroma resection [1-5]. We present the case of a 27-year-old male with 1.5 years of progressive headaches, tinnitus, imbalance and hearing loss. Imaging revealed a left Koos 4 acoustic neuroma. The patient underwent a retrosigmoid approach for resection. During surgery, a vein of significant size within the capsule of the tumor was encountered and was necessary to take to proceed with resection. After coagulation of the vein, intraoperative venous congestion with cerebellar edema and hemorrhagic infarction ensued, requiring resection of a portion of the cerebellum. Given the hemorrhagic nature of the tumor, continuing tumor resection was necessary to prevent postoperative hemorrhage. This was carried out until hemostasis was achieved. 85 % resection was achieved, leaving a residual against the brainstem and cisternal course of the facial nerve. Postoperatively, the patient required 5 weeks hospitalization followed by 1 month of rehabilitation. At discharge to rehabilitation, patient had trach, PEG, left House-Brackmann 5 facial weakness, left sided deafness, and right upper extremity hemiparesis (1/5). At 7 months follow up, he continued to have left House-Brackmann 5 facial weakness and left sided deafness but trach and PEG had been removed and strength had improved to 5/5. We demonstrate in this video the unfortunate and rare occurrence of intraoperative venous hemorrhagic infarction during acoustic neuroma resection - particularly for large tumors in young patients - and discuss its etiology and surgical steps that are necessary to partially remedy its devastating impact on the patient. The patient consented to the procedure and participating in this surgical video., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Research on the causes of sudden cardiac arrest (CA) after ischemic stroke, especially disruption of the autonomic nervous system's central control, has recently focused more on the widespread cortical and subcortical network than on autonomic circuits at the spinal and brainstem level. However, no clinical case of sudden CA requiring cardiopulmonary resuscitation (CPR) after brainstem infarction has been reported. We report a case of a 78-year-old woman who died suddenly from a brainstem infarction. Her husband heard a falling sound and found her unresponsive and lying with agonal breathing. The initial cardiac rhythm was pulseless electrical activity confirmed by emergency medical technicians. Recovery of spontaneous circulation was achieved after CPR. Basilar artery occlusion was shown on computed tomography, but no other findings that could have caused CA were found. Targeted temperature management was initiated, but she died on hospital day 22. Brainstem infarction may cause sudden CA; therefore, definitive treatment may achieve better outcomes.

Wall-eyed bilateral internuclear ophthalmoplegia (WEBINO) is an uncommon disorder of ocular motility that possesses a unique spectrum of clinical findings, consisting of primary gaze exotropia, adduction impairment and nystagmus of the abducting eye. WEBINO is a variant of internuclear ophthalmoplegia (INO) sharing similar pathophysiology and aetiologies. Much of the literature published on internuclear ophthalmoplegia and its variants focuses on aetiology and pathophysiology, whereas there has been less information addressing prognosis and management. This review will provide current perspectives on the pathogenesis, prognosis and management of WEBINO syndrome. [ABSTRACT FROM AUTHOR]

Limb-shaking transient ischemic attack (LS-TIA) is a rare clinical manifestation of steno-occlusive carotid lesions. Reports of LS-TIA caused by posterior circulation ischemia are rare. Here, the case of a 56-year-old male patient with a history of epilepsy, who presented with dizziness, nausea and vomiting, is reported. Initial brain magnetic resonance imaging (MRI) indicated no signs of acute ischemia, and the patient's symptoms had not relieved despite drug administration to treat dizziness. During a vestibular function test on the next day, he developed sudden left-limb shaking without disturbance of consciousness or facial twitching. Considering a seizure, an anti-epileptic drug was administered, but no improvement was observed. Eight hours later, the patient experienced left-limb paralysis, and re-examination of the MRI indicated brainstem infarction. The patient recovered well with antiplatelet and antiatherosclerotic therapy. While LS-TIA is a rare manifestation of TIA of the carotid arterial system, posterior circulation ischemia may also manifest as LS-TIA. If a patient presents with limb shaking due to postural changes despite a history of epilepsy, LS-TIA should be highly suspected.

A woman had anosognosia for hemiplegia as a manifestation of brainstem infarction. She had no mental or neuropsychological disturbances, and had involvement of the brainstem in the frontal/parietal-subcortical circuits to the right cerebral hemisphere. Brainstem lesions that disrupt frontal/parietal-subcortical areas may affect anosognosia for hemiplegia.

Background: The purpose of this study is to compare the patterns of voiding dysfunction according to the locations of brainstem lesions. Methods: Between November 2008 and December 2011, a total of 30 patients participated in this study. All 30 subjects, consisting of 16 men and 14 women, aged between 41 and 82 years (mean age, 63.0 ± 11.0 years) underwent a urodynamic study within 7 days after the onset of a stroke. Results: Twenty-one (70%) patients had a pontine lesion and 9 (30%) had a medullary lesion. Fourteen of these patients (46.7%) had bladder storage disorder, 7 patients (23.3%) had bladder emptying disorder, and 9 patients (30%) had a normal report. Five of the patients who had a medullary lesion (55.6%) had bladder emptying disorder, whereas only 2 patients who had a pontine lesion (9.5%) had bladder emptying disorder. Thirteen patients who had a pontine lesion (61.9%) showed bladder storage disorder. Discussion: The descending pathway from the midbrain tegmentum is inhibitory, and the pathway from the pontine tegmentum is stimulatory. Because of their location pontine lesions could disrupt the descending fibers of the midbrain tegmentum and medullary lesions could disrupt the descending fibers of the pontine tegmentum. Copyright © 2013 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Vertebral artery hypoplasia is not currently considered an independent risk factor for stroke. Emerging evidence suggest that vertebral artery hypoplasia may contribute to posterior circulation ischemic events, especially when other risk factors coexist. In the present literature review, we present published data to discuss the relationship between a hypoplastic vertebral artery and posterior circulation cerebral ischemia. Despite difficulties and controversies in the accurate definition and prevalence estimation of vertebral artery hypoplasia, ultrasound studies reveal that the reduced blood flow observed ipsilateral to the hypoplastic vertebral artery may result in local cerebral hypoperfusion and subsequent focal neurological symptomatology. That risk of cerebral ischemia is related to the severity of the hypoplasia, suggesting that the smaller of paired arteries are more vulnerable to occlusion. Existing cohort studies further support clinical observations that hypoplastic vertebral artery enhances synergistically the vascular risk for posterior circulation ischemic events and is closely associated with both atherosclerotic and prothrombotic processes. Copyright © 2013 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Bilateral infarction of the medial medulla (MMI) is rare. Limited information is available on clinical characteristics, etiology, and prognosis. High-resolution neuroimaging has a major role in elucidating the underlying stroke mechanism. The aim of this systematic review was to analyze the clinical presentations, stroke mechanisms, and outcomes in patients with bilateral MMI. We performed a systematic review of the literature from 1992-2011 that reported on clinical presentations, stroke mechanism, and/or outcomes in patients with magnetic resonance imaging–proven bilateral MMI. Medline, EMBASE, and Web of Science Scholars Portal were searched without language restriction. Two reviewers independently assessed identified studies to determine eligibility, validity, and quality. The primary outcome was inpatient mortality; a secondary outcome was case fatality at 12 months. We identified 138 articles from Medline, EMBASE, and Scholars Portal including the MeSH terms “brainstem infarction,” “medulla,” and “bilateral.” Twenty-nine articles met our inclusion criteria, including a total of 38 cases with bilateral MMI, and included in our study. These 38 patients had a mean age of 62.2 years and were predominately male (74.2%). The most common clinical presentations were motor weakness in 78.4%, dysarthria in 48.6%, and hypoglossal palsy in 40.5%. The most common vascular pathology was vertebral artery atherosclerosis, in 38.5%. The clinical outcome was poor (mortality, 23.8%; dependency, 61.9%). Bilateral medial medullary infarction is a rare stroke syndrome. Clinical presentations were mostly rostral medullary lesions. Large-artery atherosclerosis and branch disease were the most common stroke mechanisms. The clinical outcome was usually poor. [Copyright &y& Elsevier]

Background: The goal of the study was to clarify the association between diabetes mellitus (DM) and brainstem infarctions (BSIs) and to investigate the clinicotopographic characteristics of BSIs in patients with diabetes. Methods: Data were retrospectively reviewed for 1026 consecutive patients admitted to our hospital because of acute cerebral infarctions from January 2004 to August 2010. Acute symptomatic BSIs were explored on radiologic images and classified into multiple infarctions with BSIs, multifocal BSIs, and monofocal BSIs. Isolated BSIs were further classified based on the vertical distribution into midbrain, pontine, and medullary infarctions, and on the horizontal distribution into anterior-dominant, posterior-dominant, and anterior/posterior BSIs. Neurologic symptoms of BSIs and clinical background were compared between DM and non-DM patients. Results: The prevalence of BSIs was 2.6-fold higher (P < .0001) in DM patients. Logistic regression analysis including age, sex, smoking, previous stroke, atrial fibrillation, other cardiac diseases, hypertension, hyperlipidemia, and DM showed that DM was independently associated with BSIs (odds ratio [OR] 2.814; 95% confidence interval [CI] 1.936-4.090; P < .0001). Compared with non-DM patients, DM patients showed more frequent monofocal BSIs (P < .0001) and multifocal BSIs (P = .0296). Monofocal BSIs (n = 114) more frequently involved the pons (P < .0001) and medulla (P = .0212). Anterior-dominant BSIs (P < .0001) were more common in DM patients than in non-DM patients. Symptoms of BSIs included more frequent motor paresis (P = .0180) and less frequent diplopia (P = .0298) in DM patients than in non-DM patients. Conclusions: DM is important in the development of BSIs, and the associated clinical characteristics include more frequent motor paresis and less frequent diplopia. [Copyright &y& Elsevier]

The usefulness of diffusion-weighted magnetic resonance imaging studies in pupil-sparing oculomotor nerve palsy due to midbrain infarction is illustrated in two interventional case reports. Two cases are presented illustrating the superior sensitivity of diffusion-weighted magnetic resonance imaging in detecting midbrain infarction in this clinical situation. [ABSTRACT FROM AUTHOR]

Traumatic intracranial vertebral artery injury is a relatively rare but potentially fatal disease. We present a case of a 63-year-old man who presented with sudden onset of loss of consciousness after hitting his head. After immediate resuscitation, he showed quadriplegia and absence of spontaneous breathing. Brain and cervical spine magnetic resonance imaging revealed an atlantoaxial subluxation, fractured C2 odontoid process, left vertebral artery occlusion, and bilateral extensive ischemia in the medulla oblongata and high cervical spinal cord. Digital subtraction angiography demonstrated left vertebral artery dissection just below the level of vertebral body C2. [ABSTRACT FROM AUTHOR]

Symptomatic trigeminal neuralgia due to a brainstem infarction is said to be rare. However, facial pain is not uncommon in Wallenberg's syndrome. Facial pain related to a Wallenberg's syndrome may be either persistent of intermittent, and occasionally occurs in brief attacks. Here, we report a patient with a right lateral medullary infarction who started having first division trigeminal neuralgia 1 month after the stroke. The pain paroxysms were suppressed with gabapentin. [ABSTRACT FROM AUTHOR]

The relationships among diabetes mellitus (DM), brainstem infarctions (BSIs) and involvement of the basilar artery (BA) were investigated in 254 patients with acute cerebral infarctions detected on magnetic resonance (MR) imaging. Radiological findings included lesion topography and size (mm2) of BSIs on MR images, and the extent of BA stenosis measured by MR angiography. Adjusted logistic regression analyses showed that DM (OR 4.018; p = 0.0006) and BA stenosis (OR 1.003 per 1 mm; p < 0.0001) had an independent association with the incidence of BSIs, but the lesion size of the BSIs was only associated with BA stenosis (β coefficient 0.280; p < 0.0001). Diabetic patients showed significantly more frequent isolated pontine infarctions and a lesser degree of BA stenosis (p < 0.005) compared to non-diabetic patients. Preferential involvement of the pons and smaller vessels may be characteristics of diabetic patients. Copyright © 2010 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

In comparison with the lateral (Wallenberg), medial (Dejerine) and hemimedullary (Reinhold) medulla oblongata syndromes, the Babinski-Nageotte and Cestan-Chenais syndromes are much less familiar cerebrovascular disorders. While the Babinski-Nageotte syndrome is usually confused with the hemimedullary syndrome, reports of the extremely rare Cestan-Chenais syndrome are missing from the modern neurological literature. The pathological and magnetic resonance imaging (MRI) correlations of the Cestan-Chenais syndrome have not been shown so far. We compared clinical and MRI features of two patients exhibiting classical Babinski-Nageotte and Cestan-Chenais syndromes according to their original descriptions with those of three patients with lateral, medial and hemimedullary syndromes. Our study shows that Babinski-Nageotte syndrome includes all symptoms of the Wallenberg syndrome and additionally contralateral hemiparesis due to a spreading of the “Wallenbergian” lateral lesion to the pyramidal tract. The Cestan-Chenais syndrome includes all symptoms of the Babinski-Nageotte syndrome with the exception of the ipsilateral cerebellary hemiataxia because of sparing of the posterior spinocerebellar tract. The Babinski-Nageotte syndrome is neither clinically nor on MRI identical with hemimedullary syndrome. Hypoglossal palsy, an invariable symptom of hemimedullary lesion is not part of the Babinski-Nageotte syndrome. The contralateral hypesthesia is dissociated in the Babinski-Nageotte syndrome. The Babinski-Nageotte and Cestan-Chenais syndromes are intermediolateral medullary syndromes with all (Babinski-Nageotte) or nearly all (Cestan-Chenais) features of the lateral and some features of the medial medulla oblongata syndromes. [ABSTRACT FROM AUTHOR]