Isolated lateral thalamic infarction: the role of posterior cerebral artery disease

Background and purpose: Lateral thalamic infarction (LTI) is usually caused by small vessel disease (SVD), i.e., occlusion of the deep perforator. However, focal atherosclerotic posterior cerebral artery disease (PCAD) may produce LTI via thrombotic occlusion of the perforator. We aimed to investigate the prevalence of PCAD in LTI and differences in clinical and imaging findings between LTIs associated with PCAD and SVD. Methods: We retrospectively evaluated 58 consecutive patients with isolated LTI who underwent diffusion‐weighted imaging (DWI) and MR angiography (MRA) within 7 days after stroke onset. Patients were divided into two groups: those with PCAD and those with SVD. Clinical syndromes were divided into pure sensory stroke (PSS) and sensory stroke plus (SS‐plus), i.e., the concomitant presence of motor dysfunction or ataxia. Clinical and imaging findings were compared between these two groups. Results: Of the 58 patients, 13 (22.4%) had PCAD. PSS was more frequently associated with SVD than with PCAD (57.8% vs. 23.1%, P = 0.032). Initial DWI lesion volume (cm³) was significantly larger in PCAD than in patients with SVD (0.38 ± 0.13 vs. 0.33 ± 0.22, P = 0.025). Among the 23 patients (39.7%) who underwent follow‐up DWI, patients with PCAD showed a significantly greater increase in subacute lesion volume than those with SVD (P = 0.019). Although National Institutes of Health Stroke Scale scores did not differ at admission (P = 0.185), they were significantly higher at discharge in PCAD than in patients with SVD (P = 0.012). Conclusions: Our data suggest that PCAD is an important cause of LTI, being related to SS‐plus, larger lesion volume, and worse clinical outcomes.     

Medial posterior choroidal artery territory infarction associated with tumor removal in the pineal/tectum/thalamus region through the occipital transtentorial approach

Object

Damage to the deep venous system, occipital lobe, and/or corpus callosum is well known to cause complications associated with the occipital transtentorial approach (OTA), but ischemic complications are not well documented. The authors investigated the high incidences of ischemic complications associated with removal of pineal/tectal/thalamic tumors through the OTA.

Methods

Clinical records of 29 patients who underwent 31 surgeries using the OTA from December 2001 to May 2011 were retrospectively studied. Tumor locations were the pineal/tectal/thalamic region for 19, cerebellum for 7, and medial temporal lobe for 3.

Results

Postoperative diffusion-weighted magnetic resonance images obtained within 72 h after surgery detected infarction in the tectal/splenial/thalamic region, presumably representing the medial posterior choroidal artery (MPChA) territory, in 10 patients. All these patients had tumor in the pineal/tectal/thalamic region. Deteriorated or newly developed eye symptoms including vertical gaze palsy tended to persist in these patients compared to those without ischemic complications.

Conclusions

A relatively high incidence of MPChA territory infarction was associated with removal of tumors in the pineal/tectal/thalamic region through the OTA. Eye symptoms often occurred post-surgery and tended to persist in these patients. Neurosurgeons must be aware of the possibility of MPChA territory infarction to further increase the safety of the OTA.     

A new view of anterior choroidal artery territory infarction

Summary Infarction in the territory of the anterior choroidal artery (AchA) has been the subject of several recent reports. To the classical clinical syndrome of hemimotor, hemisensory, and visual field deficit has been added hemiataxia acute pseudobulbar mutism, pure motor and pure sensory syndromes and disorders of higher cortical function. The definition of anatomic and clinical correlates to AchA stroke is aided by CT-MRI findings and reveals an unexpected superior extension of infarct to include the periventricular caudate nucleus and inferior corona radiata. Prognosis depends upon unilaterality, bilateral strokes having often a fatal outcome. Etiology and treatment may be intimately related to hypertension.     

A case of lateral medullary infarction after endovascular trapping of the vertebral artery dissecting aneurysm

We report an unusual case of lateral medullary infarction after successful embolization of the vertebral artery dissecting aneurysm (VADA). A 49-year-old man who had no noteworthy previous medical history was admitted to our hospital with a severe headache. Computed tomography (CT) revealed a subarachnoid hemorrhage, located in the basal cistern and posterior fossa. Cerebral angiography showed a VADA, that did not involve the origin of the posterior inferior cerebellar artery (PICA). We treated this aneurysm via endovascular trapping of the vertebral artery distal to the PICA. After operation, CT revealed post-hemorrhagic hydrocephalus, which we resolved with a permanent ventriculoperitoneal shunt procedure. Postoperatively, the patient experienced transient mild hoarsness and dysphagia. Magnetic resonance image (MRI) showed a small infarction in the right side of the medulla. The patient recovered well, though he still had some residual symptom of dysphagia at discharge. Such an event is uncommon but can be a major clinical concern. Further investigation to reveal risk factors and/or causative mechanisms for the medullary infarction after successful endovascular trapping of the VADA are sorely needed, to minimize such a complication.     

Anterior choroidal artery infarction: a clinical, etiologic and prognostic study

Objectives –  To analyze the clinical, etiologic and prognostic profile of anterior choroidal artery (AChA) infarcts.
Methods –  42 consecutive patients with AChA infarction were included. Symptoms, etiology and scores on neurological and functional scales were analyzed on admission, discharge and at 3-month follow-up. A comparative study was performed between deep ( n  = 23) and deep + superficial ( n  = 19) infarcts.
Results –  Lacunar syndrome was present in 83.3% of patients. Etiology was large-vessel disease in 38.1% and cryptogenic in 38.1%. Ten patients had a National Institute of Health Stroke Scale score >7 on admission. At discharge, 45.3% had an modified Rankin Scale >2 (35.7% after 3 months). Infarcts involving superficial territory were more severe at admission ( P  = 0.034) and were associated with a worse functional status at discharge ( P  = 0.0008).
Conclusion –  AChA infarcts usually present with lacunar syndrome, although they are often not lacunar infarcts. At discharge, almost half of the patients are dependent in their activities of daily living, and most remain so at 3-month follow-up. Infarcts involving superficial territory are associated with worse prognosis.     

Bilateral posterior medullary and cervical stroke: a case report

Abstract Spinal strokes are often localised in the anterior spinal artery territory, whereas an involvement of the posterior spinal arteries (PSA) is uncommon, and usually unilateral. Bilateral PSA stroke is exceptional. A 70-year-old woman, after a mild head trauma, presented with cervical pain, left hypoaesthesia and sensitive ataxia, which then extended to the right hemibody, including face. A Doppler ultrasound showed an only systolic flow signal in the left vertebral artery (VA). MR showed a bilateral infarction extending from the posterior medulla oblongata to C4 and a left hypoplasic VA with lack of visualisation of the V3 segment. This case was peculiar, implying a bilateral stroke in the PSA territory, possibly related to a left VA dissection, and in the presence of a dominant PSA, originating from the hypoplasic VA and of hyposupply of posterior radiculomedullary arteries and anastomoses.     

Isolated medial medullary infarction due to vertebral artery dissection

Abstract. A 54-year-old man developed left hemiparesis and tactile and deep sensory disturbance following onset of rightside cervical pain. These symptoms resulted from an isolated infarct in the right medial area of the upper medulla oblongata and intracranial vertebral artery (VA) dissection. Atherosclerotic disease of the VA is the most common cause of medial medullary infarction. In past reports of isolated medial medullary infarction, only a few cases involved VA dissection.     

Recurrent cerebral infarction in anterior and posterior circulation territories associated with persistent primitive hypoglossal artery and carotid artery dissection: a case report

The persistent primitive hypoglossal artery (PPHA) is the second most common persistent carotid-vertebrobasilar anastomosis. We present a rare case of an 82-year-old woman who diagnosed as acute cerebral infarction three times in both the anterior and posterior circulation territories with a right-sided PPHA and ipsilateral carotid artery dissection (CAD). Microembolus monitoring results suggested that microembolic caused by CAD associated with PPHA should be recognized as a possible cause of multiple infarctions in both the anterior and posterior circulation territories. For these patients, appropriate treatment measures should be taken for prevention of stroke recurrence.     

表现为孤立性眩晕的大脑中动脉穿支梗死

目的孤立性眩晕主要见于前庭周围性病变,罕见于大脑中动脉(MCA)穿支脑梗死,本文探讨MCA穿支梗死出现孤立性眩晕与头晕的临床特征。方法报道3例表现为孤立性眩晕和头晕的MCA穿支急性腔隙性脑梗死患者的临床表现、影像学资料,同时通过PubMed检索之前报道的病例,回顾总结其临床特征。结果包括文献共5例表现为眩晕和头晕的MCA穿支梗死病例。3例表现为孤立性眩晕和头晕,1例表现为持续性头晕伴随短暂性言语不清,1例有轻偏瘫,2例有眼球震颤。眩晕与头晕严重程度均为中度,经治疗后眩晕和头晕多在病程7 d内完全缓解。4例梗死灶位于左侧内囊或放射冠区,1例位于右侧放射冠。颈部及头部增强血管成像有2例显示右侧椎动脉纤细狭窄,4例完成了头部增强CTA检查均提示前循环血管正常。本文3例患者在核磁共振成像(MRI)检查证实为急性腔隙性脑梗死之前,均未有明确诊断。结论 MCA穿支脑梗死可以表现为孤立性眩晕和头晕,严重程度较轻,持续时间通常数日,自主神经症状不明显。为了避免漏诊或误诊,推荐神经影像学检查,特别是MRI弥散成像(DWI)可作为老年首次眩晕和头晕的常规检查项目。     

基底动脉动脉瘤合并胚胎型大脑后动脉自发性闭塞的诊治分析(附1例报道并文献复习)

目的 总结基底动脉动脉瘤合并胚胎型大脑后动脉（FPCA）自发性闭塞致枕叶梗死的诊治经验,以提高此类疾病的认识,避免将FPCA残端误诊为动脉瘤。方法 回顾性分析1例基底动脉动脉瘤合并FPCA自发性闭塞致枕叶梗死的临床资料。结果 病人以突发右上肢麻木及视物模糊起病,外院DWI显示左侧枕叶内侧面梗死伴左侧丘脑灶样梗死,外院头颈部CTA示左侧颈内动脉后交通动脉动脉瘤（呈梭形）、基底动脉动脉瘤以及颅内多发血管硬化狭窄。我院左侧颈内动脉造影见左侧后交通动脉闭塞残端,残端远端可见中断后又部分显影,左侧大脑后动脉P1、P2均闭塞,椎动脉造影未见P1段发育,基底动脉中段动脉瘤。结合病人DWI梗死部位及术前灌注成像所示灌注失代偿区,考虑为左侧FPCA急性闭塞引起同侧枕叶梗死,CTA所谓的“梭样动脉瘤”其实为闭塞后的残端。采用双支架套叠辅助弹簧圈栓塞治疗基底动脉中段动脉瘤,出院时改良Rankin量表评分1分。结论 FPCA自发性闭塞临床极其罕见,急性闭塞后是否行血管内治疗依然存在争议;应加强对其影像学特征的认识和了解,以避免将其闭塞后残端误当做动脉瘤。     

Isolated hypoglossal nerve palsy due to an anomalous vertebral artery course: report of two cases

The authors report two patients with isolated unilateral tongue atrophy. Magnetic resonance imaging (MRI) of the brain stem and angio-MRI demonstrated a dolichovertebral artery with an abnormal course compressing the medulla oblongata at the emergence of the hypoglossal rootlets. The semeiological observation of a sectorial and not uniform distribution of atrophy in the half-affected tongue is discussed in relation to the lesional site.

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Sommario Gli Autori descrivono due pazienti affetti da isolata atrofia monolaterale della lingua. La risonanza magnetica nucleare del troncoencefalo e l'angiografia a risonanza magnetica dimostrarono la presenza di una arteria vertebrale con anomalo decorso tortuoso the determinava compressione del bulbo a livello dell'emergenza delle radicole del nervo ipoglosso. L'osservazione semeiologica di una distribuzione settoriale e non uniforme dell'atrofia nella metà affetta della lingua viene discussa in relazione alla sede della lesione.

     

Dissecting aneurysms of the posterior inferior cerebellar artery: report of four cases and review of the literature

Dissecting aneurysms frequently involve the vertebral arteries and their branches, but those exclusively on the posterior inferior cerebellar artery (PICA) represent only 24 cases in the literature, including the four cases discussed in this article. The clinical diagnosis lacks pathognomonic signs or symptoms, with presentations such as subarachnoid haemorrhage or ischaemia of the brain stem or the cerebellum, and the management is controversial. Wrapping, clipping and embolisation of the aneurysms were tried in this series with different outcomes. Exclusion of the pathological segment should be performed, as shown by rebleeding from our case which was wrapped or by progression of the vascular disease in cases where treatment was delayed. Surgical or endovascular occlusion are well tolerated in our cases and in those reported from the literature, which implies the absence of normal perforating branches to the brain stem arising from the proximal dissected segment of the PICA and a good collateral circulation. A revascularisation procedure using the occipital artery can be performed in order to prevent infarction if an endovascular test occlusion is not tolerated.     

甲状腺功能亢进症合并颅内动脉痉挛致脑梗死一例

正患者男性,28岁。主因头痛1月余伴言语不清、右侧肢体无力18 h,于2014年10月9日入院。患者入院前1个月出现左侧额顶部憋闷性头痛,呈无规律间歇性发作,最长持续约30 min。当地医院头部MRI显示,左侧额顶叶片状长T1、长T2信号、FLAIR成像高信号(图1),病灶明显强化(图2);MRA可见左侧大脑中动脉水平段局限性狭窄(图3)。临床诊断为脑梗死。经阿司匹林200 mg/d抗血小板、改善循环并神经营养治疗(具体方案不详),症状好转。入院前18 h因甲状腺功能亢进症予放     

Comparison of the configuration of the posterior bifurcation of the posterior communicating artery between fetal and adult brains: A study of a Sri Lankan population

Objective:

The purpose of this study was to examine the degree of contribution from the vertebrobasilar and carotid systems to the origin of the PCA in fetal autopsy brains of last trimester of pregnancy and to compare with published data on the configuration of adult and fetal brains in a population of Sri Lankan origin.

Materials and Methods:

The external diameter of the PcomA, pre-communicating part (P1), and the post-communicating part (P2) of posterior cerebral artery (PCA) of 34 fetal brain in the last trimester of pregnancy (30 to 40 weeks of gestation) was measured using a stereomicroscope equipped with a micrometer calibrator.

Results:

The blood supply to the occipital lobe mainly via the PCA was seen in 25 (59%) of fetal brains as compared to that in the literature 220 (93%) in adults brains and the blood supply to the occipital lobe mainly via the internal carotid artery (ICA) was seen in 16 (34%) of fetal brains as compared to 25 (7%) of adults brains (P < 0.0001), transitional configuration where the PcomA is equal in diameter to P1 segment of the PCA was seen in 5 (7.4%) of fetal brains and 8 (2%) of adults brains.

Conclusions:

The present study reveals that from the newborn to the adult there is shift from carotid system to the vertebrobasilar system, this justifies further studies on different racial and geographic regions which may give a clearer picture about the cerebral hemodynamics from childhood to adult.     

1例以双侧展神经麻痹为首发症状的双侧颈内-后交通支动脉瘤报告

1 病例介绍患者男性,58岁,主因“视物成双1周”入院.患者于入院前1周,无明显诱因出现视物成双,虚像与实像呈水平排列,无头晕、头痛,无恶心、呕吐,无视物不清及旋转,无耳聋、耳鸣,无言语及吞咽障碍,无肢体活动及感觉障碍,无意识不清及抽搐,无二便障碍,外院眼科检查提示双侧眼球外展差,行头核磁平扫检查未见异常,为求进一步诊疗人院.