Cerebellar infarction in the superior cerebellar artery distribution

Three patients with CT and angiographic documentation of cerebellar infarction in the superior cerebellar artery distribution had ataxic gait with little or no vertigo. Limb ataxia occurred in two patients. Transient chorea and signs of pontine infarction were also noted. CT demonstrated infarcts on the upper surface of a cerebellar hemisphere and/or vermis. Angiograms disclosed occlusion of the top of the basilar artery in two cases and distal superior cerebellar artery (SCA) branches in one. One patient later died after distal basilar artery occlusion; the others recovered.     

Cerebellar infarction in the territory of the superior cerebellar artery in children

Posterior circulation infarction is uncommon in children. Vertebral artery dissection is an unusual cause of posterior circulation infarction in children. We report on a 12-year-old boy with spontaneous left-extracranial vertebral artery dissection associated with isolated ipsilateral superior cerebellar artery territory infarction, diagnosed clinically and by brain computed tomography, magnetic resonance imaging, and magnetic resonance angiography. Cerebral angiography demonstrated a flame-like occlusion of the left vertebral artery at level C(2)-C(3), and indicated that artery-to-artery embolus may be a mechanism of superior cerebellar artery territory infarction. We emphasize that vertebral artery dissection should be considered in a child with acute signs of posterior circulation ischemia.     

Cerebellar infarction in the territory of the superior cerebellar artery: a clinicopathologic study of 33 cases

We reviewed the clinical and pathologic findings in 33 patients with infarcts in the territory of the superior cerebellar artery (SCA). The clinical manifestations included the rostral basilar artery syndrome (8); coma at onset, often with tetraplegia (11); cerebellar and vestibular signs (9, with delayed coma due to cerebellar swelling in 6); and, in only 1 patient, the "classic" syndrome of the SCA. Clinical features were overshadowed by an infarct in the territory of the middle cerebral artery in 3 other patients, and the diagnosis was made only at autopsy in a fourth. Pathologically, SCA infarcts occurred in isolation in 7 patients. The most striking finding was the high frequency of associated infarcts in the territory of the rostral part of the basilar artery (73%). One-third of patients also had an infarct in the territory of the posterior inferior cerebellar artery, sometimes associated with infarction of the anterior inferior cerebellar artery. Tonsillar herniation was observed in 15 patients, 8 of whom had no infarcts in other cerebellar territories. Occlusions occurred mainly in the distal basilar artery and distal vertebral artery. The infarcts were mostly caused by cardiac and artery-to-artery emboli.     

Cerebellar infarction in the territory of the medial branch of the superior cerebellar artery

The authors studied 14 patients with an isolated cerebellar infarct in the territory of the medial branch of the superior cerebellar artery (MSCA). The most common clinical finding was severe gait ataxia with sudden falling (n = 9) or severe veering (n = 2). Cerebellar dysarthria was found in 8 patients. Eight patients had a mild unilateral limb ataxia. These findings emphasize that MSCA territory cerebellar infarction presented with the prominent gait ataxia and cerebellar dysarthria.     

Bilateral simultaneous cerebellar infarction in the medial branches of the posterior inferior cerebellar artery territories

We present an unusual case of simultaneous bilateral cerebellar infarction in the territory of the medial and intermediate branches of the posterior inferior cerebellar arteries (mPICA). The patient, a 57-yr old woman, had no risk factors for cerebrovascular disease but a long-standing hypertension. Pathogenetic hypotheses of this unusual ischemic site of lesion may be referred to: A) two PICAs arising from an occluded basilar artery; B) both medial branches arising from the same PICA on one side; C) a haemodynamic mechanism with hypoperfusion in the most peripheral branches of the arteries; D) a double, simultaneous embolic stroke in mPICAs territory. Based on clinical course, supraortic duplex-scan, echocardiography, MRI, angioMRI and CT scans, and digital subtraction angiography, none of these hypotheses could be clearly associated with the pathogenesis of the lesion. Nevertheless, we propose that an anomalous common mPICA for both cerebellar territories should represent the necessary condition for the ischemic insult and, simultaneously, other factors should intervene as possible determining events.

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Sommario Descriviamo il caso di un infarto bilaterale nel territorio delle branche mediali della arteria cerebellare postero inferiore (mPICA). La paziente, una donna di 57 anni, non aveva fattori di rischio per cerebropatia vascolare, eccettuata una lunga storia di ipertensione arteriosa. Sono state formulate diverse ipotesi patogenetiche in grado di giustificare questo inusuale sito di lesione: A) due PICA che originino da una arteria basilare occlusa; B) entrambe le branche mediali che originino dalla stessa PICA in un lato; C) una genesi emodinamica con una ipoperfusione nelle branche più periferiche delle arterie; D) un doppio simultaneo stroke embolico nel territorio delle mPICA. Sulla base del decorso clinico e degli esami strumentali (Ecodoppler dei vv. epiaortici, ecocardiogramma, RM, angioRM, TC ed angiografia digitale intrarteriosa) nessuna di queste ipotesi può essere singolarmente considerata come responsabile della lesione. Proponiamo, quindi, che una anastomosi tra le PICA debba rappresentare la necessaria predisponente condizione sulla quale siano poi intervenuti ulteriori fattori determinanti l'evento ischemico acuto.

     

后颅窝枕下减压术治疗大面积小脑梗死的预后分析

目的分析后颅窝枕下减压术治疗大面积小脑梗死的手术时机、手术方式及预后。 方法回顾性分析济南军区总医院神经外科自2010年1月至2018年2月符合纳入标准的大面积小脑梗死患者的临床资料。所有患者于CT及MRI检查确诊后24 h内行后颅窝枕下减压术,如有急性脑积水发生,先行脑室外引流术,再进行后颅窝枕下减压术。 结果本组患者12例,术前CT显示出现脑积水者4例,先行脑室穿刺外引流术,后行颅窝减压术。根据GOS评分评价患者外科治疗效果：良好7例,中残2例,重残1例,植物生存1例,死亡1例。 结论后颅窝减压术能避免大面积小脑梗死临床症状恶化进行性发展,改善预后。     

Dissecting aneurysm of the posterior cerebellar artery

Dissecting aneurysms affecting exclusively to the posterior inferior cerebellar artery (PICA) are rare entities. Depending on the dissecting plane of the arterial wall, the clinical manifestations are subarachnoid hemorrhage (SAH) due to rupture or ischemia caused by stenosis or occlusion. Angiographic findings are fusiform dilatation with a narrowing of various degrees proximal to and distal to the fusiform lesion. Magnetic resonance imaging (MRI) can be useful demonstrating the intramural hematoma. We report a 47-year-old man who suffered from SAH. He was neurologicaly intact and vertebral angiography demonstrated and fusiform aneurysm at the origin of the left PICA. He was operated by trapping of the dissecting segment. The patient's postoperative course was uneventful despite of severe vasospasm showed in follow up angiography. Aggressive treatment has been recommended for dissecting aneurysms of the PICA and specially for those presenting with SAH. Both the surgical and endovascular procedures are effective and with good results.     

Anterior and posterior inferior cerebellar artery infarction with sudden deafness and vertigo

We report a patient with anterior and posterior inferior cerebellar artery infarction, which manifested as profound deafness, transient vertigo, and minimal cerebellar signs. We suspect that ischaemia of the left internal auditory artery, which originates from the anterior inferior cerebellar artery, caused the deafness and transient vertigo. A small lesion in the middle cerebellar peduncle in the anterior inferior cerebellar artery territory and no lesion in the dentate nucleus in the posterior inferior cerebellar artery territory are thought to explain the minimal cerebellar signs despite the relatively large size of the infarction. Thus a relatively large infarction of the vertebral-basilar territory can manifest as sudden deafness with vertigo. Neuroimaging, including magnetic resonance imaging, is strongly recommended for patients with sudden deafness and vertigo to exclude infarction of the vertebral-basilar artery territory.     

Fenestration of the posterior inferior cerebellar artery

Fenestration of the posterior inferior cerebellar artery (PICA) is exceedingly rare. Only one known example – a right PICA fenestration, has been documented in the peer-reviewed literature. A left-sided PICA fenestration is presented in this unique case illustration.     

Acute bilateral cerebellar infarcts in the territory of posterior inferior cerebellar artery

The authors report 12 patients with acute bilateral cerebellar infarcts in posterior inferior cerebellar artery (PICA) territory. They found three topographic patterns: A) bilateral medial PICA in six patients; B) unilateral whole + contralateral medial PICA in four; and C) bilateral small multiple in two. Nine patients in Groups A and B had unilateral PICA or vertebral artery disease, and both patients in Group C had bilateral vertebral artery disease. These findings support that unilateral supply to both medial PICA territories may be the most relevant pathogenesis of this syndrome.     

Vertical gaze ophthalmoplegia from infarction in the area of the posterior thalamo-subthalamic paramedian artery

Three cases of a stroke syndrome of acute supranuclear vertical gaze ophthalmoplegia are presented. Voluntary vertical gaze and the vertical vestibulo-ocular reflex were absent or diminished initially in all three patients. The patients also had loss of convergence and alteration in their mental status. Computed tomography scans showed lesions in the region of the rostral midbrain and lower diencephalon in the area surrounding the third ventricle. The blood supply, ischemic stroke syndrome and function of this region with reference to the supranuclear control of vertical gaze are discussed.     

Extracranial aneurysm of the posterior inferior cerebellar artery

Aneurysms of the posterior inferior cerebellar artery (PICA) are rare, and may arise in unusual locations due to the complex and variable anatomy of this artery. The PICA does not usually originate from the extracranial vertebral artery. Of the few reported extracranial PICA aneurysms, all affected the distal segment. We describe an unusual extracranial PICA-vertebral artery (VA) junction aneurysm.     

Extracranial aneurysms of the posterior inferior cerebellar artery

OBJECTIVE: Extracranial aneurysms of the distal posterior inferior cerebellar artery (PICA) are extremely rare and sometimes difficult to diagnose without an adequate angiogram. We present the first series of 3 patients who were evaluated by the senior author and treated surgically. METHODS AND RESULTS: All 3 patients presented with subarachnoid hemorrhage (SAH). Clincial symptoms, included occipital headache, nuchal rigidity, abducens nerve palsy and rapid neurologic deterioration. A unilateral injection of the vertebral artery failed to show the distal contralateral PICA and the aneurysm in 1 patient. All patients underwent aneurysm clipping through a posterior fossa craniectomy and C-1 laminectomy. The aneurysms were located on the tonsillomedullary segment of the PICA, 10-12 mm below the level of the foramen magnum. CONCLUSIONS: It is important to adequately visualize the distal extent of both PICAs or these aneurysms may not be seen. Patients who present with SAH must have the entirety of both vertebral arteries evaluated to avoid missing these aneurysms. The aneurysms were located adjacent to the atlas necessitating an upper cervical laminectomy for adequate surgical exposure. In general, the patients did well postoperatively and none of the patients developed cerebral vasospasm.     

小脑后下动脉解剖变异致双侧小脑梗死2例报道并文献复习

目的 探讨小脑后下动脉(posterior inferior cerebellar artery, PICA)解剖变异致双侧小脑梗死的临床特征及发病机制。方法 对2例经颅脑MRI确诊的双侧小脑梗死患者采用CT血管造影(CTA)、磁共振血管成像(MRA)或数字减影血管造影(DSA)显示其头颈部血管,从而了解后循环血管的形态特征并复习相关文献。结果 病例1经DSA证实左侧椎动脉较细,远端管腔闭塞,通过右椎动脉代偿供血原左侧PICA供血区但欠充分,双侧PICA共同起源于右侧椎动脉。病例2经CTA证实右侧椎动脉较左侧明显细且远端显示欠清,MRA示双侧PICA共同起源于左侧椎动脉。结论 2例双侧小脑梗死患者均存在一侧椎动脉优势供血,且双侧PICA共同起源于该侧椎动脉。在该解剖变异基础上一侧椎动脉发生病变时可出现双侧小脑梗死。因此,在临床中出现双侧小脑梗死时临床医师不能忽略这一解剖变异基础。     

小脑后下动脉(PICA)的显微解剖研究

目的研究小脑后下动脉(PICA)的显微解剖结构。方法对16具(共32侧)完好的人脑标本在显微镜下测量PICA。结果平均管径(1.23±0.48)mm,24侧(75.0%)由同侧椎动脉发出,距椎基汇合点(18.83±4.92)mm,19侧(59.4%)走行于第Ⅸ￣Ⅺ脑神经后方。结论小脑后下动脉是颅后窝椎基动脉系统较重要的分支,变异多;熟悉其解剖结构,在手术中多加保护是非常必要的。     

Cerebellar infarction in the young.

BACKGROUND AND PURPOSE: Ischemic cerebrovascular disease in children and young adults usually affects the anterior circulation. SUMMARY OF REPORT: We describe two cases of cerebellar infarction in the territory of vertebral artery supply, associated with physical exertion, in a young adult and in a child. Review of 31 previous cases of cerebellar infarction occurring in the first 2 decades of life demonstrated a mostly obscure causation; where a likely cause was found, trauma was most frequent. In 12 of the 31 patients, a vertebral artery (usually the left) was occluded. Patients were sometimes predisposed to such occlusions by subluxation between the first and second cervical vertebrae, allowing abnormal neck movements that can cause arterial injury and thromboembolism. Some of these cerebellar infarcts, like those of our patients, have followed physical exertion. CONCLUSIONS: Cerebellar infarction can be life-threatening, but half of the patients, including ours, have had complete or near-complete recovery.     

小脑后下动脉动脉瘤的治疗进展

小脑后下动脉（PICA）动脉瘤是导致蛛网膜下腔出血及后循环缺血的原因之一,由于解剖结构较复杂,故该动脉瘤治疗难度较大,预后较差。根据动脉瘤位置的不同、性质的不同,可选用的治疗方案也各不相同。该文在复习文献的基础上就累及PICA动脉瘤的最新治疗进展进行综述。     

Superior cerebellar artery infarction and vertebral artery dissection

Isolated superior cerebellar artery infarction is rare, and the mechanism is often not readily apparent. We describe a patient with an isolated superior cerebellar artery infarction resulting from an ipsilateral vertebral artery dissection. Angiography demonstrated intraluminal clot in the superior cerebellar artery, suggesting artery-to-artery embolus as a mechanism of this uncommon stroke syndrome.