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.     

A case of bilateral cerebellar infarction in the distribution of the bilateral superior cerebellar artery]

We reported a case of bilateral cerebellar hemorrhagic infarction in the distribution of the bilateral superior cerebellar artery. A 58-year-old man suddenly developed dizziness and transient loss of consciousness. The neurological examination revealed left hearing disturbance, left sensory disturbance involving face, dysarthria and bilateral ataxia. This patient was considered to be classic clinical syndrome of right superior cerebellar artery. CT and MRI revealed hemorrhagic infarction corresponding to the full territory of the bilateral superior cerebellar artery. The right posterior cerebral artery was filling through the right posterior communicating artery on the right carotid angiography taken 2 hours after the onset. Bilateral vertebral angiography on the 18th day demonstrated no occlusions in the basilar artery and the bilateral superior cerebellar artery. Hemorrhagic infarction corresponding to the full territory of the bilateral superior cerebellar artery, sparing other territories as the present case, is extremely rare. In this case, cerebral embolism (top of the basilar syndrome) was suggested because of existence of atrial fibrillation and sudden onset.     

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.     

Infarction of the territory supplied by the contralateral superior cerebellar artery in a case of descending transtentorial herniation

Infarction of the territory supplied by the contralateral superior cerebellar artery in cases of descending transtentorial herniation has not been reported. The authors experienced a primitive neuroectodermal tumor in a patient whose consciousness deteriorated transiently due to descending transtentorial herniation. On the magnetic resonance imaging taken 8 days after the herniation, lesions thought to be infarction of territories supplied by the ipsilateral posterior cerebral artery and the contralateral superior cerebellar artery were noted. The possible mechanism of this peculiar pattern of infarction is discussed.     

A case of emotional facial palsy with ipsilateral anterior inferior cerebellar artery territory infarction

Emotional facial palsy (EFP) commonly results from anterolateral thalamic or striatocapsular infarcts. Its occurrence in brainstem lesions is uncommon, with previously reported cases being restricted to superior cerebellar artery infarction (3 cases). We report an unusual case of EFP ipsilateral to an anterior inferior cerebellar artery infarction, which opens new insights into the facial corticobulbar tract pathway.     

Efficacy of carbamazepine on cerebellar tremors in patients with superior cerebellar artery syndrome

Summary Three patients with postural and intention cerebellar tremor caused by a cerebellar infarction in the superior cerebellar artery distribution were studied; treatment with carbamazepine resulted in marked improvement.     

Recovery from multiple brain infarcts complicating basilar artery dissection

A 38-year-old woman suffered a spontaneous basilar artery dissection leading to bilateral occipital, right thalamic and cerebellar infarction and a dorsal midbrain syndrome. Computerized tomography showed left cerebellar, right thalamic and bilateral occipital infarctions and selective angiography showed a narrowed segment in the basilar artery, absent filling of the right superior cerebellar artery and narrowing of the right posterior cerebral artery. She improved rapidly without specific therapy and made a near full recovery. Basilar artery dissection, while often fatal, may have a benign outcome and we review the literature in this regard.     

Isolated body lateropulsion caused by a lesion of the rostral vermis

A 66-year-old man presented with axial lateropulsion, exhibiting sudden falling as the sole clinical sign of cerebellar infarction in the territory of the medial branch of the superior cerebellar artery (mSCA). A brain MRI showed acute infarction selectively involving the centralis of the rostral vermis. This patient illustrates that cerebellar infarction in the territory of the mSCA can present as an isolated body lateropulsion. The possible mechanism of an isolated body lateropulsion is considered.     

Bilateral Superior Cerebellar Artery Infarction after Stent-Angioplasty for Internal Carotid Artery Stenosis

Spontaneous bilateral cerebellar infarction in the territory of the superior cerebellar arteries is extremely rare. Occasionally there have been reports of bilateral cerebellar infarction due to vertebrobasilar atherosclerotic occlusion or stenosis, whereas no report of bilateral cerebellar infarction due to complicated hemodynamic changes. In this report, we present a patient with bilateral cerebral infarctions related to stenoses of bilateral internal carotid arteries, in whom vertebrobasilar system was supplied by multiple collaterals from both posterior communicating arteries and right external carotid artery. We performed stent-angioplasty of bilateral internal cerebral arterial stenosis, and then acute infarction developed on bilateral superior cerebellar artery territories. The authors assumed that the infarction occurred due to hemodynamic change between internal carotid artery and external carotid artery after stent-angioplasty for stenosis of right internal carotid artery.     

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.     

Embolism from vertebral artery origin occlusive disease.

We report 10 patients with severe occlusive disease of the vertebral artery (VA) origin in the neck with intra-arterial embolism to the posterior circulation. The VA lesions in seven patients were complete occlusions, and three patients had severe atherostenosis. All patients had strokes in the vertebrobasilar territory. The most frequent recipient sites of intra-arterial embolism were the intracranial VA-posterior inferior cerebellar artery region (8), and the distal basilar artery (BA) and its superior cerebellar and posterior cerebral artery branches (7). Two patients had pontine infarction due to BA embolism. The most common clinical signs were due to cerebellar infarction. Atherosclerotic disease of the VA origin has features in common with disease of the internal carotid artery origin. Both have similar risk factors and demography, and each can cause strokes by intracranial intra-arterial embolism.     

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。     

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.     

Distal infarction of the left superior cerebellar artery presenting with dysarthria and unsteadiness

Small cerebellar infarction with a benign outcome occurs more frequently than a massive infarction with brainstem compression. Retrospective CT studies have shown it. These infarcts are more often localized in the superior hemisphere of the cerebellum which semiology is not well known. Some reports pointed out that an acute cerebellar infarction in the PICA territory may mimic labyrinthine lesion. The authors report a case of an acute small cerebellar infarction in the SCA territory presenting as a dysarthria and unsteadiness, involving the left lobulus semilunaris superior, in a paravermal zone, on CT scan.     

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.     

The endovascular management of superior cerebellar artery aneurysms

BACKGROUND: Superior cerebellar artery aneurysms are rare. We present a clinical series of twelve of these aneurysms that were treated exclusively with endovascular coils. METHOD: A retrospective analysis of a prospectively collected database of cerebral aneurysms treated with coil embolization was performed. Clinical notes and radiological images were reviewed. RESULTS: Twelve superior cerebellar artery aneurysms were treated in eleven patients between 1992 and 2001. Seven patients presented with subarachnoid hemorrhage, two with neurologic deficit, and two had asymptomatic aneurysms. Coiling resulted in complete aneurysm obliteration in six patients and incomplete obliteration in the other six. No subsequent hemorrhage occurred with follow-up between 6 and 119 months (mean follow-up 50 months). Procedural morbidity was one superior cerebellar artery infarct with good recovery. Management morbidity was one middle cerebral artery embolus during a follow-up angiogram that required thrombolysis with a good clinical result. Nine out of 11 patients on follow-up were performing at Glasgow Outcome Scale (GOS) 5. One patient with GOS 3 presented with a poor grade subarachnoid hemorrhage and the other patient with GOS 4 presented with a parenchymal hemorrhage due to an arteriovenous malformation. CONCLUSION: Endovascular treatment of superior cerebellar artery aneurysms is an effective treatment strategy with low morbidity.     

Recent Advances in Cerebellar Ischemic Stroke Syndromes Causing Vertigo and Hearing Loss

Cerebellar ischemic stroke is one of the common causes of vascular vertigo. It usually accompanies other neurological symptoms or signs, but a small infarct in the cerebellum can present with vertigo without other localizing symptoms. Approximately 11 % of the patients with isolated cerebellar infarction simulated acute peripheral vestibulopathy, and most patients had an infarct in the territory of the medial branch of the posterior inferior cerebellar artery (PICA). A head impulse test can differentiate acute isolated vertigo associated with PICA territory cerebellar infarction from more benign disorders involving the inner ear. Acute hearing loss (AHL) of a vascular cause is mostly associated with cerebellar infarction in the territory of the anterior inferior cerebellar artery (AICA), but PICA territory cerebellar infarction rarely causes AHL. To date, at least eight subgroups of AICA territory infarction have been identified according to the pattern of neurotological presentations, among which the most common pattern of audiovestibular dysfunction is the combined loss of auditory and vestibular functions. Sometimes acute isolated audiovestibular loss can be the initial symptom of impending posterior circulation ischemic stroke (particularly within the territory of the AICA). Audiovestibular loss from cerebellar infarction has a good long-term outcome than previously thought. Approximately half of patients with superior cerebellar artery territory (SCA) cerebellar infarction experienced true vertigo, suggesting that the vertigo and nystagmus in the SCA territory cerebellar infarctions are more common than previously thought. In this article, recent findings on clinical features of vertigo and hearing loss from cerebellar ischemic stroke syndrome are summarized.     

Unusual neuro-ophthalmic presentation of anterior communicating artery aneurysm with third nerve paresis.

Paresis of the oculomotor nerve associated with subarachnoid haemorrhage is considered a hallmark of aneurysms located at the junction of the internal carotid artery and posterior communicating artery. Third nerve palsy can also be caused by those aneurysms located in the intracavernous part of the internal carotid artery, basilar artery, posterior cerebral artery and superior cerebellar artery. However, oculomotor nerve paresis caused by an anterior communicating artery aneurysm is a very uncommon occurrence. We report a case of an elderly female with sudden severe headache who developed an acute third nerve paresis. Angiography revealed an anterior communicating artery aneurysm. Management and the pertinent literature are reviewed along with the mechanism of third nerve compression.     

以眩晕为首发症状的小脑梗死临床类型及供血区分布

目的:探讨以眩晕为首发症状的小脑梗死临床类型及病灶供血区分布特征。方法:对26例经MRI确诊、以眩晕为首发症状的小脑梗死患者的临床资料进行回顾性分析。结果:将眩晕为首发症状的小脑梗死分为2种临床类型:①稳定型:单纯自发性持续性眩晕伴平衡失调(19/26例,73.1%);②进展型:以持续性眩晕、平衡失调为首发症状,起病2d后伴有延迟神经功能受累症状(7/26例,26.9%)。梗死病灶以小脑后下动脉内侧支(16/26例,61.5%)受累最为常见;其次为小脑前下动脉区(6/26例,23.1%)及小脑上动脉区(2/26例,7.7%)。未见多发小脑供血动脉区梗死患者以单纯眩晕为首发症状。结论:以眩晕为首发症状的小脑梗死以小脑后下动脉内侧支受累最为常见,绝大多数患者呈良性病程,但需警惕可能出现的延迟神经功能受累症状和体征。     

Internal carotid artery-to-posterior cerebral artery bypass for revascularization of the brainstem

We describe a novel bypass technique used to revascularize the brainstem by anastomosing the internal carotid artery (ICA) to the posterior cerebral artery (PCA) using a radial artery graft, effectively creating a functional alternative to the posterior communicating artery. A 72-year-old male patient presented with rapidly progressive neurological symptoms attributable to brainstem compression; imaging showed a giant, fusiform, partially thrombosed, vertebrobasilar artery aneurysm. An Alcock’s test revealed no significant collateral circulation from the posterior communicating arteries. To revascularize the top of the basilar artery, we performed an ICA-to-PCA bypass using a radial artery interposition graft. Specifically, we used the radial artery graft to connect the supraclinoid ICA to the P2 segment of the PCA. The basilar artery was subsequently occluded during the same operation by placing a clip below the superior cerebellar arteries. Although the bypass remained patent, the patient suffered an acute thrombosis of the aneurysm, resulting in fatal pontine infarction.