Contents

1. Case Report
2. Introduction
3. Signs and symptoms
4. Pathophysiology
5. Diagnosis
6. Treatment
7. Hypertensive Pontine Hemorrhage Video

Case Report

• 52yr old male
• k/c/o HTN not on regular medication
• Presented with sudden onset loss of consciousness

On Examination

• GCS - E1VetM1
• Pupils -B/L 1mm NRTL (Pin-Point Pupils)
• Planters B/L mute

CT Scan

Hypertensive Pontine Hemorrhage

Hypertensive Pontine Hemorrhage: Introduction

• Seen in long standing poorly-controlled chronic hypertension. 
• It carries a very poor prognosis.
• Pontine hemorrhage accounts for 5-10% of all hemorrhagic strokes (Jang et al 2011)

Signs and symptoms

• "classic" pontine hematoma syndrome characterized by coma, quadriparesis, and eventual demise (Kushner et al 1985)
• Clinical features of Pontine Hematoma are (Deng and Gaillard et al.)
• • Loss of consciousness (most common)
  • long tract signs including tetraparesis
  • cranial nerve palsies
  • seizures
  • Cheyne-Stokes respiration
• CST does not play an essential role in recovery of independent walking and vestibulospinal tracts may not crucially affect recovery of independent walking in patients with pontine hemorrhage. In contrast, and intact CRP (corticoreticular pathway) or changes of the CRP integrity appear to be related to the recovery of gait function (Yeo et al 2020)

Pathophysiology

Hypertensive Pontine Hemorrhage

• Due to rupture of penetrating arteries from the basilar artery extending into the pons 
• These arteries are prone to lipohyalinosis as a result of poorly-controlled hypertension 
• This makes the vessel wall prone to rupture. 
• Larger paramedian perforators are more commonly the culprit vessels

Other Causes of Pontine Hemorrhage

Other causes of pontine hemorrhage include

• Cavernoma
• AV Malformation
• Tumour bleed
• Transtentorial herniation (Duret Hemorrhage)

Diagnosis

NCCT Brain is the investigation of choice. It shows:

• Acute intraparenchymal hemorrhage within the pons
• The hematoma frequently ruptures into the 4th ventricle 

Treatment

• Poor prognosis
• Large bleeds are almost universally fatal. 
• Open surgical evacuation of the clot is usually not performed
• In smaller hemorrhages, medical management and treatment of hydrocephalus with extraventricular drains may be life saving, 
• Mortality ranges between 30% and 90% (Jang et al 2011)
• Outcome depends on the volume of the bleed and initial GCS

Hypertensive Pontine Hemorrhage Video

Hypertensive Pontine Hemorrhage Video

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The CT comma sign is a characteristic sign seen in head trauma. 
It is the presence of concurrent epidural and subdural hematomas, 
which gives the characteristic appearance of this sign as a "comma" shape.           

70/M 

Chief Complaints: Numbness Lt Arm, 1 Episode of Partial seizure,Lt grip weakness since today morning. 

H/o Fall 3 days back. 

K/C/O HTN/DM/Post CABG 1994 with implanted defibrillator device (CRTD)/ Post Mechanical Thrombectomy for Rt MCA territory Infarct (March2020) on Ecospirin and T. APIXABAN(last dose today). 

Kn chronic  smoker and alcoholic. 

O/E 

E4V5M6

Pupils B/L 2mm RTL . 

Power Lt side 4/5. 

Left Hand grip 70%.

Since the patient was having multiple comorbidities with deranged coagulation and the GCS was 15, it was decided to manage the patient conservatively. Ecospirin and APIXABAN were stopped after consulting with a cardiologist and neurologist. 

#neuroradiology#neuroscience

#neurosurgeon #brainmri #braincat 

Reference

https://radiopaedia.org/articles/ct-comma-sign-head

5/08/2020 10:28:00 AM

 


1. MR spectroscopy provides a measure of brain chemistry.
2. The most common nuclei that are used are 
• 1H (proton)
• 23Na (sodium)
• 31P (phosphorus). 
• Proton spectroscopy is easier to perform and provides much higher signal-to-noise than either sodium or phosphorus.
3. MRS can be performed within 10-15 minutes and can be added on to conventional MR imaging protocols. 
4. It can be used to serially monitor biochemical changes in tumors, stroke, epilepsy, metabolic disorders, infections, and neurodegenerative diseases. 
5. They require interpretation and should always be correlated with the MR images before making a final diagnosis.

5/05/2020 01:23:00 AM

What are Arnold Chiari Malformations?

• These comprise a group of abnormalities involving the rhombencephalon (hindbrain) and the contents of the CV junction 
• With common feature of impaired CSF circulation through the foramen magnum  
• May be Congenital or Acquired
• Ranging from simple herniation of the cerebellar tonsils through the foramen magnum to complete agenesis of the cerebellum 
• Presently there is no consensus regarding the precise definition, classification, etiology and the surgical management 
• Five types 
• No anatomical or embryological correlation between them 

Historical Background of Arnold Chiari Malformations

• 1883, John Cleland (Professor of anatomy in Glasgow, Scotland) - described hindbrain hernia in a child with myelodysplasia.
• 1891 and 1896, Hans Chiari- (Professor of Pathology at German University, Prague, Czechoslovakia): analyzed data from >40 postmortem examinations of patients with hindbrain malformations
• Chiari malformations I, II and III were coined in the earlier work and Chiari malformation IV was added in 1896 publication. 
• 1894, Julius A. Arnold(Professor of Pathology at Heidelberg, Germany)- described a single myelodysplastic patient with associated hindbrain herniation.
• Schwalbe & Gerdig included Arnold name in the eponym & designated it ARNOLD –CHIARI malformation 

What are the types of Chiari Malformations?

Chiari type 0 malformation

• alteration in Cerebro Spinal Fluid (CSF) hydrodynamics at the level of the foramen magnum. 
• they have syringomyelia either without tonsil herniation or with only mild tonsil herniation

Chiari Type I malformation

• caudal herniation of the cerebellar tonsils more than 5 mm below the foramen magnum
• typically associated with hydrosyringomyelia.
• not usually accompanied by descent of the brain stem or IV ventricle, nor associated with the presence of hydrocephalus.
• Most common type
• Presents in young 

Chiari type II malformation

• caudal herniation of the cerebellar vermis, brain stem, and IV ventricle through the foramen magnum. 
• associated with myelomeningocele, hydrocephalus, and, less frequently, hydrosyringomyelia. 
• hypoplastic tentorium cerebelli, cranial lacunae, anomalies of the Sylvius aqueduct may exist.

Chiari type III malformation

• consists of occipital encephalocoele, with some of the intracranial defects associated with Chiari II malformation.

Chiari type IV malformation

• cerebellar aplasia or hypoplasia, associated with aplasia of the tentorium cerebelli.

Images showing various Chiari malformations

Image of a Type 1 Arnold-Chiari Malformation. The cerebellum has descended 7mm and there are herniated cerebellar tonsils into the foramen magnum.

Artist's representation of a Chiari II malformation showing the points of potential obstruction that yield different subtypes of hydrocephalus

Neonate with Chiari malformation type III.T2-weighted mid-sagittal MRI scan of the patient shows a small posterior fossa, an deep parieooccipitalis fissure (open arrow), ad a partial callosal agenesis (curved arrow), and a caudal herniation of part of the brain stem through the foramen magnum, with inferior tip appearing between C5 and C6 (closed arrow). (https://www.sciencedirect.com/science/article/pii/S1930043315302697)

T1 weighted sagittal MRI showing a so called “Chiari IV” or primary cerebellar agenesis. There is a tiny portion of residual quadrangular lobule just caudal to the tectum and a normal sized posterior fossa. No associated meningomyelocele is present.

References

• Greenberg Handbook of Neurosurgery
• Fernández AA, Guerrero AI, Martínez MI, et al. Malformations of the craniocervical junction (Chiari type I and syringomyelia: classification, diagnosis and treatment). BMC Musculoskelet Disord. 2009;10 Suppl 1(Suppl 1):S1. Published 2009 Dec 17. doi:10.1186/1471-2474-10-S1-S1 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2796052/
• Hidalgo JA, Varacallo M. Arnold Chiari Malformation. [Updated 2019 Nov 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK431076/
• https://commons.wikimedia.org/wiki/File:MRI_of_human_brain_with_type-1_Arnold-Chiari_malformation_and_herniated_cerebellum_es.jpg
• https://commons.wikimedia.org/wiki/File:Chiari2.jpg
• Chiari malformation type III: Case report and review of the literature. Christina Andica, Ristaniah D. Soetikno. Radiology Case Reports, 8, 3, 2013 https://doi.org/10.2484/rcr.v8i3.831
• The Chiari malformations. Donald M. Hadley. Neurology in Practice, 72, 2, 2002 http://dx.doi.org/10.1136/jnnp.72.suppl_2.ii38

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Anatomy of Basal Ganglia - Axial View

Structures generally included in the basal ganglia are the caudate, putamen, and globus pallidus in the cerebrum, the substantia nigra in the midbrain, and the subthalamic nucleus in the diencephalon.

Basal ganglia's primary function is likely to control and regulate activities of the motor and premotor cortical areas so that voluntary movements can be performed smoothly.

Dysfunction results in a wide range of neurological conditions including disorders of behaviour control and movement.

Those of behaviour include Tourette syndrome, obsessive–compulsive disorder, and addiction.

Movement disorders include, most notably Parkinson's disease, which involves degeneration of the dopamine-producing cells in the substantia nigra, Huntington's disease, which primarily involves damage to the striatum, dystonia, and hemiballismus


 #neurosurgeon #neuro #neurosurgery #neurological #basalganglia #neuroscience #neurology #neurochirurgie #neuroradiology #BGBleed #caudate #caudatenucleus https://ift.tt/33tMQAo via WSF Instagram

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