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When the embolus extends into proximal posterior cerebral arteries mesencephalic arteries , regions of the thalamus and cerebral peduncle may be affected, as in this patient. The temporal and occipital lobes are often involved if the thrombus extends beyond the posterior communicating arteries or if these are small in caliber [ 19 ]. There are several potential explanations for the multi-focal infarction of specific nuclei and fascicles within the midbrain tegmentum.

First, the density of capillary networks may vary within the brainstem tegmentum, leading to selective vulnerability to ischemia for neurons and axons with less dense vascularization.


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Second, incomplete occlusion or rapid revascularization of the anteromedial and lateral group of mesencephalic arteries may have led to sparing of structures supplied by these arteries, with infarction of structures that were not as rapidly reperfused [ 20 ]. A distinguishing feature of the reverse locked-in syndrome described here is the complete recovery of consciousness and the near-complete recovery of extremity motor function. For example, hypersomnolence with bilateral third nerve palsies was initially reported in due to infarction of the reticular formation in the midbrain tegmentum [ 21 ].

Bilateral ophthalmoplegia with bilateral ptosis has been reported in association with extremity motor dysfunction, involvement of additional cranial nerves or sensory disturbance leading to adverse outcomes including death [ 22 , 23 ]. The syndrome of wall-eyed bilateral internuclear ophthalmoplegia WEBINO syndrome has also been described with lesions in the midline of the midbrain tegmentum that affected the bilateral medial longitudinal fasciculi MLF and pretectum. In WEBINO syndrome, the primary gaze is dysconjugate due to exotropia of both eyes wall-eyed with bilateral internuclear ophthalmoplegia and impaired convergence [ 24 , 25 ].

This pseudosixth phenomenon or pseudoabducens palsy refers to failure of ocular abduction without dysfunction of sixth nerve when there is lesion near the midbrain-diencephalic junction [ 26 , 27 ]. All of these nuclei and fascicles were affected to varying extents by the infarction, as detected by post-thrombectomy DWI. However, it is important to consider that the full extent of the infarction could not be precisely defined by the DWI data due to their limited spatial resolution, particularly in the superior-inferior axis 4. Indeed, near-complete sparing of brainstem arousal nuclei was observed on our lesion mapping analysis of the MRI data using the AAN atlas Figure 3.

Except for a small region of the midbrain reticular formation that overlapped with the infarct, all other nearby brainstem arousal nuclei e.

Although the bilateral paramedian thalami were more significantly affected than the brainstem arousal nuclei, the asymmetry of the thalamic lesions, with relative sparing of the left thalamus, may explain why our patient did not demonstrate the disorientation, confusion, hypersomnolence, coma or akinetic mutism that have been previously described in patients with bilateral paramedian infarcts [ 29 ]. Similarly, the relative sparing of the descending corticospinal tracts traveling through the cerebral peduncles, with only minimal involvement of the right peduncle, likely explains his rapid recovery of motor function.

Although he presented in a coma and quadriplegic with fixed, dilated pupils, within 2 hours of the procedure he had recovered consciousness, was following commands and was moving all 4 extremities purposefully. At 9 months, he had a favorable outcome characterized by near-complete independence for activities of daily living.

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We propose the term reverse locked-in syndrome to describe the constellation of neurological deficits experienced by our patient with bilateral ptosis, ophthalmoplegia, and pupillary non-reactivity to light but preserved consciousness and extremity motor function. As endovascular thrombectomy of basilar clots is performed with increasing frequency, rapid recanalization is likely to limit the size of brainstem infarcts, which may increase the incidence of atypical stroke syndromes such as the reverse locked-in syndrome.

McDonnell Foundation. Ram V. Tamara B. Jennifer A. Meaghan V. Sherry H-Y. Brian L.

When Stroke Affects the Thalamus

Europe PMC requires Javascript to function effectively. Recent Activity. Basilar artery occlusion can cause locked-in syndrome, which is characterized by quadriplegia, anarthria, and limited communication via eye movements. Here, we describe an uncommon stroke syndrome associated with endovascular recanalization of the top of the basilar artery: "reverse locked-in syndrome. We perform neuroanatomic localization of the patient's infarcts by mapping the magnetic resonance imaging MRI data onto a brainstem atlas. A year-old man presented with acute coma and quadriplegia due to top of the basilar artery occlusion.

The patient regained consciousness and purposeful movement in all four extremities, but the post-procedure neurological examination demonstrated bilateral ptosis with complete pupillary and oculomotor paralysis. MRI revealed infarction of the bilateral oculomotor nuclei in the midbrain tegmentum. At 9-month follow-up, he had anisocoria and dysconjugate gaze, but was living at home and required minimal assistance in performing all activities of daily living.

Since the patient's deficits were the exact opposite of those described in locked-in syndrome, we propose the term "reverse locked-in syndrome" to describe this neurological entity characterized by bilateral ptosis, non-reactive pupils, and ophthalmoplegia with preservation of consciousness and extremity motor function.

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The snippet could not be located in the article text. This may be because the snippet appears in a figure legend, contains special characters or spans different sections of the article. Neurocrit Care. Author manuscript; available in PMC Aug 1. PMID: Pooja Raibagkar , Ram V. Chavali , Tamara B. Kaplan , Jennifer A. Kim , Meaghan V. Nitka , Sherry H-Y. Chou , and Brian L. Corresponding Author: Dr.

Copyright notice. The publisher's final edited version of this article is available at Neurocrit Care. See other articles in PMC that cite the published article. Abstract Background Basilar artery occlusion can cause locked-in syndrome, which is characterized by quadriplegia, anarthria and limited communication via eye movements. Methods We report the case of a patient with atypical neurological deficits caused by acute ischemic stroke of the brainstem tegmentum.

Results A year-old man presented with acute coma and quadriplegia due to top-of-the-basilar artery occlusion. Keywords: Top-of-the-basilar artery, locked-in syndrome, midbrain tegmentum, endovascular thrombectomy, ophthalmoparesis. Introduction Basilar artery occlusion causes several of the most disabling and feared stroke syndromes.

Methods Clinical Data from Acute Hospitalization A year-old man with a history of left medial medullary infarction in and atrial fibrillation on warfarin collapsed while teaching in a classroom and became immediately unresponsive. Open in a separate window. Follow-up Assessment Six months later, repeat neurological examination demonstrated normal arousal and alertness, full orientation to self, place, and date, and normal comprehension with reliable command-following. Results The brainstem nuclei and fascicles affected by the infarction were: bilateral oculomotor nuclei and fascicles; bilateral medial longitudinal fasciculi MLF ; rostral interstitial nucleus of the MLF riMLF ; pretectal or midsection of posterior commissure; and bilateral Edinger-Westphal nuclei.

Conclusion We propose the term reverse locked-in syndrome to describe the constellation of neurological deficits experienced by our patient with bilateral ptosis, ophthalmoplegia, and pupillary non-reactivity to light but preserved consciousness and extremity motor function. References 1. Clinical features of proven basilar artery occlusion. Plum F, Posner JB.

CHAPTER THE BRAIN, CRANIAL NERVES, AND MENINGES BRAIN

The diagnosis of stupor and coma. Contemp Neurol Ser. Brandt T. Diagnosis and thrombolytic therapy of acute basilar artery occlusion: a review. Clin Exp Hypertens. It also inhibits endotoxin-induced lung inflammation [57].

The concentration of SP-B in amniotic fluid of patients with intra-amniotic infection is significantly increased compared to that of healthy pregnant women [58]. Consistent with these findings, we propose that SP-B is upregulated during exogenously induced inflammation in order to limit and counterbalance the detrimental effects caused by the host's immune system. Specifically, we hypothesize that SP-B is a protein of the CSF, constitutively produced by the choroid plexus to facilitate CSF flow with a reactively increased production rate in case of pathogen-induced or ischemically triggered, acute neuroinflammation.

Autoimmune CNS conditions like multiple sclerosis are coupled with permanent inflammation, influx of immune cells and cell death in the CNS [59]. The persistent chronic inflammation may lead to a high consumption of SP-B, resulting in a functional insufficiency of the choroid plexus and the ependymal cells to produce SP-B, finally leading to a decreased concentration of SP-B in the CSF. The involvement of SP-B in autoimmune conditions has not been investigated as yet to our knowledge. A thorough review of the literature on this issue revealed no evidence of studies focusing on lipophilic SPs in autoimmune diseases.

It is therefore conceivable that this premature form may be regulated differently in the investigated groups of CNS conditions, but the ELISA system we used may also not be capable of detecting the 12 kDa form. Their expression at different locations in the CNS indicates participation of the SPs in processes like host defense and maintenance of CSF flow, but the dimension of their importance and their exact function must be investigated in subsequent studies.

The concentration of surfactant proteins in the CSF of healthy subjects deviates from patients with CNS conditions of autoimmune, ischemic and infectious etiology. This also speaks for the importance of the SPs in processes such as fine-tuning of inflammation and host defense. It is still not clear which cells are exactly responsible for production of the collectin-type SPs within the CNS.

This remains to be investigated prior to more functional studies. Browse Subject Areas? Click through the PLOS taxonomy to find articles in your field. Abstract Surfactant proteins SP have been studied intensively in the respiratory system. Introduction The healthy central nervous system has conventionally been considered to be almost completely independent of the immune system [1].

Materials and Methods The study was conducted in compliance with Institutional Review Board regulations, informed consent regulations, and the provisions of the Declaration of Helsinki. Tissue Because of the origin of tissue samples and the background of acquisition of csf samples no ethics committee approval was necessary.

Download: PPT. Table 1.

Antibodies Antibodies displayed in table 2 and 3 were used for Western blot analysis as well as for immunohistochemical investigations as specified by the manufacturer.