Bilateral paramedian midbrain infarct: an uncommon variant of the "top of the basilar" syndrome

Spengos, Konstantinos; Wöhrle, Jochen; Tsivgoulis, Georgios; Stouraitis, Georgios; Vemmos, Kostas; Zis, Vassilios

doi:10.1136/jnnp.2004.050146

Cited by 18 publications

(11 citation statements)

References 5 publications

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“…Acute thrombosis of distal or 'top-of-the' basilar artery may result in acute infarction in both thalami [1]. Our patient showed normal flow signals in the vertebrobasilar system as well as both PCAs on MR angiography and TCD.…”

Section: Discussionmentioning

confidence: 86%

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Bilateral thalamic infarctions due to occlusion of artery of Percheron

Teoh¹,

Ahmad²,

Yeo³

et al. 2010

Journal of the Neurological Sciences

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Section: Discussionmentioning

confidence: 86%

“…Furthermore, thrombophilia and vasculitic screen were unremarkable. Thrombotic occlusion of the 'top-of-the basilar' artery can result in similar bilateral thalamic ischemic infarctions [1]. However, this segment of the basilar artery in our patient was patent on an initial MRA, performed about 12 h after the symptom-onset.…”

Section: Discussionmentioning

confidence: 90%

Bilateral thalamic infarctions due to occlusion of artery of Percheron

Teoh¹,

Ahmad²,

Yeo³

et al. 2010

Journal of the Neurological Sciences

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“…partially interrupted. To the best of our knowledge, 2 cases with an infarct located at the paramedian midbrain presented with tetra-ataxia and ophthalmoplegia during the acute phase of the stroke and developed tremor during the acute or chronic phase [9,10] . The concomitant occurrence of tetra-ataxia and skeletal tremor without oculomotor disorders due to mesencephalic stroke can occur, but it seems to be very rare.…”

Section: Resultsmentioning

confidence: 99%

“…Our patient's stenosis of the distal basilar artery also suggests that the occlusion of penetrating branches originating from the basilar artery could cause stroke. Spengos et al [10] highlighted the vascular variation in the uncommon 'top of the basilar' syndrome with both posterior cerebral arteries arising from the corresponding internal carotid arteries as an etiological mechanism of the small bilateral paramedian midbrain infarction with tremor and tetra-ataxia. The fact that the P1-segment of the right posterior cerebral artery was narrow in our patient might also have contributed to the unusual configuration of isolated midbrain infarction.…”

Section: Resultsmentioning

confidence: 99%

Kurashiki Prehospital Stroke Scale

et al. 2008

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“…Improvements in diagnostic techniques have shown that atypical TOB is not uncommon. Despite distal BA occlusion, some patients present with minimal or atypical symptoms, such as bilateral ophthalmoplegia [5,6], or atypical lesions, including infarcts limited to the thalami [5], midbrain [7], or cerebellum [8]. By contrast, other patients present with multiple lesions in the distal BA territory without angiographically identified BA occlusion, probably because of early BA recanalization [2,4].…”

Section: Introductionmentioning

confidence: 95%

Patterns and Outcomes of the Top of the Basilar Artery Syndrome: The Role of the Posterior Communicating Artery

Ahn

Kim

et al. 2018

Cerebrovasc Dis

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Background: Clinical syndromes secondary to infarcts in the distal basilar artery (BA) area have been described as “top of the basilar” (TOB) syndrome. However, in the era of advanced imaging technology, it has been realized that the clinical and imaging features are quite diverse in patients with distal BA occlusion. The aim of the present study was to investigate the patterns and clinical outcomes of TOB assessed with modern images and categorize TOBs accordingly. Additionally, we examined the possible influence of the posterior communicating artery (PcoA) on the patterns of TOB. Methods: Patients with distal BA occlusion on magnetic resonance angiography were categorized as TOB-A, and those with multiple lesions in the distal BA territory on diffusion-weighted magnetic resonance imaging as TOB-L. Patients with angiographically and lesion distribution-defined TOB were classified as having TOB-A&L; those with angiographically defined TOB as having TOB-A without TOB-L; and those with lesion distribution-defined TOB as having TOB-L without TOB-A. The PcoA was categorized as “textbook-type” (good P1) and “fetal-type” (absent P1). Factors associated with unfavorable short-term outcomes (modified Rankin Scale 5–6 at discharge), and 1-year and long-term mortalities, were assessed. Results: Of 1,466 patients with ischemic stroke in the posterior circulation who were admitted to Asan Medical Center within 24 h of symptom onset, 124 (8.5%) had TOB, including 45 with TOB-A&L, 44 with TOB-A, and 35 with TOB-L. NIHSS scores (21 [9.5–26] vs. 6 [3–11.5] vs. 6 [3–9]; p < 0.01) and rates of motor deficit (75.6 vs. 54.5 vs. 34.4%; p < 0.01), concomitant pontine lesions (17.8 vs. 25.0 vs. 2.9%; p < 0.01), PcoA presence (44.4 vs. 68.2 vs. 25.7%; p < 0.01), and unfavorable short-term outcomes (62.2 vs. 25.0 vs. 14.3%; p < 0.01) differed significantly in the 3 patient groups. Multivariate analysis showed that textbook-type PcoA was independently associated with a lower frequency of unfavorable short-term outcomes (OR 0.15, 95% CI 0.03–0.70). Reperfusion therapy (hazard ratio [HR] 0.25, 95% CI 0.07–0.89) and the presence of textbook-type PcoA (HR 0.20, 95% CI 0.05–0.90) were associated with a lower 1-year mortality rate after stroke. Conclusion: Patterns and clinical outcomes of TOB vary and are affected by the hemodynamic status of the arterial system, such as BA recanalization and the presence of textbook-type PcoA.

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Bilateral paramedian midbrain infarct: an uncommon variant of the "top of the basilar" syndrome

Cited by 18 publications

References 5 publications

Bilateral thalamic infarctions due to occlusion of artery of Percheron

Bilateral thalamic infarctions due to occlusion of artery of Percheron

Kurashiki Prehospital Stroke Scale

Patterns and Outcomes of the Top of the Basilar Artery Syndrome: The Role of the Posterior Communicating Artery

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