Man-in-the-Barrel Syndrome with Combination of Infarctions in the Anterior Spinal Artery and Posterior Inferior Cerebellar Artery Territories

Iyer²,

Journal of Neurosurgery: Case Lessons

2021

BACKGROUNDPerson-in-the-barrel syndrome is characterized by bilateral brachial diplegia, intact cranial nerves, and preserved lower-extremity strength. Most cases are due to bilateral supratentorial brain lesions at the border zone of the anterior and middle cerebral artery vascular territories. This condition has been observed with spinal pathology, primarily involving vascular dissection and thromboembolism.OBSERVATIONSThe authors’ case is the first in the literature to highlight person-in-the-barrel syndrome immediately following cervical spine surgery. Weakness of the deltoids, biceps, infraspinatus, and brachioradialis was observed bilaterally postoperatively. Electromyograph (EMG)-nerve conduction velocity (NCV) studies revealed a cervical radiculopathy involving C5 and C6 bilaterally with denervation of the deltoids, biceps, and brachioradialis. Within 8 months of cervical spine surgery, the patient regained improvement of the bilateral brachial diplegia.LESSONSEMG/NCV studies play a valuable role in detecting cervical radiculopathy after cervical spine surgery in patients with bilateral brachial diplegia. The authors postulate that this condition may have occurred following neck hyperextension during cervical cage placement, increasing the foraminal stenosis at C4–5 and C5–6 and worsening the C5 and C6 radiculopathy. Spinal surgeons should be cognizant of person-in-the-barrel syndrome that may ensue following cervical spine surgery and promptly identify and treat this condition to offer the best prognosis for a favorable patient outcome.

Section: Discussionmentioning

confidence: 99%

Person-in-the-barrel syndrome following cervical spine surgery: illustrative case

Iyer²,

Journal of Neurosurgery: Case Lessons

2021

Case Reports in Neurological Medicine

“…Many other etiologies have been described leading to a phenotypic presentation of “man-in-the-barrel syndrome.” Multiple strokes [ 23 ] and metastases [ 24 ] involving bilateral cerebral cortices have been described with the syndrome. Telfer et al described a case due to central pontine myelinolysis caused by hyponatremia [ 25 ].…”

Section: Discussionmentioning

confidence: 99%

Too Aggressive Drop in Blood Pressure in a Hypertensive Male Leading to “Man-in-the-Barrel Syndrome”

Dalugama

Jayasinghe²,

Ralapanawa

et al. 2020

Introduction. “Man-in-the-barrel syndrome” is a neurological phenotype with brachial diplegia, normal sensation, and preserved motor function of the lower limb. It has been described in various neuropathological conditions affecting the cerebral hemispheres, pons, upper spinal cord, and peripheral neurons. Severe hypotension leading to watershed infarctions leading to this phenotype has been reported. We describe the first case of “man-in-the-barrel syndrome” in a patient with a precipitous drop in blood pressure following oral antihypertensive medications. Case Presentation. A 75-year-old Sri Lankan male presented following a generalized tonic-clonic seizure to a tertiary care hospital. Upon recovery, he was noted to have severe brachia diplegia affecting shoulder movements with preserved hand muscle power and motor functions of the lower limb. The previous day, he was newly diagnosed with markedly elevated blood pressure without acute end organ involvement. Treatment with three antihypertensives had been initiated. Noncontrast CT of the brain revealed watershed infarctions affecting both cerebral hemispheres. Conclusion. It is generally unwise to lower blood pressure very rapidly, as ischemic damage can occur in vascular beds that are habituated to high levels of blood pressure in the brain. Ischemic damage caused by rapid lowering of blood pressure may rarely result in “man-in-the-barrel syndrome” leading to severe functional disability.

“…There are less than 10 cases of MBS reported due to spinal cord pathology [ Table 1 ],[ 1 2 5 6 8 9 ] where it is attributed to injury of the anterior horn cells resulting from trauma and/or vascular insults (e.g. vertebral artery dissection or thrombosis).…”

Section: Discussionmentioning

confidence: 99%

Man-in-the-barrel syndrome: Case report of ventral epidural abscess and review of the literature

Asmaro¹,

Pabaney²,

Rammo³

et al. 2018

Surg Neurol Int

Background:Man-in-the-barrel syndrome (MBS) is an uncommon clinical condition for which patients present with bilateral brachial diplegia but intact lower extremity strength. This syndrome is typically attributed to a cranial/cortical injury rather than a spinal pathology.Case Description:A 62-year-old diabetic male presented with bilateral upper extremity paresis attributed to a ventral cervical epidural abscess diagnosed on magnetic resonance imaging. Emergent cervical decompression resulted in slight improvement of upper extremity strength. However, he later expired due to sepsis and respiratory compromise.Conclusion:Establishing the correct diagnosis via clinical examination and proceeding with appropriate management of MBS attributed to a cervical epidural abscess is critical to achieve a good outcome.