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Caudal paramedian midbrain infarction: a clinical study of imaging, clinical features and stroke mechanisms

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Abstract

Caudal paramedian midbrain infarction (CPMI) is an extremely rare form of ischemic stroke and related clinical studies are scarce. Our aim is to investigate the clinical features, neuroradiological findings and stroke etiology of CPMI. We conducted a retrospective study of 12 patients with CPMI, confirmed by diffusion-weighted MRI from 6820 cerebral infarction patients at our stroke center from January 2012 to August 2018. Experienced neurologists evaluated the clinical manifestations, neuroimaging findings and stroke mechanisms. Twelve patients (11 men, 1 woman) aged 42–81 years old met the study inclusion criteria. Seven patients had a unilateral infarction (two right-sided, five left-sided) and five had bilateral infarctions. Sagittal image showed a backward oblique sign in the lower level of the midbrain. Significantly, the bilateral CPMIs presented with a characteristic “V-shaped” appearance in the axial MRI. All patients presented with bilateral cerebellar dysfunction which included dysarthric speech, truncal or gait ataxia and four-limb ataxia. In addition, diplopia and internuclear ophthalmoplegia were frequently encountered in CPMI. Five (41.7%) patients were classified with large artery atherosclerosis, four (33.3%) with small vessel disease, two (16.7%) with cardiogenic embolism, and one (8.3%) with undetermined etiology. CPMI is a rare cerebrovascular disease that destroys the Wernekink commissure, medial longitudinal fasciculi and other adjacent structures. It is characterized by bilateral cerebellar ataxia and eye movement disorders, mainly internuclear ophthalmoplegia. A distinct “V-shaped” radiological feature can be seen in bilateral CPMI patients. The primary mechanisms of unilateral CPMI involve small vessel disease. The underlying stroke mechanisms of bilateral CPMI are either large artery atherosclerosis disease or cardiac embolism.

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Acknowledgements

The authors thank Longnv Luo and Daokuan Zhou for their assistance in preparation of the manuscript.

Funding

This work was supported by Key Research Program for Higher Education of Henan Province, China (ID 18A320071)

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Authors and Affiliations

  1. Department of Neurology, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, China

    Chenguang Zhou, Yuanhong He, Yinghui Zhu, Yuanzheng Zhao & Peng Wang

  2. Department of Neurology, Zheng Zhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, 450052, Henan, China

    Zhiqiang Xu

  3. Department of Radiology, Affiliated Houjie Hospital of Guang Dong Medical University, Guangzhou, China

    Botao Huang

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  1. Chenguang Zhou
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  2. Zhiqiang Xu
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  5. Yinghui Zhu
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Correspondence to Chenguang Zhou or Yuanhong He.

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We declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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This retrospective study was approved by the Institutional Review Board of the affiliated hospital of the Fifth Affiliated Hospital of Zhengzhou University. All procedures performed in studies were in accordance with the ethical standards of the Institutional Review Board of the affiliated hospital of the Fifth Affiliated Hospital of Zhengzhou University and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Zhou, C., Xu, Z., Huang, B. et al. Caudal paramedian midbrain infarction: a clinical study of imaging, clinical features and stroke mechanisms. Acta Neurol Belg 121, 443–450 (2021). https://doi.org/10.1007/s13760-019-01204-5

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  • DOI: https://doi.org/10.1007/s13760-019-01204-5

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