Isolated acute pseudobulbar palsy with infarction of artery of percheron: case report and literature review

Introduction: Pseudobulbar palsy (PBP) is characterized by supranuclear lesions in the corticobulbar pathway. Neoplasia, inflammatory, demyelinating, and stroke are possible etiologies of this disorder. Case report: We report an elderly female who presented with dysarthria. She was dysarthric with a hypernasal voice, no apraxia or aphasia was observed. Tongue movements were slow with limited amplitude. Her soft palate dropped bilaterally; gag reflex was present. Also, she reported swallowing difficulty and choking with her saliva. Bilateral vertical and horizontal gaze were intact to either voluntary or oculocephalic movements. A cranial CT scan was suggestive of artery of Percheron (AOP) infarction. Brain magnetic resonance imaging showed hypersignal on diffusion-weighted and T2-weighted images and hyposignal on apparent diffusion coefficient in both thalami. CT angiography scan revealed an AOP originating from the left posterior cerebral artery. The swallowing study with a videofluoroscopic demonstrated oral and pharyngeal phases with severe dysfunction. Conclusion: To the authors’ knowledge, there are two cases of individuals with artery of Percheron infarction who devel- oped PBP associated with other clinical syndromes. Still, isolated PBP following infarction of Percheron’s artery was not reported. We hypothesized that the PBP may have occurred because of the existence of vascular territory variations in the perforating arteries that arise from the AOP. Keywords: Pseudobulbar palsy; thalamus; infarction.

Foix-Chavany-Marie Syndrome as a Manifestation of Unilateral Opercular Stroke

Introduction: Foix-Chavany-Marie syndrome (FCMS) is a type of pseudobulbar palsy that affects facio-pharyngo-glosso-masticatory muscles. Materials and Methods: A 62-year-old man was admitted to the emergency department after 9 hours of acute dysarthria and dysphagia. MRI showed restricted diffusion in the right operculum on diffusion-weighted imaging (DWI). No thrombolytic therapy was given. The patient had a history of mechanical aortic valve replacement under anticoagulation with a vitamin K antagonist. Work-up demonstrated suboptimal levels of INR. Due to severe dysphagia during hospitalization, a percutaneous endoscopic gastrostomy (PEG) was performed. Results: The patient was discharged 5 days later, with a modified Rankin scale (mRs) score of 3, and secondary stroke prevention. He had achieved an excellent functional outcome (mRs 1) at 6-month follow-up. Conclusion: Our patient had a satisfactory recovery due to prompt diagnosis, secondary stroke prevention, and compliance with treatment.

Dysphagia Associated with Neurological Disorders

Neurogenic dysphagia is characterized by problems with neural control of swallowing caused by various neurological diseases: vascular diseases, traumatic diseases, neoplasms, infections, neuromuscular diseases, and others. In patients of intensive care units after long-term intubation and extubation may evolve “postextubation dysphagia”, characterized by the “learned non-use” phenomenon. Neurogenic dysphagia is a component of bulbar or pseudobulbar palsy, depending on the level of the neurological lesion. Diagnoses of neurogenic dysphagia include clinical examination (water swallow test), videofluoroscopy, upper gastrointestinal tract endoscopy and manometry, fiberoptic endoscopic evaluation of swallowing, a grade of Penetration-Aspiration Scale, and Fiberoptic Endoscopic Dysphagia Severity Scale. Dysphagia complications (malnutrition, dehydration, weight loss, aspiration, and respiratory tract obstruction) associated with bad functional recovery and life prognosis, so neurogenic dysphagia need a complex treatment: correct feeding pattern of caloric value and consistency, methods of oral cavity mucosa sensitivity stimulation, swallowing process stimulation, physiotherapeutic treatment methods (electrical stimulation of the larynx and tongue root), logopedic exercises therapy, surgical correction, lifestyle correction, and others. Sometimes it is a need for replacement therapy method by nasogastric tube and percutaneous endoscopic gastrostomy, parenteral feeding in several cases. Neurogenic dysphagia patient rehabilitation includes the “swallowing enhancement” method with optimal food consistency and training method after correct preparation of the oral cavity for swallowing. Neurogenic dysphagia patient oral feeding requires correct technique and contact with the patient for safety and efficient recovery.

Surgical repair of humerus fracture in a patient with central pontine myelinolysis

Introduction Central pontine myelinolysis (CPM) is a rare neurologic disorder involving severe damage to the myelin sheath of nerve cells in the pons. Clinical features usually include tetraparesis, pseudobulbar palsy and altered mental status. Objective To review a case of humerus fracture in a female with CPM. Material and methods A 65-year-old patient with CPM sustained humerus fracture that was first treated conservatively. With two neurological examinations and a clinical case conference the humerus fracture of the high-risk patient was nailed. Results No neurological deterioration was observed postoperatively. A satisfactory bone alignment was noted radiologically. The patient was discharged from the hospital with a satisfactory outcome. Discussion The favorable outcome suggests that patients with CPM can benefit from surgical treatment. Conclusion CPM cannot be considered an absolute contraindication for surgical treatment, however, further study is required.

A-076 Acute Pontine Infarction and Deep White Matter Lesioning: Poly-etiologic Factors and Clinical Correlation with Neuropsychological Impairment and Neuroradiographic Findings

Objective Pontine infarction may include motor and sensory disturbances, eye movement disorders, cranial nerve palsies, vestibular system symptoms, dizziness, ataxia, transient loss of consciousness, tetraparesis, acute pseudobulbar palsy, and severe sensory-motor deficits (Kumral, Bayülkem, & Evyapan, 2002). Studies of clinical/. neuroradiological correlation are not abundant in the literature (Kim, Lee, Joo, Im, & Lee, 1996). Methods The present case involves a 67-year-old, right-handed Caucasian female with a medical history of hypertension, headaches, hypothyroidism, cardiovascular disease (triple bypass), chronic obstructive pulmonary disease, diabetes mellitus, and abdominal aortic aneurysm. She was referred for neuropsychological testing to evaluate deficits. related to her acute pontine stroke. Results Neuropsychological testing revealed neuropsychological impairment characterized by visual-perceptual motor and visual memory deficits, executive dysfunction, lack of concern/awareness of deficits (anosodiaphoria), decreased impulse control and disinhibition. Bi-hemispheric, cortical/subcortical pathway elements, and a preponderance of right hemisphere involvement correlated with neuroradiographic evidence. MRIs revealed a punctate acute infarct within the right paracentral pons, a. small focus of gradient susceptibility within the parasagittal right parietal lobe, and a left pons and deep ischemic white matter lesioning of the posterior left frontal lobe. Conclusion The present case provided a rare look at poly-etiologic factors associated with acute pontine infarct and associated deep ischemic white matter changes.Neuropsychological testing elucidated the severity and type of neuropsychological impairment which correlated with MRI neuroradiographic findings, and was instrumental in patient interventions. Neurocognitive rehabilitation and formal driving evaluation, given the patient’s visual-perceptual motor and visual memory difficulties and lack of concern/awareness of deficits, protected the patient, family and public.