Acta Neurol Belg DOI 10.1007/s13760-013-0274-7
NEURO-IMAGES
Pontine watershed infarction Dimitri Renard • Jonathan Broner Anne Le Floch
•
Received: 18 November 2013 / Accepted: 23 December 2013 Ó Belgian Neurological Society 2014
A 45-year-old man with a history of overweight, smoking, and untreated hypercholesterolemia presented with acute onset vertigo, nausea, right-sided tinnitus, and drowsiness. Clinical examination revealed a Glasgow coma scale of 14/15 (with decreased alertness but arousable by minor stimulation) and skew deviation (i.e., right higher than left eye), in the absence of other abnormalities. MRI showed an acute pontine infarction in the watershed area between the anteromedial/anterolateral and the lateral group of penetrating small arteries and a small size infarction in the lateral pontine tegmentum, together with a focal moderate stenosis of the basilar artery on the level corresponding to the level of the brainstem infarction (Fig. 1). Acetylsalicylic acid 160 mg od was started. Transthoracic and transoesophageal echocardiography, Holter ECG, extensive testing in search for coagulation abnormalities were all normal, whereas duplex scanning revealing the presence of non-stenotic carotid atheromatous plaques. Clinical signs disappeared progressively during the following days. Few reports describe brainstem watershed infarctions. Arterial supply of the brainstem is mainly based on the anteromedial and anterolateral arterial groups of penetrating small arteries both arising from the basilar artery, and the lateral group of penetrating small arteries arising from both the anterior inferior cerebellar artery (AICA) and the basilar artery [1]. Associated involvement of small arteries arising from the AICA could be suspected in our patient because of the presence of tinnitus, probably explained by hypoperfusion of the labyrinthine artery (usually arising from the AICA although anatomical variants—e.g., from D. Renard (&) J. Broner A. Le Floch Department of Neurology, CHU Nıˆmes, Hoˆpital Caremeau, Place Du Pr Debre´, 30029 Nıˆmes Cedex 4, France e-mail: [email protected]
the posterior inferior cerebellar artery or directly from the basilar artery—have been described). The associated small size infarction in the lateral pontine tegmentum corresponds probably also to a terminal perfusion zone of the anteromedial/anterolateral group, the lateral group, and the posterior group (arising from the superior cerebellar artery) of penetrating small arteries, sometimes also described as watershed infarction zone in the fetal and neonatal brainstem [1, 2]. Pontine infarction in the territory of the paramedian (corresponding to the anteromedial arterial group of penetrating arteries) or circumferential branches (corresponding to the lateral arterial group of penetrating arteries) of the basilar artery are though to be due to atheromatous branch occlusion related to local occlusion of the months of perforators due to a basilar artery atheromatous plaque (potentially associated with recent plaque rupture or intraplaque hemorrhage) [3, 4]. The focal stenosis of the basilar artery in our patient probably corresponded to an atheromatous plaque. Conflict of interest
We have no conflict of interest to declare.
References 1. Tatu L, Moulin T, Vuillier F, Bogousslavsky J (2012) Arterial territories of the human brain. Front Neurol Neurosci 30:99–110 2. Sarnat HB (2004) Watershed infarcts in the fetal and neonatal brainstem. An aetiology of central hypoventilation, dysphagia, Mo¨ibius syndrome and micrognathia. Eur J Paediatr Neurol 8:71–87 3. Ga´llego Cullere´ J, Erro Aguirre ME (2011) Basilar branch occlusion. Curr Treat Options Cardiovasc Med 13:247–260 4. Klein IF, Lavalle´e PC, Mazighi M, Schouman-Claeys E, Labreuche J, Amarenco P (2010) Basilar artery atherosclerotic plaques in paramedian and lacunar pontine infarctions: a high-resolution MRI study. Stroke 41:1405–1409
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Acta Neurol Belg
Fig. 1 DWI MRI (a) showing the presence of an acute pontine infarction in the watershed area (large arrowhead) between the anteromedial (small white arrow)/anterolateral (large white arrow) and the lateral group (black arrow) of penetrating small arteries and a
123
small size infarction in the lateral pontine tegmentum (small arrowhead). TOF sequences (b) reveal a focal moderate stenosis of the basilar artery (arrow)
NEURO-IMAGES
Pontine watershed infarction Dimitri Renard • Jonathan Broner Anne Le Floch
•
Received: 18 November 2013 / Accepted: 23 December 2013 Ó Belgian Neurological Society 2014
A 45-year-old man with a history of overweight, smoking, and untreated hypercholesterolemia presented with acute onset vertigo, nausea, right-sided tinnitus, and drowsiness. Clinical examination revealed a Glasgow coma scale of 14/15 (with decreased alertness but arousable by minor stimulation) and skew deviation (i.e., right higher than left eye), in the absence of other abnormalities. MRI showed an acute pontine infarction in the watershed area between the anteromedial/anterolateral and the lateral group of penetrating small arteries and a small size infarction in the lateral pontine tegmentum, together with a focal moderate stenosis of the basilar artery on the level corresponding to the level of the brainstem infarction (Fig. 1). Acetylsalicylic acid 160 mg od was started. Transthoracic and transoesophageal echocardiography, Holter ECG, extensive testing in search for coagulation abnormalities were all normal, whereas duplex scanning revealing the presence of non-stenotic carotid atheromatous plaques. Clinical signs disappeared progressively during the following days. Few reports describe brainstem watershed infarctions. Arterial supply of the brainstem is mainly based on the anteromedial and anterolateral arterial groups of penetrating small arteries both arising from the basilar artery, and the lateral group of penetrating small arteries arising from both the anterior inferior cerebellar artery (AICA) and the basilar artery [1]. Associated involvement of small arteries arising from the AICA could be suspected in our patient because of the presence of tinnitus, probably explained by hypoperfusion of the labyrinthine artery (usually arising from the AICA although anatomical variants—e.g., from D. Renard (&) J. Broner A. Le Floch Department of Neurology, CHU Nıˆmes, Hoˆpital Caremeau, Place Du Pr Debre´, 30029 Nıˆmes Cedex 4, France e-mail: [email protected]
the posterior inferior cerebellar artery or directly from the basilar artery—have been described). The associated small size infarction in the lateral pontine tegmentum corresponds probably also to a terminal perfusion zone of the anteromedial/anterolateral group, the lateral group, and the posterior group (arising from the superior cerebellar artery) of penetrating small arteries, sometimes also described as watershed infarction zone in the fetal and neonatal brainstem [1, 2]. Pontine infarction in the territory of the paramedian (corresponding to the anteromedial arterial group of penetrating arteries) or circumferential branches (corresponding to the lateral arterial group of penetrating arteries) of the basilar artery are though to be due to atheromatous branch occlusion related to local occlusion of the months of perforators due to a basilar artery atheromatous plaque (potentially associated with recent plaque rupture or intraplaque hemorrhage) [3, 4]. The focal stenosis of the basilar artery in our patient probably corresponded to an atheromatous plaque. Conflict of interest
We have no conflict of interest to declare.
References 1. Tatu L, Moulin T, Vuillier F, Bogousslavsky J (2012) Arterial territories of the human brain. Front Neurol Neurosci 30:99–110 2. Sarnat HB (2004) Watershed infarcts in the fetal and neonatal brainstem. An aetiology of central hypoventilation, dysphagia, Mo¨ibius syndrome and micrognathia. Eur J Paediatr Neurol 8:71–87 3. Ga´llego Cullere´ J, Erro Aguirre ME (2011) Basilar branch occlusion. Curr Treat Options Cardiovasc Med 13:247–260 4. Klein IF, Lavalle´e PC, Mazighi M, Schouman-Claeys E, Labreuche J, Amarenco P (2010) Basilar artery atherosclerotic plaques in paramedian and lacunar pontine infarctions: a high-resolution MRI study. Stroke 41:1405–1409
123
Acta Neurol Belg
Fig. 1 DWI MRI (a) showing the presence of an acute pontine infarction in the watershed area (large arrowhead) between the anteromedial (small white arrow)/anterolateral (large white arrow) and the lateral group (black arrow) of penetrating small arteries and a
123
small size infarction in the lateral pontine tegmentum (small arrowhead). TOF sequences (b) reveal a focal moderate stenosis of the basilar artery (arrow)
