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Rapalino O, Pourvaziri A, Maher M, Jaramillo-Cardoso A, Edlow BL, Conklin J, Huang S, Westover B, Romero JM, Halpern E, Gupta R, Pomerantz S, Schaefer P, Gonzalez RG, Mukerji SS, Lev MH. Clinical, Imaging, and Lab Correlates of Severe COVID-19 Leukoencephalopathy. AJNR Am J Neuroradiol 2021; 42:632-638. [PMID: 33414226 DOI: 10.3174/ajnr.a6966] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 10/28/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND PURPOSE Patients infected with the Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) can develop a spectrum of neurological disorders, including a leukoencephalopathy of variable severity. Our aim was to characterize imaging, lab, and clinical correlates of severe coronavirus disease 2019 (COVID-19) leukoencephalopathy, which may provide insight into the SARS-CoV-2 pathophysiology. MATERIALS AND METHODS Twenty-seven consecutive patients positive for SARS-CoV-2 who had brain MR imaging following intensive care unit admission were included. Seven (7/27, 26%) developed an unusual pattern of "leukoencephalopathy with reduced diffusivity" on diffusion-weighted MR imaging. The remaining patients did not exhibit this pattern. Clinical and laboratory indices, as well as neuroimaging findings, were compared between groups. RESULTS The reduced-diffusivity group had a significantly higher body mass index (36 versus 28 kg/m2, P < .01). Patients with reduced diffusivity trended toward more frequent acute renal failure (7/7, 100% versus 9/20, 45%; P = .06) and lower estimated glomerular filtration rate values (49 versus 85 mL/min; P = .06) at the time of MRI. Patients with reduced diffusivity also showed lesser mean values of the lowest hemoglobin levels (8.1 versus 10.2 g/dL, P < .05) and higher serum sodium levels (147 versus 139 mmol/L, P = .04) within 24 hours before MR imaging. The reduced-diffusivity group showed a striking and highly reproducible distribution of confluent, predominantly symmetric, supratentorial, and middle cerebellar peduncular white matter lesions (P < .001). CONCLUSIONS Our findings highlight notable correlations between severe COVID-19 leukoencephalopathy with reduced diffusivity and obesity, acute renal failure, mild hypernatremia, anemia, and an unusual brain MR imaging white matter lesion distribution pattern. Together, these observations may shed light on possible SARS-CoV-2 pathophysiologic mechanisms associated with leukoencephalopathy, including borderzone ischemic changes, electrolyte transport disturbances, and silent hypoxia in the setting of the known cytokine storm syndrome that accompanies severe COVID-19.
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Affiliation(s)
- O Rapalino
- From the Department of Radiology (O.R., A.P., M.M., A.J.-C., J.C., S.H., J.M.R., R.G., S.P., P.S., R.G.G., M.H.L.)
| | - A Pourvaziri
- From the Department of Radiology (O.R., A.P., M.M., A.J.-C., J.C., S.H., J.M.R., R.G., S.P., P.S., R.G.G., M.H.L.)
| | - M Maher
- From the Department of Radiology (O.R., A.P., M.M., A.J.-C., J.C., S.H., J.M.R., R.G., S.P., P.S., R.G.G., M.H.L.)
| | - A Jaramillo-Cardoso
- From the Department of Radiology (O.R., A.P., M.M., A.J.-C., J.C., S.H., J.M.R., R.G., S.P., P.S., R.G.G., M.H.L.)
| | | | - J Conklin
- From the Department of Radiology (O.R., A.P., M.M., A.J.-C., J.C., S.H., J.M.R., R.G., S.P., P.S., R.G.G., M.H.L.)
| | - S Huang
- From the Department of Radiology (O.R., A.P., M.M., A.J.-C., J.C., S.H., J.M.R., R.G., S.P., P.S., R.G.G., M.H.L.)
| | | | - J M Romero
- From the Department of Radiology (O.R., A.P., M.M., A.J.-C., J.C., S.H., J.M.R., R.G., S.P., P.S., R.G.G., M.H.L.)
| | - E Halpern
- Institute for Technology Assessment (E.H.), Massachusetts General Hospital, Boston, Massachusetts
| | - R Gupta
- From the Department of Radiology (O.R., A.P., M.M., A.J.-C., J.C., S.H., J.M.R., R.G., S.P., P.S., R.G.G., M.H.L.)
| | - S Pomerantz
- From the Department of Radiology (O.R., A.P., M.M., A.J.-C., J.C., S.H., J.M.R., R.G., S.P., P.S., R.G.G., M.H.L.)
| | - P Schaefer
- From the Department of Radiology (O.R., A.P., M.M., A.J.-C., J.C., S.H., J.M.R., R.G., S.P., P.S., R.G.G., M.H.L.)
| | - R G Gonzalez
- From the Department of Radiology (O.R., A.P., M.M., A.J.-C., J.C., S.H., J.M.R., R.G., S.P., P.S., R.G.G., M.H.L.)
| | | | - M H Lev
- From the Department of Radiology (O.R., A.P., M.M., A.J.-C., J.C., S.H., J.M.R., R.G., S.P., P.S., R.G.G., M.H.L.)
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Juneja A, Anand K, Goyal H. Bilateral middle cerebellar peduncle infarction. INDIAN JOURNAL OF MEDICAL SPECIALITIES 2021. [DOI: 10.4103/injms.injms_1_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Jiang J, Wang J, Lin M, Wang X, Zhao J, Shang X. Bilateral middle cerebellar peduncle lesions: Neuroimaging features and differential diagnoses. Brain Behav 2020; 10:e01778. [PMID: 32755074 PMCID: PMC7559600 DOI: 10.1002/brb3.1778] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 07/16/2020] [Accepted: 07/19/2020] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES Lesions limited to the bilateral middle cerebellar peduncles (MCPs) are uncommon. This retrospective study investigated diseases with a proclivity for the bilateral MCPs and explored the associations between their neuroimaging features and clinical findings for the differential diagnosis of such lesions. METHODS We enrolled 26 patients who were admitted to our department between January 2016 and March 2019 with bilateral MCP abnormalities on magnetic resonance imaging (MRI). The demographic, clinical, and neuroimaging characteristics, and the biomarkers and diagnoses were evaluated. RESULTS Although all patients exhibited symmetrical bilateral MCP hypointensities on T1-weighted imaging and hyperintensities on T2-weighted and fluid-attenuated inversion recovery imaging, they were diagnosed with different conditions. Diagnoses included acute cerebral infarction (ACI) (n = 9, 34.62%), Wallerian degeneration (WD) (n = 8, 30.77%), multiple system atrophy (MSA) (n = 6, 23.08%), neuromyelitis optica (NMO) (n = 1, 3.85%), heroin-induced leukoencephalopathy (n = 1, 3.85%), and primary central nervous system lymphoma (PCNSL) (n = 1, 3.85%). Patients with ACI exhibited bilateral MCP-restricted diffusion hyperintensities on diffusion-weighted imaging and corresponding stenosis or occlusion of the vertebrobasilar system. The initial MRI of patients with WD depicted pontine infarctions, while symmetrical MCP lesions were observed on follow-up MRI. Symmetrical MCP lesions, cruciform hyperintensity, and marked atrophy in the posterior fossa were characteristic manifestations of MSA. Longitudinally extensive myelitis affecting more than three vertebral segments on cervical MRI and positive serum AQP4-IgG may be indicative of NMO. Heroin-induced leukoencephalopathy was characterized by extra-symmetrical lesions in the posterior limbs of the internal capsules, while the anterior limbs were spared. PCNSL was indicated by a significant and characteristic "fist" sign on contrast-enhanced MRI. CONCLUSIONS Bilateral MCP lesions were most frequently observed in cerebrovascular diseases, followed by neurodegenerative diseases, inflammatory diseases, toxic encephalopathies, and lymphomas. Our findings demonstrate that bilateral MCP signal abnormalities are more common in patients with ACI and WD, with fewer degenerative processes than previously believed. The high frequency of WD may be attributed to the specific awareness of this pathology. WD can also present with stage-related restricted diffusion and should not be mistaken for a new infarction. The symmetrical bilateral MCP hypointensities on T1-weighted imaging and hyperintensities on T2-weighted imaging often raise concern regarding a demyelinating process. Our findings emphasize that neurologists should consider the aforementioned conditions and correlate the specific neuroimaging characteristics and medical history before arriving at the final diagnosis.
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Affiliation(s)
- Jiwei Jiang
- Department of Neurology, The First Affiliated Hospital of China Medical University, Shenyang City, Liaoning Province, China
| | - Jirui Wang
- Department of Neurology, The First Affiliated Hospital of China Medical University, Shenyang City, Liaoning Province, China
| | - Meiqing Lin
- Department of Neurology, The First Affiliated Hospital of China Medical University, Shenyang City, Liaoning Province, China
| | - Xiaoting Wang
- Department of Neurology, The First Affiliated Hospital of China Medical University, Shenyang City, Liaoning Province, China
| | - Jinli Zhao
- Department of Radiology, The First Affiliated Hospital of China Medical University, Shenyang City, Liaoning Province, China
| | - Xiuli Shang
- Department of Neurology, The First Affiliated Hospital of China Medical University, Shenyang City, Liaoning Province, China
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Zhou C, Fan H, Chen H, Wang H, Li Z, Xu N, Sun R, Zhu Y, He Y. Evaluation of Clinical Features and Stroke Etiology in Patients with Bilateral Middle Cerebellar Peduncle Infarction. Eur Neurol 2020; 83:271-278. [PMID: 32712611 DOI: 10.1159/000508835] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 05/11/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of this study was to characterize clinical features, etiologies, and mechanisms of strokes due to bilateral middle cerebellar peduncle infarction (BMCPI). METHODS Cases diagnosed as BMCPI in our hospital were retrieved, and a literature review was performed. Data on clinical features and brain MRI were obtained. Extracranial and intracranial segments of the vertebrobasilar artery were assessed by using digital subtraction angiography, magnetic resonance angiography, or computed tomography angiography. RESULTS Thirteen cases (11 men and 2 women) of BMCPI were identified. A high-intensity signal of diffusion-weighted imaging sequence involving the bilateral middle cerebellar peduncle was observed in all patients. Most patients experienced vertigo, dysarthria, ataxia, and hearing disorders. Eleven of these cases were classified as large artery atherosclerosis, one as traumatic vertebral artery (VA) dissection, and one as giant cell arteritis. CONCLUSION BMCPI is a rare cerebrovascular disease characterized by vertigo, ataxia, and dysarthria, which may also be accompanied by a hearing deficit or clinical signs of brainstem damage. BMCPI may be associated with hypoperfusion secondary to occlusive disease of the bilateral VA or proximal basilar artery.
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Affiliation(s)
- Chenguang Zhou
- Department of Neurology, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China,
| | - Haixia Fan
- Department of Neurology, The First Hospital of ShanXi Medical University, Taiyuan, China
| | - Hao Chen
- Department of Neurology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Haoyue Wang
- Department of Neurology, Lanzhou University Second Hospital, Lanzhou, China
| | - Zuopeng Li
- Department of Neurology, The First Hospital of ShanXi Medical University, Taiyuan, China
| | - Ning Xu
- Department of Neurology, First People Hospital of Jinan, Jinan, China
| | - Ruonan Sun
- Department of Neurology, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yinghui Zhu
- Department of Neurology, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuanhong He
- Department of Neurology, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Shen Y, Jian W, Li J, Dai T, Bao B, Nie H. Bilateral wallerian degeneration of the middle cerebellar peduncles secondary to pontine infarction: A case series. J Neurol Sci 2018; 388:182-185. [PMID: 29627018 DOI: 10.1016/j.jns.2018.03.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Revised: 03/10/2018] [Accepted: 03/15/2018] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Wallerian degeneration (WD) of middle cerebellar peduncles (MCPs) secondary to pontine infarction is rarely reported in the literature. Our aim in this study is to characterize its clinical and neuroradiological features. METHODS A retrospective review of 7 patients from a single institution was conducted. Only patients with pontine infarction and subsequent degeneration of the MCPs were included in the analysis. The features of clinical presentation and neuroimaging finding were summarized by our experienced neurologists. RESULTS Seven patients (5 male, 2 female), ranging in age from 50 to 77 years, satisfied the inclusion criteria. All patients had cardiovascular risk factors and hypertension was the most common one. Almost all of the patients had hemiparesis and dysarthria, and could achieved good clinical outcome. On the initial scan, hyperintense on T2- and diffusion-weighted images suggested the acute pontine infarction. On the follow-up scan, however, hyperintensities of bilateral MCPs on T2-weight and FLAIR images were apparently demonstrated in all patients. The specific lesions in the MCPs were attributed to bilateral WD of the pontocerebellar fibres secondary to pontine infarction. CONCLUSION WD should be taken into account when patients are initially diagnosed with paramedian pontine infarction and follow-up MRI manifest as symmetrical hyperintense in the MCPs.
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Affiliation(s)
- Yaoyao Shen
- Institute: Department of Neurology, The Affiliated Hospital of Jiujiang University, Address: No.57 Xunyang East Rode, Xunyang District, Jiujiang 332000, Jiangxi Province, China.
| | - Wen Jian
- Institute: Department of Neurology, The People's Hospital of Xinyu City, Address: No.369 Xinxin North Rode, Yushui District, Xinyu 338000, Jiangxi Province, China
| | - Juan Li
- Institute: Department of Neurology, The Second Affiliated Hospital of Nanchang University, Address: No.1 Mingde Rode, Donghu District, Nanchang 330006, Jiangxi Province, China
| | - Tingmin Dai
- Institute: Department of Neurology, The Affiliated Hospital of Jiujiang University, Address: No.57 Xunyang East Rode, Xunyang District, Jiujiang 332000, Jiangxi Province, China
| | - Bing Bao
- Institute: Department of Neurology, The Affiliated Hospital of Jiujiang University, Address: No.57 Xunyang East Rode, Xunyang District, Jiujiang 332000, Jiangxi Province, China
| | - Hongbing Nie
- Institute: Department of Neurology, The Affiliated Hospital of Jiujiang University, Address: No.57 Xunyang East Rode, Xunyang District, Jiujiang 332000, Jiangxi Province, China.
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Dong Q, Jing G, Han J. The endovascular treatment of bilateral infarction of middle cerebellar peduncles. Etiology and endovascular treatment analysis. NEUROSCIENCES (RIYADH, SAUDI ARABIA) 2017; 22:56-61. [PMID: 28064332 PMCID: PMC5726839 DOI: 10.17712/nsj.2017.1.20160169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Infarction of the symmetrical middle cerebellar peduncles is often induced by ischemic cerebrovascular disease. Adams described the anterior inferior cerebellar artery (AICA) syndrome as early as 1943, but clinical and imaging studies following this failed to shed more light regarding the condition until the advent of magnetic resonance imaging that comprehension regarding AICA improved significantly. Infarction of the middle cerebellar peduncles (MCP) is uncommon and the endovascular treatment of this condition is even more rare. We studied 4 patients with simultaneous bilateral cerebellar infarction of whom 2 received intracranial vascular therapy and demonstrated improvement in symptoms. Our findings suggest that patients with vertebral basilar artery stenosis with potential bilateral cerebellar infarction may benefit from endovascular treatment.
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Affiliation(s)
- Qihao Dong
- Department of Neurology, Qianfoshan Hospital Affiliated to Shandong University, Jinan, Shandong, China
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Sosa P, Dujovny M, Onyekachi I, Sockwell N, Cremaschi F, Savastano LE. Microvascular anatomy of the cerebellar parafloccular perforating space. J Neurosurg 2016; 124:440-9. [DOI: 10.3171/2015.2.jns142693] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
The cerebellopontine angle is a common site for tumor growth and vascular pathologies requiring surgical manipulations that jeopardize cranial nerve integrity and cerebellar and brainstem perfusion. To date, a detailed study of vessels perforating the cisternal surface of the middle cerebellar peduncle—namely, the paraflocculus or parafloccular perforating space—has yet to be published. In this report, the perforating vessels of the anterior inferior cerebellar artery (AICA) in the parafloccular space, or on the cisternal surface of the middle cerebellar peduncle, are described to elucidate their relevance pertaining to microsurgery and the different pathologies that occur at the cerebellopontine angle.
METHODS
Fourteen cadaveric cerebellopontine cisterns (CPCs) were studied. Anatomical dissections and analysis of the perforating arteries of the AICA and posterior inferior cerebellar artery at the parafloccular space were recorded using direct visualization by surgical microscope, optical histology, and scanning electron microscope. A comprehensive review of the English-language and Spanish-language literature was also performed, and findings related to anatomy, histology, physiology, neurology, neuroradiology, microsurgery, and endovascular surgery pertaining to the cerebellar flocculus or parafloccular spaces are summarized.
RESULTS
A total of 298 perforating arteries were found in the dissected specimens, with a minimum of 15 to a maximum of 26 vessels per parafloccular perforating space. The average outer diameter of the cisternal portion of the perforating arteries was 0.11 ± 0.042 mm (mean ± SD) and the average length was 2.84 ± 1.2 mm. Detailed schematics and the surgical anatomy of the perforating vessels at the CPC and their clinical relevance are reported.
CONCLUSIONS
The parafloccular space is a key entry point for many perforating vessels toward the middle cerebellar peduncle and lateral brainstem, and it must be respected and protected during surgical approaches to the cerebellopontine angle.
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Affiliation(s)
- Pablo Sosa
- 1Department of Neuroscience, Clinical and Surgical Neurology, School of Medicine, National University of Cuyo, Mendoza, Argentina
| | - Manuel Dujovny
- 2Departments of Neurosurgery and Electrical Engineering, Wayne State University, Detroit; and
| | - Ibe Onyekachi
- 2Departments of Neurosurgery and Electrical Engineering, Wayne State University, Detroit; and
| | - Noressia Sockwell
- 2Departments of Neurosurgery and Electrical Engineering, Wayne State University, Detroit; and
| | - Fabián Cremaschi
- 1Department of Neuroscience, Clinical and Surgical Neurology, School of Medicine, National University of Cuyo, Mendoza, Argentina
| | - Luis E. Savastano
- 3Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
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Thabet FI, Khalil S, Naz F, Dyme IZ. Cerebellar mutism and reversible cytotoxic edema in influenza B-associated encephalopathy. Pediatr Neurol 2013; 49:489-92. [PMID: 24095574 DOI: 10.1016/j.pediatrneurol.2013.06.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2013] [Revised: 05/29/2013] [Accepted: 06/01/2013] [Indexed: 11/24/2022]
Abstract
BACKGROUND Influenza virus-associated neurological complications are rare, though well-documented, especially in children. Encephalopathy and seizures are the most common complications and are typically associated with influenza A infection. Cerebellar mutism has been rarely reported in association with influenza B infection. PATIENT We describe a 3-year-old boy who presented with cough, fever, altered mental status, seizure, hypotonia, and mutism. He tested positive for influenza B virus. His brain magnetic resonance imaging showed reversible cytotoxic edema limited to the middle cerebellar peduncles and the dentate nuclei. Other viral, vascular, toxic, and metabolic causes were ruled out. CONCLUSION Our patient represents a case of cerebellar mutism associated with influenza B encephalopathy in which the brain magnetic resonance imaging scan showed reversible cytotoxic edema limited to the middle cerebellar peduncles and the dentate nuclei. This clinicoradiological correlation supports other reports in which the dentate nuclei play a major rule in the pathogenesis of cerebellar mutism.
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Affiliation(s)
- Farouq I Thabet
- Department of Pediatrics and Human Development, Michigan State University, Lansing, Michigan.
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John S, Hegazy M, Cheng Ching E, Katzan I. Isolated Bilateral Middle Cerebellar Peduncle Infarcts. J Stroke Cerebrovasc Dis 2013; 22:e645-6. [DOI: 10.1016/j.jstrokecerebrovasdis.2013.03.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Revised: 03/28/2013] [Accepted: 03/30/2013] [Indexed: 10/26/2022] Open
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Roh SY, Jang HS, Kim YH. Hot cross bun sign following bilateral pontine infarction: a case report. J Mov Disord 2013; 6:37-9. [PMID: 24868425 PMCID: PMC4027643 DOI: 10.14802/jmd.13009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2013] [Revised: 09/02/2013] [Accepted: 09/10/2013] [Indexed: 11/24/2022] Open
Abstract
The hot cross bun sign is characterized by cruciform T2 signal hyperintensity in the pons and has been reported to be a specific but not pathognomic for multiple system atrophy. It reflects degeneration of pontine neurons and transverse pontocerebellar fibers, regardless of the underlying pathogenic process. Here, we report a case of hot cross bun sign following bilateral pontine infarction due to Wallerian degeneration of the pontocerebellar fibers.
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Affiliation(s)
- Sook Young Roh
- Departments of Neurology, Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Hyun-Soon Jang
- Departments of Neurology, Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Yoon Hee Kim
- Neuroradiology, Bundang Jesaeng General Hospital, Seongnam, Korea
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