The Guillain-Mollaret triangle: a key player in motor coordination and control with implications for neurological disorders

Early-Onset Palatal Myoclonus in Wernekink Commissure Syndrome Secondary to Caudal Paramedian Midbrain Infarction: a Case Report and a Mini Review of the Literature

INTRODUCTION

Wernekinck commissure syndrome (WCS) is an extremely rare midbrain syndrome, which selectively destroys the decussation of the superior cerebellar peduncle and the central tegmental tract, which commonly presents with bilateral cerebellar ataxia, dysarthria, and internuclear ophthalmoplegia. Palatal myoclonus in Wernekinck commissure syndrome is uncommom and oftern occurs as a late phenomenon due to hypertrophic degeneration of bilateral inferior olivary nuclei.

MATERIAL AND METHOD

A patient with WCS, admitted to our hospital from December, 2023, was chosen for this study, and the syndrome's clinical manifestations, imaging features, and etiology were retrospectively analyzed based on the literatures. A 68-year-old right-handed East Asian man presented with dizziness, slurred speech, difficulty with swallowing and walking, and rhythmic contractions of the soft palate. He had several risk factors for ischemic cerebrovascular diseases (age, sex, dyslipide mia, hypertension and smoking history). Brain magnetic resonance imaging showed hyperintensity of DWI and hypointensity of ADC at the caudal midbrain which around the paramedian mesencephalic tegmentum anterior to the aqueduct of midbrain.

RESULTS

He was diagnosed with Wernekinck commissure syndrome (WCS) secondary to caudal paramedian midbrain infarction. He was started on dual antiplatelet therapy (aspirin and clopidogrel) and intensive statin therapy. Blood pressure and glucose were also adjusted. His symptoms improved rapidly, and he walked steadily and speak clearly after 7 days of treatment.

CONCLUSIONS

Palatal myoclonus is known to occur as a late phenomenon due to hypertrophic degeneration of bilateral inferior olivary nuclei. However, Our case suggests that palatal myoclonus can occur in the early stages in WCS.

Short-Term Efficacy of Cerebello-spinal tDCS and Body Weight-Supported Treadmill Training in the Hypertrophic Olivary Degeneration: a Rare Case Report

The present case study reported a patient diagnosed with hypertrophic olivary degeneration, a rare condition characterized by a trans-neuronal degeneration and signal enhancement in T2-weighted images on magnetic resonance imaging, usually caused by cerebral hemorrhage, cerebral infarction, and trauma. Furthermore, the relevant literature review was performed. The existing pharmacological treatment has limited clinical benefits on the patient. Since spontaneous remission hardly occurs in the disease, there are no other effective treatments. In this case, the patient was a 55-year-old Chinese male who presented progressive gait difficulty for several months due to both-sided ataxia. Neurological examination revealed upper extremity and lower limb bilateral spasticity, ataxia, slurred speech, and dysmetria. Therefore, our study treated the patient through the inventive application of cerebello-spinal transcranial direct current stimulation and body weight-supported treadmill training. After a 4-week treatment, the patient could walk independently, without aid, speeding up by 7%, as well as the ataxia symptoms, and balance has improved significantly. It was demonstrated in this case report that the combination of cerebello-spinal tDCS and body weight-supported treadmill training can be an effective treatment for patients with Hypertrophic olivary degeneration.

A Presentation of Meige Syndrome With Associated Upper Motor Neuron Symptoms

Meige syndrome (MS) is a cranial dystonia that involves blepharospasm and oromandibular dystonia. It can also evolve to include other adjacent muscle groups in the cervical region. It typically presents in middle-aged females, and while the disorder is relatively uncommon, its exact prevalence varies. Diagnosis is typically made with a thorough history and physical and workup to rule out other causes. Treatment options include medical management with gamma-aminobutyric acid (GABA) antagonists, dopamine antagonists, and anticholinergics for short-term management. Long-term treatment options are Botox and deep brain stimulation. This case report presents a 56-year-old female with a complex presentation of MS; the patient's symptoms progressed from isolated blepharospasms to involve orofacial and cervical musculature. A distinctive aspect of this case was the simultaneous presence of upper motor neuron (UMN) signs in the patient alongside acute to subacute compression fractures of the superior endplate of C7 and T3, as revealed by cervical spine imaging. Treatment with clonazepam led to significant symptomatic improvement, highlighting the importance of a multimodal approach in managing MS. This case underscores the need for careful clinical evaluation, collaboration with movement disorder specialists, and ongoing research efforts to enhance understanding and treatment of MS.

Investigations into the anatomical location, physiological function, clinical implications, and significance of the nucleus of Perlia

BACKGROUND

The article discusses the investigations into the nucleus of Perlia (NP), a spindle-shaped nucleus located in the dorsal aspect of the oculomotor complex. However, there is still debate over its exact location and function, with conflicting findings in nonhuman primates. Therefore, the current study aimed the describe the location, function, clinical and surgical implications of NP.

METHODS

A systematic review was conducted to identify studies related to the following MeSH terms: "perlia nucleus" OR "nucleus of "perlia" OR "convergence nucleus" OR "nucleus of convergence" OR "Perlia's nucleus". The search was conducted until September 2022.

RESULTS

The location of the NP has been consistently reported in various studies, with most describing it as situated ventral to the Edinger-Westphal nucleus (EW) and dorsomedial to the oculomotor complex. The incidence of the NP in humans has been reported to range from 9 to 40%. In primates, it was observed to be absent in 77% of midbrains, while well developed in 9%. It is also noted that the NP is not a single nucleus, but rather a group of nuclei that are interconnected and involved in the coordination of eye movements that contain parasympathetic neurons.

CONCLUSIONS

The study of the NP holds clinical implications for understanding the neural mechanisms underlying the irregularities in the pupillary light reflex, such as anisocoria or abnormal responses to light, diagnosis, and treatment of neurological disorders like Horner's syndrome, and management of eye movement disorders including one-and-a-half syndrome, vertical gaze palsy, skew deviation and ptosis. The current study also highlighted the limitations of previous studies, including variations in the reported prevalence of the NP, limitations of the histological techniques, and inconsistent findings across human and animal studies.

Volumetric and Asymmetric Index Analysis of Subcortical Structures in Multiple Sclerosis Patients: A Retrospective Study Using volBrain Software

Introduction Multiple sclerosis (MS) is a chronic and autoimmune disease that has a significant influence on the central nervous system, such as the brain and spinal cord, affecting millions of individuals globally. Understanding the connection between subcortical brain regions and MS is crucial for effective diagnostic and therapeutic approaches for treating this disabling disease. This study explores the relationship between volume and contours of asymmetry index of subcortical brain regions in individuals with MS using volBrain software (https://www.volbrain.net; developed by José V. Manjón (Valencia Polytechnic University, Valencia, Spain) and Pierrick Coupé (University of Bordeaux, Bordeaux, France)). Methods In our retrospective investigation, we admitted 100 Turkish individuals, comprising 50 patients diagnosed with relapsing-remitting MS (RRMS) (24 (48%) males and 26 (52%) females) and 50 healthy controls (23 (46%) males and 27 (54%) females), registered between October 2017 and February 2022 for five years and underwent assessment in the radiology department at the Teaching and Research Hospital of Kocaeli University; 1,150 Turkish patients were excluded from our study based on our exclusion criteria. We used magnetic resonance imaging with a 3-Tesla (3T) scanner and volBrain software to assess volumes (cm3) and asymmetry indexes due to asymmetry for different levels of atrophy of total intracranial, total brain, gray matter, white matter, and subcortical regions, the most affected regions in MS patients for both patient and control cohorts. Results Statistical analysis revealed a significant difference between patient and control groups (p < 0.001), with patient group mean age at 38.32 years and control group mean age at 32.88 years. Patient group exhibited lower values for total intracranial, total brain, gray matter, white matter, and cerebrospinal fluid volume compared to control group (p < 0.05). The results indicated a statistically significant decrease (p < 0.05) in the values for total intracranial and total brain volume, whereas all other values remained unchanged. We compared volumes of subcortical structures on the right and left sides and found that the putamen, thalamus, and globus pallidus had statistically lower values in the patient group than in the control group (p < 0.001), apart from the lateral ventricle. Furthermore, our retrospective investigation demonstrated a statistically significant difference in the globus pallidus asymmetry index, indicating a preference for the patient group (p < 0.05). A lower asymmetry index value signifies a larger volume for the right side of the subcortical regions of the brain when compared to the left side. Conclusion Brain atrophy, although characterized by irreversible tissue damage, is targeted by therapeutic interventions to prevent progression. It is, therefore, imperative to develop a universally accepted measurement standard for subcortical structures that also considers the inherent variability present within each structure. Our findings serve as an important basis and indicator for the determination of subcortical atrophy and asymmetry in MS, the prognosis of the disease, and the etiology of clinical symptoms. Subsequent research may benefit by adopting the novel approach of considering brain atrophy as an outcome rather than a predictor, thereby facilitating the elucidation of the intricate biological mechanisms that give rise to volume loss.

Physiotherapy Approach to an Internal Capsule Infarct With Upper Motor Neuron Facial Nerve Palsy: A Case Report

The internal capsule (IC) is a vital brain structure housing descending and ascending fiber tracts, with traditional assumptions about the corticobulbar and corticospinal tracts descending through the genu and anterior third of the posterior limb of internal capsule (PLIC), respectively. However, observations of IC infarctions reveal that symptoms often deviate from the expected fiber pattern, prompting a deeper exploration of these complexities. The posterior limb of the IC receives its blood supply from the lenticulostriate branches of the middle cerebral artery and the anterior choroidal artery (AChA). AChA infarctions present a diverse array of symptoms beyond the classic triad, reflecting the intricate vascular supply and lesion patterns within this region. We present a case of a 74-year-old male farmer with right-hand dominance, who experienced a fall resulting in head and right lower limb injuries. Subsequently, he developed weakness in his left upper and lower limbs, facial deviation, slurred speech, and swelling in the right lower limb. Following these symptoms, his family promptly brought him to the hospital on November 30, 2023. Extensive investigations, including magnetic resonance imaging (MRI), revealed a hyper-acute infarct in the posterior limb of the left IC. The patient was admitted to the intensive care unit (ICU) for three days and later shifted to the neurology ward where medical management was commenced, including physiotherapy protocol that was started on December 2, 2023. Physiotherapy interventions were designed to address the patient's weakness, altered sensation, and diminished reflexes. Therapeutic goals focused on preventing complications, improving posture, enhancing range of motion (ROM), and mitigating breathing difficulties and mobility issues. The physiotherapy aimed to enhance the patient's overall physical and mental well-being, emphasizing independence and improved quality of life. Regular assessments and adjustments to the therapeutic interventions were made based on the patient's progress. This case underscores the importance of tailored physiotherapy interventions in addressing the diverse manifestations of IC infarctions, contributing to a comprehensive understanding of rehabilitation strategies in neurologically compromised individuals.

A Rare Presentation of Idiopathic Unilateral Hypertrophic Olivary Degeneration

Hypertrophic olivary degeneration (HOD) is a rare form of trans-synaptic degeneration affecting the inferior olivary nucleus (ION). Its classical description involves a lesion in the Guillain-Mollaret triangle (GMT), characteristic imaging findings, and associated oculopalatal tremor. However, understanding of this disease entity is incomplete, as its overall rarity has limited strong classification. Case reports and small studies indicate that a variety of presentations can occur, including non-existent or non-classical lesions as well as variations in physical symptoms. Here we report the exceedingly rare case of idiopathic, nonlesional, unilateral HOD in a female patient.

Incidental Petrous Apex Cephalocele Presenting With Transient Global Amnesia: A Case Report and Rapid Literature Review

Transient global amnesia (TGA) constitutes a rare clinical entity that manifests with temporary memory without any other neurological manifestation. Several pathogenetic mechanisms have been implicated, including temporal hypoperfusion, venous congestion, and cortical spreading potentials. Accordingly, the only relevant imaging findings are hippocampal CA1 areas of restricted diffusion on diffusion-weighted images. In the current case report, we present the rare case of a patient with TGA associated with bilateral petrous apex cephalocele (PAC). A 63-year-old female presented with a single episode of transient memory. The brain MRI showed a bilateral PAC and an empty sella. The patient was neurologically intact upon examination and was conservatively managed. There was no symptom recurrence during the six months of follow-up. We hypothesize that the presence of the meningocele could be associated with the pathogenesis of TGA. To the best of our knowledge, this is the first case of a petrous apex meningocele presenting with TGA. Most previously reported patients were females in their fourth decade of life, usually presenting with headaches or incidentally. Almost half of the cases were bilateral, with an empty sella. Surgical treatment was reserved for symptomatic patients with cerebrospinal fluid leaks and excruciating trigeminal neuralgia. Patients with TGA may be associated with temporal lesions, including PAC. Likewise, PAC is an extremely rare clinical entity that could occasionally present with TGA.

Review on Emerging Therapeutic Strategies for Managing Cardiovascular Disease

Cardiovascular disease (CVD) remains a foremost global health concern, necessitating ongoing exploration of innovative therapeutic strategies. This review surveys the latest developments in cardiovascular therapeutics, offering a comprehensive overview of emerging approaches poised to transform disease management. The examination begins by elucidating the current epidemiological landscape of CVD and the economic challenges it poses to healthcare systems. It proceeds to scrutinize the limitations of traditional therapies, emphasizing the need for progressive interventions. The core focus is on novel pharmacological interventions, including advancements in drug development, targeted therapies, and repurposing existing medications. The burgeoning field of gene therapy and its potential in addressing genetic predispositions to cardiovascular disorders are explored, alongside the integration of artificial intelligence and machine learning in risk assessment and treatment optimization. Non-pharmacological interventions take center stage, with an exploration of digital health technologies, wearable devices, and telemedicine as transformative tools in CVD management. Regenerative medicine and stem cell therapies, offering promises of tissue repair and functional recovery, are investigated for their potential impact on cardiac health. This review also delves into the interplay of lifestyle modifications, diet, exercise, and behavioral changes, emphasizing their pivotal role in cardiovascular health and disease prevention. As precision medicine gains prominence, this synthesis of emerging therapeutic modalities aims to guide clinicians and researchers in navigating the dynamic landscape of cardiovascular disease management, fostering a collective effort to alleviate the global burden of CVD and promote a healthier future.

Increased intrinsic membrane excitability is associated with hypertrophic olivary degeneration in spinocerebellar ataxia type 1

One of the characteristic areas of brainstem degeneration across multiple spinocerebellar ataxias (SCAs) is the inferior olive (IO), a medullary nucleus that plays a key role in motor learning. In addition to its vulnerability in SCAs, the IO is also susceptible to a distinct pathology known as hypertrophic olivary degeneration (HOD). Clinically, HOD has been exclusively observed after lesions in the brainstem disrupt inhibitory afferents to the IO. Here, for the first time, we describe HOD in another context: spinocerebellar ataxia type 1 (SCA1). Using the genetically-precise SCA1 knock-in mouse model (SCA1-KI; both sexes used), we assessed SCA1-associated changes in IO neuron structure and function. Concurrent with degeneration, we found that SCA1-KI IO neurons are hypertrophic, exhibiting early dendrite lengthening and later somatic expansion. Unlike in previous descriptions of HOD, we observed no clear loss of IO inhibitory innervation; nevertheless, patch-clamp recordings from brainstem slices reveal that SCA1-KI IO neurons are hyperexcitable. Rather than synaptic disinhibition, we identify increases in intrinsic membrane excitability as the more likely mechanism underlying this novel SCA1 phenotype. Specifically, transcriptome analysis indicates that SCA1-KI IO hyperexcitability is associated with a reduced medullary expression of ion channels responsible for spike afterhyperpolarization (AHP) in IO neurons - a result that has a functional consequence, as SCA1-KI IO neuron spikes exhibit a diminished AHP. These results reveal membrane excitability as a potential link between disparate causes of IO degeneration, suggesting that HOD can result from any cause, intrinsic or extrinsic, that increases excitability of the IO neuron membrane.

The Brainstem Cavernoma Case Series: A Formula for Surgery and Surgical Technique

Background and Objectives: Cavernous malformations (CM) are vascular malformations with low blood flow. The removal of brainstem CMs (BS) is associated with high surgical morbidity, and there is no general consensus on when to treat deep-seated BS CMs. The aim of this study is to compare the surgical outcomes of a series of deep-seated BS CMs with the surgical outcomes of a series of superficially located BS CMs operated on at the Department of Neurosurgery, College of Tuebingen, Germany. Materials and Methods: A retrospective evaluation was performed using patient charts, surgical video recordings, and outpatient examinations. Factors were identified in which surgical intervention was performed in cases of BS CMs. Preoperative radiological examinations included MRI and diffusion tensor imaging (DTI). For deep-seated BS CMs, a voxel-based 3D neuronavigation system and electrophysiological mapping of the brainstem surface were used. Results: A total of 34 consecutive patients with primary superficial (n = 20/58.8%) and deep-seated (n = 14/41.2%) brainstem cavernomas (BS CM) were enrolled in this comparative study. Complete removal was achieved in 31 patients (91.2%). Deep-seated BS CMs: The mean diameter was 14.7 mm (range: 8.3 to 27.7 mm). All but one of these lesions were completely removed. The median follow-up time was 5.8 years. Two patients (5.9%) developed new neurologic deficits after surgery. Superficial BS CMs: The median diameter was 14.9 mm (range: 7.2 to 27.3 mm). All but two of the superficial BS CMs could be completely removed. New permanent neurologic deficits were observed in two patients (5.9%) after surgery. The median follow-up time in this group was 3.6 years. Conclusions: The treatment of BS CMs remains complex. However, the results of this study demonstrate that with less invasive posterior fossa approaches, brainstem mapping, and neuronavigation combined with the use of a blunt "spinal cord" dissection technique, deep-seated BS CMs can be completely removed in selected cases, with good functional outcomes comparable to those of superficial BS CM.