Differentiation of Pontine Infarction by Size

Monocyte to High-Density Lipoprotein Ratio Is Associated With Early Neurological Deterioration in Acute Isolated Pontine Infarction

Objectives: The monocyte to high-density lipoprotein ratio (MHR) has been considered to be a novel inflammatory marker of atherosclerotic cardiovascular disease. However, its role in the acute phase of acute isolated pontine infarctions remains elusive. We explored whether an association existed between elevated MHR levels and early neurological deterioration (END) in patients with isolated pontine infarction.

Methods: Data from 212 patients with acute isolated pontine infarction were retrospectively analyzed. We examined the MHR in quartiles of increasing levels to evaluate for possible threshold effects. END was defined as an elevation in the total National Institutes of Health Stroke Scale (NIHSS) score ≥2 or an increase in NIHSS score ≥1 in motor power within the first week after symptom onset. Patients were divided into an END group and a non-END group. The association of MHR on END following pontine infarction was examined by logistic regression models after adjusting for age, NIHSS at admission, basilar artery stenosis, history of hypertension or hyperlipidemia or stroke, infarct size, fasting blood glucose, and paramedian pontine infarction.

Results: The mean MHR was 0.44 ± 0.22. A total of 58 (27.36%) patients were diagnosed with END. END occurred within the first 48 h after hospitalization in 38 patients (65.52%). After adjusting for confounding and risk factors, the multivariate logistic regression analysis showed NIHSS at admission [odds ratio (OR), 1.228; 95% confidence interval (CI), 1.036–1.456], basilar artery stenosis (OR, 2.843; 95% CI, 1.205–6.727), and fasting blood glucose (OR, 1.296; 95% CI, 1.004–1.672) were independently associated with END. The odds ratio of END increased as the quartile level of MHR increased, with the lowest quartile used as the reference value. Compared to the first quartile of MHR, the third and fourth quartiles were associated with 4.847-fold (95% CI, 1.532–15.336) and 5.824-fold (95% CI, 1.845–18.385) higher odds of END in multivariate analysis.

Conclusions: Elevated MHR levels may be valuable as a biomarker of END in patients with isolated pontine infarction. The elevated MHR was independently associated with END in isolated pontine infarction.

Millard-Gubler Syndrome Associated with Cerebellar Ataxia in a Patient with Isolated Paramedian Pontine Infarction - A Rarely Observed Combination with a Benign Prognosis: A Case Report

Isolated pontine infarction accounts for 7% of all ischemic strokes. Millard-Gubler syndrome is a clinical syndrome which occurs following lesions involving the ventral portion of the caudal pons, resulting in classic clinical features such as ipsilateral abducens and facial nerve palsy and contralateral hemiparesis. We report the case of a 55-year-old male patient having presented to the Yehuleshet Specialty Clinic 6 years back with sudden-onset dysarthria and appendicular ataxia of 10 days duration. He reported having right hemibody weakness and blurred vision, which have significantly improved since then. He had a history of smoking of 30 pack-years. However, he quit smoking 8 years ago. There was no history of prior stroke, transient ischemic attack, diabetes, hypertension, head trauma, or dyslipidemia. On examination, he had horizontal left gaze palsy with horizontal nystagmus suggesting left-sided 6th cranial nerve palsy. He had mild left-sided facial palsy causing dysarthric speech. Right upper limb dysmetria was observed during examination; otherwise, motor, sensory, fundus, and gait examination results were normal. He had low serum vitamin D. Brain magnetic resonance imaging examination showed a 25 × 10 mm segmental lesion in the left median pons involving the basis pontis and tegmentum section. The lesion had T2 and T1 abnormal prolongation with no diffusion restriction, suggesting a subacute pontine infarct. The patient was managed with aspirin 325 mg, atorvastatin 80 mg, physical therapy, and vitamin D supplementation, and advised on behavioral risk factors. Six years after his isolated pontine infarction, the patient is fully recovered from dysarthria, facial palsy, hemiparesis, right-sided appendicular ataxia, and horizontal nystagmus, and the follow-up brain MRI showed radiological evidence of chronic paramedian pontine perforator infarction. Millard-Gubler syndrome may present with cerebellar ataxia if the paramedian pontine infarction area slightly extends laterally, affecting the middle cerebellar peduncles. Isolated pontine infarction may have a good prognosis if diagnosed and managed early.