Medullar respiratory centers are composed of ventral and dorsal groups. A direct infarction to their structure could lead to a complete loss of respiratory drive, despite unilateral brainstem lesion is rarely associated with central respiratory dysfunction. A 70-year-old man was admitted with sudden dizziness and disequilibrium without motor weakness. Brain MRI (diffuse weight image) shows high signals intensities on left PICA territory of cerebellum and medulla oblongata including reticular formation, nucleus of tractus solitarius, nucleus ambiguus, and nucleus retroambiguus but sparing corticospinal and corticobulbar pathway. On 3rd hospital day, he had a complete loss of respiratory drive involving both autonomic and voluntary components. He didn't get the respiratory drive during CO2 retention while his consciousness and motor power were preserved.
Aged ; Brain ; Brain Stem ; Cerebellum ; Consciousness ; Dizziness ; Humans ; Infarction* ; Magnetic Resonance Imaging ; Medulla Oblongata ; Pica* ; Respiratory Center ; Respiratory Insufficiency* ; Reticular Formation

INTRODUCTIONThere is increasing belief that a formal protocol-based multidisciplinary care model should be adopted as an optimal care model in oncology. However, there is minimal outcome evidence to demonstrate an improvement in patient care. The aim of this study was to compare clinical quality outcomes between patients with high-grade glioma managed at one hospital using a formal neuro-oncology multidisciplinary tumour clinic (MTC) and a second hospital with a traditional on-call referral pattern (non-MTC).

MATERIALS AND METHODSPatients with high-grade glioma managed radically with radiation therapy at 2 Singapore hospitals from May 2002 to May 2006 were entered into a prospective database. Patients were grouped into management via MTC or non-MTC. Four clinical quality indicators were chosen retrospectively to assess the variation in practice: a) Use of computed tomography (CT) or magnetic resonance (MR) imaging post-resection (POI) for assessment of residual disease; b) Commencement of radiation therapy (RT) within 28 days of surgery; c) Adjuvant chemotherapy use for glioblastoma multiforme (CTGBM) and d) Median survival.

RESULTSSixty-seven patients were managed radically, with 47 by MTC and by 20 by non-MTC. MTC patients were more likely to have POI (P = 0.042), and CTGBM (P = 0.025). Although the RT start time was similar for the whole cohort (60% versus 45%: P = 0.296); for GBM patients, the RT start was earlier (63% vs 33% P = 0.024). The median survival for the MTC group was 18.7 months versus 11.9 months for the non-MTC group (P = 0.11).

CONCLUSIONClinical quality outcomes were significantly improved in patients with high-grade glioma managed in this neuro-oncology MTC.

Cancer Care Facilities ; Female ; Glioma ; classification ; drug therapy ; pathology ; radiotherapy ; Humans ; Interdisciplinary Communication ; Male ; Middle Aged ; Prospective Studies ; Quality Indicators, Health Care ; Quality of Health Care ; Survival Analysis

BACKGROUND: The thalamus has multiple connections with areas of the cerebral cortex involved in arousal and cognition. Thalamic damage has been reported to be associated with variable neuropsychological dysfunctions and dementia. This study investigates the changes of regional cerebral blood flow (rCBF) by using SPM analysis of 99mTc-ECD SPECT and examining the neuropsychological abnormalities of 4 patients with anterior thalamic infarctions. METHODS: Four patients with left anterior thalamic infarctions and eleven normal controls were evaluated. K-MMSE and the Seoul Neuropsychological Screening Battery were performed within 2 days after stroke. The normalized SPECT data of 4 patients were compared to those of 11 controls for the detection of areas with decreased rCBF by SPM analysis. RESULTS: All 4 patients showed anterograde amnesia in their verbal memory, which was not improved by recognition. Dysexecutive features were occasionally present, such as decreased word fluency and impaired Stroop test results. SPM analysis revealed decreased rCBF in the left supramarginal gyrus, the superior temporal gyrus, the middle and inferior frontal gyrus, the medial dorsal and anterior nucleus of the left thalamus. CONCLUSIONS: The changes of rCBF in patients with left anterior thalamic infarctions may be due to the remote suppression on metabolism by the interruption of the cortico-subcortial circuit, which connects the anterior thalamic nucleus and various cortical areas. The executive dysfunction and dysnomia may be caused by the left dorsolateral frontal dysfunction of the thalamocortical circuit. Anterograde amnesia with storage deficit may be caused by the disruption of mamillothalamic tract.
Amnesia, Anterograde ; Anomia ; Arousal ; Cerebral Cortex ; Cognition ; Dementia ; Humans ; Infarction* ; Mass Screening ; Memory ; Metabolism ; Seoul ; Stroke ; Stroop Test ; Thalamus ; Tomography, Emission-Computed, Single-Photon*