Abstract Details

Title Cord and Brain Stem Extensive Wallerian Degeneration: Rare Sequelae of Pontine Hemorrhage

Topic Cerebrovascular Disease and Interventional Neurology

Presentation(s) P3 - Poster Session 3 (11:45 AM-12:45 PM)

Poster/Presentation
Number 14-013

Objective We describe a case of extensive Wallerian degeneration (WD) as a complication of pontine hemorrhage causing initial diagnostic challenges.

Background Wallerian degeneration of the pontocerebellar and corticospinal tracts can be seen post pontine insult. Given this is uncommon, these imaging abnormalities may be misdiagnosed for other neurological conditions such as demyelinating disease.

Design/Methods N/A

Results A 55-year-old male with a history of poorly controlled hypertension, untreated obstructive sleep apnea, remote lacunar infarct and alcohol use disorder initially presented with sudden-onset right upper extremity weakness. CT brain showed an acute left pontine hemorrhage. Following rehabilitation, the motor symptoms improved significantly with minimal residual deficits. Approximately 3 months from his initial admission, he experienced subacute right-sided weakness in the right upper and lower extremities. MRI Brain and cervical spine with contrast showed FLAIR/T2 hyperintensities involving the bilateral middle cerebellar peduncles. In addition, there were FLAIR/T2 hyperintensities involving the anterior left medulla and upper spinal cord which then decussated into the right lateral corticospinal tract and extended inferiorly to C5 without contrast enhancement. The patient was treated with intravenous methylprednisolone for 5 days with some improvement in symptoms due to concerns for demyelinating disease. After further review of the imaging, findings were thought to be due to WD related to the prior pontine hemorrhage; additional areas of WD were also noted involving the corpus callosum secondary to remote white matter infarcts. This highlights the importance of awareness of different patterns of WD, and not mistaking such imaging findings for alternate etiologies such as a toxic/metabolic process or demyelinating disease.

Conclusions While uncommon, this case demonstrates that extensive Wallerian degeneration of the pontocerebellar and corticospinal tracts can be seen as T2 lesions on the MRI post pontine stroke and should not be mistaken for alternate etiologies.

Authors/Disclosures
Kajal Patel, MD (The Lumen) PRESENTER	Dr. Patel has nothing to disclose.
Casandra MacLeod, DO (Cleveland Clinic)	Dr. MacLeod has nothing to disclose.
Kim Griffin, MD (Mayo Clinic)	Dr. Griffin has nothing to disclose.
Chintan Shah (Cleveland Clinic)	An immediate family member of Chintan Shah has received personal compensation for serving as an employee of Pfizer, Inc. Chintan Shah has stock in Penumbra, Inc.
Emmanuel Obusez (Cleveland Clinic)	Emmanuel Obusez has nothing to disclose.
Paul Ruggieri, MD (Cleveland Clinic)	Dr. Ruggieri has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Cleveland Clinic.
Jayashree Sundararajan, MD (Cleveland Clinic Neurological Inst.)	Dr. Sundararajan has nothing to disclose.
Justin Abbatemarco, MD	Dr. Abbatemarco has received personal compensation in the range of $5,000-$9,999 for serving on a Scientific Advisory or Data Safety Monitoring board for EMD Serono. Dr. Abbatemarco has received personal compensation in the range of $5,000-$9,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Horizon. Dr. Abbatemarco has received personal compensation in the range of $5,000-$9,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Genentech . Dr. Abbatemarco has received personal compensation in the range of $5,000-$9,999 for serving on a Scientific Advisory or Data Safety Monitoring board for TG Therapeutics, Inc.. Dr. Abbatemarco has received personal compensation in the range of $5,000-$9,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Amgen. The institution of Dr. Abbatemarco has received research support from Amgen.

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