Brainstem syndromes are characterized by reduced blood flow to the vessels supplying the brain stem. There are several brainstem syndromes named after their first descriptor, for example, Foville syndrome, Weber syndrome, and Wallenberg syndrome. Causes of acute brainstem syndromes include cerebral hemorrhage, cerebral infarction, or inflammation.
What is brainstem syndrome?
Brainstem syndromes result from cerebral ischemia, which is an inadequate supply of blood to the cerebrum. In most disorders, impaired blood flow to the vertebral artery or basilar artery is the primary cause. Together with the subclavian artery, the vertebral artery belongs to the arteries supplying the brain. The basilar artery belongs to the arteries supplying the brain with oxygenated blood. If the blood supply is reduced by cerebral infarction, cerebral hemorrhage, or inflammation, various brainstem syndromes may develop, depending on the local location.
Causes
The main causes of brainstem syndromes are cerebral ischemias, which result in a reduced blood supply to the cerebrum. Most commonly, these circulatory disturbances occur in the vertebral artery and the arteries that supply the brain. Infections, injuries, tumors, obesity, high blood pressure and multiple sclerosis can equally lead to an undersupply of blood to the brain. There are several brainstem syndromes, which are mainly divided into three subtypes depending on the location of the damage:
- Circulatory disturbance of the brain stem (pons) belonging to the central nervous system.
- Disturbance of blood circulation in the midbrain
- Circulatory disturbance in the area of the spinal cord extension (medulla-oblongata).
The three different syndromes are named after their first descriptors: Millard-Gubler syndrome, Weber syndrome and Wallenberg syndrome. Depending on the nature of the symptoms and the location of the damage, medicine knows several other brainstem syndromes, for example, Foville syndrome, Nothnagel syndrome or Babinski-Nageotte syndrome.
Symptoms, complaints, and signs
Depending on the type of brainstem syndrome, different symptoms are present. Almost all brainstem syndromes are characterized by cranial nerve failure and damage to the long nerve pathways responsible for motor function and sensitivity. Other prominent symptoms include dizziness, headache, fatigue, sensory delusions, intracranial pressure, and neck stiffness. Accompanying phenomena are photophobia and autonomic disturbances such as vomiting, nausea, sweating, and psychic changes. From the sum of the symptoms, the treating physician can infer the location of the damage. Characteristic of damage to the spinal cord extension is Wallenberg syndrome, other alternating syndromes are equally possible. Damage to the caudal bridging foot (pons) is usually due to Foville or Millard-Gubler syndrome with horizontal gaze paralysis. Causes may include tumors and circulatory disturbances in the arteries and their stromal areas. Weber, Benedict, and Notnagel syndromes are characteristic of midbrain lesions. Patients often suffer from visual disturbances and drowsiness. In severe damage with separation of brainstem and cerebral cortex, primitive brain reflexes occur in the form of apallic syndrome, which leads to brain death. Brainstem syndromes often occur that are not fully or typically expressed, making a definitive diagnosis difficult.
Diagnosis and disease progression
In incomplete brainstem syndromes, symptoms occur alternately or bilaterally. Depending on the site of damage, symptoms appear on either the same or the opposite side of the body. In the case of general damage, there are sensory deficits such as disturbances of the sense of vibration, the sense of touch and temperature, and paralysis. The parts of the body that are supplied by the longest nerve tracts, i.e. the feet, are particularly affected. As the disease progresses, these sensory disturbances spread proximally to the body. If individual nerves are locally damaged, different symptoms and complaints occur. In addition to the sensory deficiency symptoms, there are motor deficits and damage to the autonomic nervous system. These are manifested by disturbances in the regulation of circulation and perspiration in conjunction with loss of balance and coordination (ataxia).Damage to the nerve roots, which is manifested by reflex weakening and muscle weakness, can be caused by disc damage. Modern medicine offers different diagnostic methods to reliably diagnose brainstem syndrome. The first step is a clinical history, with which the physician asks the patient all the important questions about symptoms, previous illnesses, and life and behavior patterns in order to create a clinical picture. If this questioning is not possible, for example in the case of an acute emergency, a diagnosis is immediately made by MRI, CT and ultrasound. This modern diagnostic technique allows physicians to rule out other conditions and diseases, such as tumors or inflammation, if they are not responsible for the circulatory disorder in the brain.
Complications
Brainstem syndrome causes decreased blood flow to the brain. This complaint can lead to many different complications, usually as a result of an infarction or inflammation. The affected person suffers from dizziness and severe headaches. Furthermore, fatigue and tiredness occur. Paralysis and various sensory disturbances may also occur. However, it cannot be predicted which areas of the body will be paralyzed by brainstem syndrome. Furthermore, the affected person may suffer from vomiting and nausea and may also lose consciousness. It is not uncommon for hearing difficulties or visual disturbances to occur. The symptoms extremely restrict the patient’s everyday life. In the worst case, brainstem syndrome leads to brain death and then complete death of the patient. For this reason, immediate treatment by a physician is necessary for the patient to survive. The treatment is carried out with the help of medication and does not itself lead to any complications. However, consequential damages cannot be excluded. These depend strongly on when the treatment was started. If necessary, brainstem syndrome also reduces the patient’s life expectancy.
When should you see a doctor?
A visit to the doctor is necessary as soon as the affected person suffers from various functional disorders. If there is loss of vision, problems with hearing, or ambiguity in speech formation, a doctor is needed. Control examinations must be initiated in order to determine the cause and to be able to take appropriate measures. If there is repeated tiredness, a feeling of faintness or an inner weakness, a visit to the doctor should be made. Sleep disturbances and an increased need for sleep are warning signs of the organism. If they occur over several weeks or increase in intensity, a clarification of the signs should be made. If there is a feeling of pressure inside the head, stiffness of the neck or restrictions in the range of motion of the neck, a doctor should be consulted. Dizziness, vomiting and nausea should be medically examined and treated. If fever, elevated blood pressure, rapid heartbeat or circulation problems occur, a doctor is needed. Circulatory problems, profuse sweating that cannot be explained, or a feeling of illness should be examined by a physician. Gaze paralysis is considered particularly unusual and should be treated as soon as possible. Balance and coordination problems as well as changes in the musculature are reasons to see a doctor. Because in severe cases brainstem syndrome can lead to a shortened life expectancy, a visit to the doctor is advisable at the first signs and irregularities.
Treatment and therapy
The preferred method of treatment is lysis therapy, also known as thrombolysis. The thrombus is dissolved with the help of medication. With local treatment, the patient gets the drug injected directly into the affected vessel through a catheter. With systemic lysis therapy, the drug is administered intravenously so that it can spread through the bloodstream and reach the affected site. If an ischemic cerebral infarction is present, intravenous lysis therapy with recombinant plasminogen activator has been shown to be particularly effective. However, treatment must be given no later than 4.5 hours after the onset of the first symptoms. The treating physician must perform a risk-benefit assessment, since the risk of cerebral hemorrhage is high. Alternatively, surgical removal of the blood clot is also possible.If brainstem syndrome is associated with difficulty swallowing and impaired breathing,. Sometimes the placement of a feeding tube or long-term ventilation may be necessary prior to treatment. Depending on the severity of the disease course, physicians may recommend long-term therapy at specialized medical centers or subsequent physical therapy if the disease course is mild.
Outlook and prognosis
The prognosis of brainstem syndrome is determined according to the present cause and therefore must be evaluated on an individual basis. The greater the region of the present infarct that has been damaged, the less favorable the outlook for recovery. The risk of death increases sharply in these patients. With early diagnosis, mild damage to brain tissue, and rapid treatment, complete recovery is possible in individual cases. The minor neurological damage can be almost completely corrected after a few months with optimal therapy. However, medical care must be provided within a few hours of the onset of the first signs of irregularity. In addition, within the treatment and therapy process, the patient must actively cooperate in the recovery and adhere to the instructions of the treating physician. Subsequently, the patient should participate in regular check-ups so that early warning signs can be detected more quickly and immediate action can be taken in the event of a recurrence of an infarct. In acute situations, the patient has a severe vascular occlusion, which significantly increases the risk of premature death. The probability of death here is 80% of documented cases. Without treatment, there is little chance of survival for the patient. In addition, brainstem syndrome may result in lifelong sequelae or dysfunction of individual systems.
Prevention
Because brainstem syndromes result from a variety of causes, there is no one ideal way to prevent them. In general, however, doctors advise people to reconsider their own lifestyle and to take care to avoid obesity and, consequently, high blood pressure. Both factors favor the development of brainstem syndrome. A conscious diet that avoids too much fat, sugar and artificial additives can also help prevent this disease. Other detrimental factors include excessive alcohol and nicotine consumption, which should be avoided especially by high-risk patients with a hereditary predisposition and who are overweight.
Follow-up
In brainstem syndrome, there are usually few or even no aftercare measures and options available to the affected person, so the affected person must primarily consult a physician in this regard to prevent further complications or discomfort. In many cases, however, brainstem syndrome cannot be fully treated, so that the patient’s life expectancy is also often significantly reduced by this disease. The treatment of this disease is usually carried out with the help of medication. Care must be taken to ensure that the correct dosage is given and that the medication is taken regularly in order to prevent further complications. Likewise, regular check-ups and examinations by a doctor are very important in order to correctly recognize and control the symptoms of brainstem syndrome. Since the disease can also cause movement disorders, physiotherapy should be performed. The affected person can do and repeat many exercises from such therapy in his own home, which may speed up the healing process. In this context, loving care and support from one’s own family or friends also has a positive effect on the course of the disease and can prevent depression or psychological upsets.
What you can do yourself
Brainstem syndrome is an acutely life-threatening disease for affected individuals, so self-help measures should be refrained from without the doctor’s consent. In their own interest, patients should seek medical attention as soon as possible in order to initiate appropriate therapy quickly. The symptoms associated with brainstem syndrome usually noticeably restrict the patient’s quality of life and prevent them from carrying out their usual daily routine. For example, patients are no longer able to pursue their work and should refrain from corresponding attempts in the interest of their health.Patients are forced to rest and temporarily withdraw from social life due to symptoms such as dizziness, motor and sensory limitations, or visual and hearing impairments. In most cases, hospitalization is appropriate to treat the acute causes of brainstem syndrome. During inpatient care, patients follow all instructions given by hospital staff and physicians. Typically, patients temporarily maintain bed rest and decrease physical activities. Diet is also tailored to the patient’s disease and condition, and the prescribed diet plan must be followed by the patient. After successful treatment, patients follow the doctor’s instructions to avoid relapse.
