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Favorable outcome from a locked-in state despite extensive pontine infarction by MRI
Edgar Andres Samaniego1, Maarten G Lansberg, Michael DeGeorgia
1Stanford Stroke Center, 701 Welch Road, Bldg B, Ste 325, Palo Alto, CA 94304-1702, USA. esamanie@stanford.edu
Introduction:
Outcome prediction of patients who are in a locked-in state is challenging. Extensive pontine infarction on diffusion weighted imaging MRI (DWI) has been proposed as a poor prognosticator. We report on three patients with a locked-in state with unexpected favorable recoveries despite DWI evidence of widespread pontine ischemia.
Methods:
Report of three cases.
Results:
Three young patients (32-, 30-, and 16-years-old) presented with a locked-in state caused by pontine infarction. The first patient did not receive any acute stroke therapies, the second patient underwent endovascular therapy 20 h after symptom onset resulting in partial recanalization of the basilar artery, and the third patient progressed to a locked-in state despite having received intravenous tissue plasminogen activator. The DWI of all three patients demonstrated acute and widespread pontine infarction involving more than two-thirds of the pons. Two patients regained full independence in their activities of daily living. The third patient remained wheelchair bound, but lives with her family, eats independently, uses a typewriter and wrote a book.
Conclusion:
Patients who are in a locked-in state may have substantial functional recovery despite DWI evidence of extensive pontine infarction.
Insights
Patients with locked-in syndrome can achieve significant recovery even with extensive pontine infarction on MRI. This challenges the assumption that widespread pontine ischemia predicts poor outcomes.
Area of Science:
- Neurology
- Neuroimaging
- Stroke Medicine
Background:
- Locked-in syndrome presents significant challenges in outcome prediction.
- Extensive pontine infarction on diffusion-weighted imaging (DWI) is often considered a poor prognostic indicator.
Observation:
- This report details three young patients experiencing a locked-in state due to pontine infarction.
- All patients exhibited widespread pontine ischemia on DWI, involving over two-thirds of the pons.
Findings:
- Two patients achieved full independence in daily activities.
- The third patient, though wheelchair-bound, demonstrated significant functional gains, including independent eating and writing.
Implications:
- These cases suggest that substantial functional recovery is possible in locked-in syndrome patients, even with extensive pontine infarction.
- The findings may necessitate a re-evaluation of prognostic models for locked-in syndrome based on neuroimaging alone.
