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Microbleeds as a Causative Factor in Diffusion-Weighted Imaging-Negative Acute Brainstem Stroke Syndrome: A Report of

Chi-Ju Lin1, Chun-Jen Lin2, Chih-Ping Chung1,2

  • 1Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.

Acta Neurologica Taiwanica
|July 30, 2026
PubMed

Insights

Cerebral microbleeds (CMBs) may cause acute stroke symptoms, even with negative diffusion-weighted imaging (DWI) on MRI. These microbleeds should be considered in brainstem stroke diagnoses, especially when DWI is inconclusive.

Area of Science:

  • Neurology
  • Neuroradiology
  • Neuroimaging

Background:

  • Acute stroke syndrome often presents with negative diffusion-weighted imaging (DWI) on brain magnetic resonance imaging (MRI).
  • Cerebral microbleeds (CMBs), indicative of small vessel disease, are typically excluded from the differential diagnosis of acute neurological deficits.
  • Brainstem syndromes can manifest with diverse symptoms, including ocular motor deficits, dizziness, and ataxia.

Purpose of the Study:

  • To investigate the potential role of cerebral microbleeds (CMBs) as a cause of DWI-negative acute brainstem syndrome.
  • To highlight the importance of considering CMBs in the differential diagnosis of posterior circulation stroke syndromes.
  • To emphasize the need for further research into CMB-related acute neurological deficits.

Main Methods:

  • Case series analysis of three patients with acute-onset brainstem syndrome and negative DWI findings.
  • Detailed neurological assessment including ocular motor function, balance, and facial nerve function.
  • Brain MRI to identify cerebral microbleeds (CMBs) and correlate their location with neurological deficits.

Main Results:

  • All three patients presented with acute brainstem syndrome and negative DWI findings on brain MRI.
  • Cerebral microbleeds (CMBs) were identified in locations corresponding to the patients' specific neurological deficits.
  • All patients experienced symptom resolution within 7 days, suggesting a transient, microbleed-related etiology.

Conclusions:

  • Cerebral microbleeds (CMBs) should be considered a potential cause of DWI-negative acute brainstem syndrome.
  • The findings underscore the necessity of including CMBs in the differential diagnosis for posterior circulation stroke syndromes.
  • Further investigation is warranted to understand long-term outcomes and develop targeted management for CMB-related neurological deficits.
Keywords:
Case reportcerebral microbleedsdiffusion-weighted imaging-negative stroke

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