Download PDF
J Neurol Surg A Cent Eur Neurosurg 2019; 80(01): 062-066
DOI: 10.1055/s-0038-1661401
Case Report
Georg Thieme Verlag KG Stuttgart · New York

Change of Ascending Reticular Activating System Following Shunt Operation for Hydrocephalus in a Subarachnoid Hemorrhage Patient

SungHo Jang
1   Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University, Daegu, Republic of Korea
,
HanDo Lee
1   Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University, Daegu, Republic of Korea
› Author Affiliations Source of Funding This work was supported by the DGIST R&D Program of the Ministry of Science, ICT and Future Planning (18-BD-0401).
Further Information

Publication History

13 November 2017

16 April 2018

Publication Date:
16 July 2018 (online)

    Permissions and Reprints

Abstract

Objective To demonstrate the change of the ascending reticular activating system (ARAS) concurrent with the recovery of impaired consciousness following a shunt operation in a stroke patient.

Methods A 65-year-old female patient underwent coiling of a ruptured right posterior communicating artery and, subsequently, underwent right external ventricular drain (EVD) placement, left EVD placement, and lumbar drain placement for management of intraventricular hemorrhage. After 6 months from onset, she began rehabilitation, and brain magnetic resonance imaging showed dilatation of the ventricular system. The patient exhibited impaired alertness, with a Glasgow Coma Scale (GCS) score of 7. At ∼ 20 days after starting rehabilitation, the patient underwent a ventriculoperitoneal shunt operation for hydrocephalus. At 10 days postsurgery, her GCS improved to 15.

Results Regarding the change of neural connectivity of the thalamic intralaminar nuclei, compared with preoperative diffusion tensor tractography (DTT), postoperative DTT showed that neural connectivity to the prefrontal cortex was increased in both hemispheres. In terms of configuration of DTT, the lower portion of the ARAS between the reticular formation and the intralaminar thalamic nuclei did not show a significant change.

Conclusions A patient with subarachnoid and intraventricular hemorrhage showed recovery of an injured ARAS and consciousness after a shunt operation for hydrocephalus.

Keywords

diffusion tensor imaging - ascending reticular activating system - consciousness - stroke
 

  • References

  • 1 Oi S. Classification of hydrocephalus: critical analysis of classification categories and advantages of “Multi-categorical Hydrocephalus Classification” (Mc HC). Childs Nerv Syst 2011; 27 (10) 1523-1533
    CrossrefPubMedGoogle Scholar
  • 2 Jang SH, Choi BY, Chang CH. , et al. The effects of hydrocephalus on the periventricular white matter in intracerebral hemorrhage: a diffuser tensor imaging study. Int J Neurosci 2013; 123 (06) 420-424
    CrossrefPubMedGoogle Scholar
  • 3 Edlow BL, Takahashi E, Wu O. , et al. Neuroanatomic connectivity of the human ascending arousal system critical to consciousness and its disorders. J Neuropathol Exp Neurol 2012; 71 (06) 531-546
    CrossrefPubMedGoogle Scholar
  • 4 Edlow BL, Haynes RL, Takahashi E. , et al. Disconnection of the ascending arousal system in traumatic coma. J Neuropathol Exp Neurol 2013; 72 (06) 505-523
    CrossrefPubMedGoogle Scholar
  • 5 Chen Z, Yang Y, Chen G, Wang M, Song W. Impact of ventriculoperitoneal shunting on chronic normal pressure hydrocephalus in consciousness rehabilitation. J Rehabil Med 2014; 46 (09) 876-881
    CrossrefPubMedGoogle Scholar
  • 6 Xin H, Yun S, Jun X, Liang W, Ye-Lin C, Xiao-Feng Y. Long-term outcomes after shunt implantation in patients with posttraumatic hydrocephalus and severe conscious disturbance. J Craniofac Surg 2014; 25 (04) 1280-1283
    CrossrefPubMedGoogle Scholar
  • 7 Yeo SS, Chang PH, Jang SH. The ascending reticular activating system from pontine reticular formation to the thalamus in the human brain. Front Hum Neurosci 2013; 7: 416
    PubMedGoogle Scholar
  • 8 Jang SH, Lim HW, Yeo SS. The neural connectivity of the intralaminar thalamic nuclei in the human brain: a diffusion tensor tractography study. Neurosci Lett 2014; 579: 140-144
    CrossrefPubMedGoogle Scholar
  • 9 Jang SH, Kim SH, Lim HW, Yeo SS. Injury of the lower ascending reticular activating system in patients with hypoxic-ischemic brain injury: diffusion tensor imaging study. Neuroradiology 2014; 56 (11) 965-970
    CrossrefPubMedGoogle Scholar
  • 10 Jang SH, Kim SH, Lim HW, Yeo SS. Recovery of injured lower portion of the ascending reticular activating system in a patient with traumatic brain injury. Am J Phys Med Rehabil 2015; 94 (03) 250-253
    CrossrefPubMedGoogle Scholar
  • 11 Jang SH, Lee HD. Ascending reticular activating system recovery in a patient with brain injury. Neurology 2015; 84 (19) 1997-1999
    CrossrefPubMedGoogle Scholar
  • 12 Jang SH, Lee HD. The ascending reticular activating system in a patient with severe injury of the cerebral cortex: a case report. Medicine (Baltimore) 2015; 94 (42) e1838
    PubMedGoogle Scholar
  • 13 Jang SH, Lee HD, Chang CH, Jung YJ. Recovery of hypersomnia concurrent with recovery of an injured ascending reticular activating system in a stroke patient: a case report. Medicine (Baltimore) 2016; 95 (02) e2484
    PubMedGoogle Scholar
  • 14 Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974; 2 (7872): 81-84
    PubMedGoogle Scholar
  • 15 Daube JR. Medical Neurosciences: An Approach to Anatomy, Pathology, and Physiology by Systems and Levels. 2nd ed. Boston, MA: Little, Brown; 1986
    Google Scholar
  • 16 Afifi AK, Bergman RA. Functional Neuroanatomy: Text and Atlas. 2nd ed. New York, NY: Lange Medical Books/McGraw-Hill; 2005
    Google Scholar
  • 17 Morel A. Stereotactic Atlas of the Human Thalamus and Basal Ganglia. New York, NY: Informa Healthcare; 2007
    Google Scholar
  • 18 Smith SM, Jenkinson M, Woolrich MW. , et al. Advances in functional and structural MR image analysis and implementation as FSL. Neuroimage 2004; 23 (Suppl. 01) S208-S219
    CrossrefPubMedGoogle Scholar
  • 19 Schiff ND. Central thalamic contributions to arousal regulation and neurological disorders of consciousness. Ann N Y Acad Sci 2008; 1129: 105-118
    CrossrefPubMedGoogle Scholar
  • 20 Schiff ND. Recovery of consciousness after brain injury: a mesocircuit hypothesis. Trends Neurosci 2010; 33 (01) 1-9
    CrossrefPubMedGoogle Scholar
  • 21 Goldfine AM, Schiff ND. Consciousness: its neurobiology and the major classes of impairment. Neurol Clin 2011; 29 (04) 723-737
    CrossrefPubMedGoogle Scholar
  • 22 Demertzi A, Soddu A, Laureys S. Consciousness supporting networks. Curr Opin Neurobiol 2013; 23 (02) 239-244
    CrossrefPubMedGoogle Scholar
  • 23 Assaf Y, Ben-Sira L, Constantini S, Chang LC, Beni-Adani L. Diffusion tensor imaging in hydrocephalus: initial experience. AJNR Am J Neuroradiol 2006; 27 (08) 1717-1724
    PubMedGoogle Scholar
  • 24 Jang SH, Ho Kim S. Diffusion tensor imaging following shunt in a patient with hydrocephalus. J Neuroimaging 2011; 21 (01) 69-72
    CrossrefPubMedGoogle Scholar
  • 25 Hasan KM, Eluvathingal TJ, Kramer LA, Ewing-Cobbs L, Dennis M, Fletcher JM. White matter microstructural abnormalities in children with spina bifida myelomeningocele and hydrocephalus: a diffusion tensor tractography study of the association pathways. J Magn Reson Imaging 2008; 27 (04) 700-709
    CrossrefPubMedGoogle Scholar
  • 26 Hasan KM, Sankar A, Halphen C. , et al. Quantitative diffusion tensor imaging and intellectual outcomes in spina bifida: laboratory investigation. J Neurosurg Pediatr 2008; 2 (01) 75-82
    CrossrefPubMedGoogle Scholar
  • 27 Hattingen E, Jurcoane A, Melber J. , et al. Diffusion tensor imaging in patients with adult chronic idiopathic hydrocephalus. Neurosurgery 2010; 66 (05) 917-924
    CrossrefPubMedGoogle Scholar
  • 28 Kanno S, Abe N, Saito M. , et al. White matter involvement in idiopathic normal pressure hydrocephalus: a voxel-based diffusion tensor imaging study. J Neurol 2011; 258 (11) 1949-1957
    CrossrefPubMedGoogle Scholar
  • 29 Hattori T, Ito K, Aoki S. , et al. White matter alteration in idiopathic normal pressure hydrocephalus: tract-based spatial statistics study. AJNR Am J Neuroradiol 2012; 33 (01) 97-103
    CrossrefPubMedGoogle Scholar
  • 30 Yamada K, Sakai K, Akazawa K, Yuen S, Nishimura T. MR tractography: a review of its clinical applications. Magn Reson Med Sci 2009; 8 (04) 165-174
    CrossrefPubMedGoogle Scholar