User:181kotj/sandbox
| 181kotj/sandbox | |
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| Other names | Bilateral perisylvian polymicrogyria |
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| Lateral sulcus (Sylvian fissure) | |
| Specialty | Neurology |
Perisylvian syndrome is a rare neurological disease characterized by damage to the sylvian fissure (lateral sulcus), an area in the brain involved in language and speech. The main symptoms are difficulty chewing and swallowing, low muscle tone in the face and tongue, speech and language development disorders, and epilepsy. These symptoms are also often accompanied by difficulties with mobility and intellectual disabilities.[1]
The history and exact underlying cause of this condition has not been sourced by researchers and other experts. Due to its low prevalence, there is a lack of definitive information regarding diagnosis, treatment. Many articles postulate several sources for causes, such as stroke and external trauma to the head, causing damage to the fissure and resulting in malfunctioning structures that interact with it. Interestingly, it has become and increasing focus due to the significant anatomical structures that cross it[2].
It is not to be confused with Congenital Bilateral Perisylvian Syndrome (CBPS), which is a form of PS that occurs in embryo and appears in birth and childhood[3].
Signs and Symptoms
[edit]Due to the relationships the fissure has with multiple vital parts of the brain, damage to any one of them can alter the function of the adjacent cortical regions, disrupting the connection between the cognitive, neural, and muscular network[4].
It is unclear if these are specific to long term or short term in duration, but symptoms are implied to be permanent without medical intervention[4].
Speech:
[edit]Trauma to the fissure near the temporal lobe can cause speech issues. Wernickes area is located on the temporal gyrus next to the end of the Sylvian fissure that sits towards the back of the head. This area is part of the language system, and majorly functions in the ability to recall speech sounds associated with written letters. Damage to this area can cause Anomia, a language disorder that makes it difficult to locate words, and Phonemic Paraphasia. [4]
The sylvian surface on the frontal lobe (located deep in the sylvian fissure) contains a bundle of fibers called the arcuate fasciculus (AF) that curve around the fissure, and comes from Brocas area, which is involved in language production and comprehension. Damage to this nerve bundle can cause conditions such as Brocas Aphasia and Expressive Aphasia[4].
Auditory Processing Disorders:
[edit]Damage to the fissure near the temporal lobe may also cause auditory processing disorders due to the disruption in the neural pathway in the area of the temporal lobe the fissure sits in[4].
Epilepsy
[edit]Epilepsy is common in studies related to congenital (pre-birth), bilateral (both sides), and unilateral(one side) Perisylvian syndrome. Kuzniecky et all. Reported 90% of Perisylvian Syndrome cases with epilepsy. [5]
Facial paralysis
[edit]While the Sylvian fissure does not directly connect to the cranial nerves, previous exploratory dissection reveals that the middle cerebral artery (specifically the M2 segment) runs through the deep insular tissue. Damage to the Sylvian tissue may cause damage or malfunction to the arterial supply of the M2 branch and create an infarction resulting in hemiparesis (unilateral paralysis).[4] . Mavili E et all. Study found that 89% of patients were present with psychomotor retardation, 84% with speech disorders, and 57% with cerebral palsy [5].
Cause and Prevention
[edit]There are not many definitive pre-occuring conditions and risk factors that lead to the following causes of Perisylvian syndrome. Though the definitive cause is still being explored, it has been well defined that the condition cannot be spread from person to person. One study proposes several of the following causes that may create trauma to the fissure[5]:
- Cerebral hypoperfusion- a condition where there is inadequate blood flow to the brain, and can be caused by smoking, blood pressure disorders, stroke, and sepsis[6]
- Stroke - A condition where blood flow to the brain is disrupted, causing brain cells to die off[7]
- Possible injury during neuronal migration in fetal development (See: congenital bilateral perisylvian syndrome)
- Brain lesions - An area of damaged brain tissues from injury or disease[2]
Other studies have also explored its link to genetics.[5]
In the majority of cases however, the condition appears sporadically[4].
Cysts
[edit]Arachnoid cysts represent <1% of intracranial lesions, with the Sylvian fissure being the most common location, most predominant in males on the left side[4].
Cysts are often discovered incidentally during imaging, and most common associated symptoms are headaches, seizures, and motor deficit due to the pressure the cyst applies to the temporal lobe[4].
Pathophysiology and Mechanism
[edit]The Sylvian fissure is the most prominent crease on the brain. It sits on the lateral hemisphere of the brain, separating the temporal and frontal lobe. It extends into the parietal lobe, and sits perpendicular to the central sulcus, a prominent groove on top of the brain. It also sits in the insula, a part of the brain involved in various functions such as decision making, social emotions, empathy, pain processing, interception, auditory processing. The site is also closely associated with a major cranial artery known as the middle cerebral artery, a vital and the largest branch of the internal carotid artery that is responsible for blood supply to the brains frontal, temporal, and parietal lobes. It is made up of 4 branches that extend throughout the brain tissue, labeled as M1, M2, M3, and M4.
In most cases of Perisylvian syndrome, the condition exists congenitally and is not typically developed throughout one’s lifetime without some sort of significant trauma to the head, causing lesions, pressure, or tissue death, and trickles down to the rest of neural processing in other vital functions of the brain. Once neural processes weaken in these areas, the brain is not able to send signals to its respective parts of the body.[5]
Diagnosis
[edit]A neurologist would be seen if a diagnosis is desired. Considering the symptoms, a diagnosis may be suggested with visual evidence of the following:
CT scan
[edit]Early signs of the middle cerebral artery occlusion (MCA) can be found upon discovery of a hyperdense MCA. It appears with increased amplitude of the M1 segment, or with hyperdensity in the distal MCA & branches inside the Sylvian fissure[4].
Brain MRI
[edit]Appearance of ‘bat wings’ – bilateral open fissure typically seen in type 1 Glutaric aciduria.[4]
Angiography
[edit]The Sylvian triangle is an important landmark on lateral cerebral angiograms. It is made up of 3 lines; one if a straight line that follows the loops of the M2 segment, paired with a large trunk of the MCA anterior, and the first ascending insular branch of the M2 segment posterior[4].
History of Aneurysms:
[edit]Bifurcation of trifurcation of the M1 segment, located in the Sylvian fissure sphenoidal compartment, may arise intracranial saccular aneurysms from the MCA. (Occurs in 22% of people)[4].
It is important to note that these methods are not definitive when investigating this condition. It is more likely for neurologists to diagnose a separate neurological condition based on the symptoms and patient history, and conclude the possible source using the above visual evidence[4].
Treatment and Prognosis
[edit]Data in prognosis is very limited for this syndrome. However, neurological conditions affecting multiple parts of the brain have had a wide range of recovery timelines. However, there have been many invasive surgical interventions to improve symptoms.
Aneurysms
[edit]Possible exploratory treatments include transluminal embolization techniques, microsurgical techniques, and hybrid techniques involving multiple procedures[4].
Inside-out dissection:
[edit]General principle for surgery: the patient lays in supine position with the head rotated away at 30%. There are 3 spaces to consider with different challenges for each.
In the superficial ocular compartment, the best point to begin is at the anterior sylvian point, below the pars traignularis, a triangular shape in the frontal lobe responsible for speech production and language processing. Then, a sharp incision of the outer arachnoid membrane is created on frontal side of superficial Sylvian veins. Then, a gentle superficial veins are displaced from the temporal lobe. Finally, dissection of arachnoid bands that connects brain tissue to brain tissue, and veins to veins, exposes the Sylvian membrane[4].
Following this, another dissection of lateral sylvian membrane occurs to expose the compartment, then dissection of deep arachnoid bands, mainly brain tissue to brain and artery connection to brain tissue[4].
Lastly, in the Cisternal compartment, the M2 segment must be identified, deeply seated on lateral insular surface[4].
Cysts
[edit]Options for treatment and management may include conservative and surgical alternatives such as endoscopies, microsurgical craniotomy, and shunting. Neuroendoscopic fenestration is best initial procedure for middle cranial fossa arachnoid cysts[4].
Medication:
[edit]While medication cannot treat the condition, it may treat some associated symptoms:
One woman with bilateral Perisylvian Syndrome was treated for her epilepsy with lamotrigine and oxcarbazepine and was in remission for 8 years. When reappeared, treatment included LTG and levetiracetam, and resulted in significant clinical improvement[5].
Epidemiology
[edit]With the condition occurring sporadically, there is minimal linkage to explore populations at risk. However, some studies report that Perisylvian syndrome may be genetically linked, as it may be passed from parent to child as some families may have many affected members. It is unknown whether this is autosomal recessive, dominant, or X-linked.[8] Some studies also suggest that those who have had previous significant head trauma may be at risk.[5]
Recent Research
[edit]In 2017, a study conducted by Freri et all. explored a new surgical treatment to improve symptoms of epilepsy in the perisylvian region for 16 pediatric patients who were resistant to medication, the median age during time of surgery was 12 years old. Prior to the procedure, patients completed a preoperative assessment including analysis of clinical history, EEG monitoring, High-resolution MRI, and a cognitive/neuropsychological evaluation. The procedure was preformed with the goal of removing the epileptogenic zone, a part of the brain where seizure activity occurs. It was found post-operatively (39 months) that seizure outcome improved satisfactory in 69% of patients, with 7 being seizure-free, and two were free from disabling seizures. Cognition improved in 38% of patients as well[9].
In 2020, a study conducted by Steriade et all. explored the relationship between encephalitis and seizure patterns in patients with drug-resistant epilepsy. Using 17 patients with encephalitis, and 17 control patients with drug-resistant epilepsy and no history of encephalitis, a stereotactic EEG was used to locate the onset and spread of seizures. The findings concluded that there were 4 distinct patterns of onset seizures, with 59% of the cohort having a Perisylvian onset. This was unique to the group with a history of encephalitis, and may indicate that encephalitic-related damage may cause an increase in vulnerability to damage at the Perisylvian Fissure[10].
References
[edit]- ^ "Perisylvian syndrome". www.socialstyrelsen.se. Retrieved 2015-08-13.
- ^ a b Singh A, Kate MP, Nair MD, Kesavadas C, Kapilamoorthy TR. Bilateral perisylvian infarct: a rare cause and a rare occurrence. Singapore Med J. 2011 Apr;52(4):e62-5. PMID: 21552775.
- ^ Gowda AK, Mane RS, Kumar A. Congenital bilateral perislyvian syndrome: case report and review of literature. J Clin Neonatol. 2013 Oct;2(4):196-8. doi: 10.4103/2249-4847.123106. PMID: 24404535; PMCID: PMC3883218.
- ^ a b c d e f g h i j k l m n o p q r s Alvarez Toledo N, Munakomi S, Prestigiacomo CJ. Neuroanatomy, Sylvian Fissure. [Updated 2023 Aug 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK574552/
- ^ a b c d e f g Mameniškienė, R., et al. "Bilateral Perisylvian Syndrome With Autonomic Seizures and Autonomic Status Epilepticus: A Case Report With Long-Term Follow-up." Neurologijos seminarai 18.3 (2014).
- ^ Ciacciarelli A, Sette G, Giubilei F, Orzi F. Chronic cerebral hypoperfusion: An undefined, relevant entity. J Clin Neurosci. 2020 Mar;73:8-12. doi: 10.1016/j.jocn.2020.01.026. Epub 2020 Jan 14. PMID: 31948882.
- ^ Stephen JX. Murphy, David J. Werring, Stroke: causes and clinical features, Medicine, Volume 48, Issue 9, 2020, Pages 561-566, ISSN 1357-3039, https://doi.org/10.1016/j.mpmed.2020.06.002.(https://www.sciencedirect.com/science/article/pii/S1357303920301389)
- ^ Oliveira, Ecila Paula dos Mesquita de; Guerreiro, Marilisa Mantovani; Guimarães, Catarina Abraão; Brandão-Almeida, Iara Lêda; Montenegro, Maria Augusta; Cendes, Fernando; Hage, Simone Rocha de Vasconcellos. "Characterization of the linguistic profile of a family with Perisylvian Syndrome". Pró-Fono Revista de Atualização Científica. 17.
- ^ Fereri, E., Matricardi, S., Gozzo, F., Cossu, M., Granata, T., & Tassi, L. (2017, June 23). Perisylvian, including insular, childhood epilepsy: Presurgical workup and surgical outcome. online library.wiley.com. https://onlinelibrary.wiley.com/doi/10.1111/epi.13816
- ^ Claude Steriade, Lara Jehi, Balu Krishnan, Marcia Morita-Sherman, Ahsan N.V. Moosa, Stephen Hantus, Patrick Chauvel, Perisylvian vulnerability to postencephalitic epilepsy, Clinical Neurophysiology, Volume 131, Issue 8, 2020, Pages 1702-1710, ISSN 1388-2457, https://doi.org/10.1016/j.clinph.2020.04.019.(https://www.sciencedirect.com/science/article/pii/S1388245720301747)
External links
[edit]Category:Rare syndromes Category:Neurological disorders
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