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Corresponding author at: Department of Neurology, Gates Vascular Institute, School of Medicine and Biomedical Sciences, State University of New York (SUNY) at Buffalo, 100 High Street, Buffalo, NY 14203, United States. Tel.: +1 716 859 7540; fax: +1 716 859 2430.
A 61 year old male presented with right sided weakness and was diagnosed with acute left
paramedian pontine infarction (Fig. 1 A, B ) secondary to occlusion of the perforating pontine branches of the basilar artery,
and was started on antiplatelet therapy and high dose of statin. Follow-up brain Magnetic
Resonance Imaging (MRI) after 6 weeks demonstrated bilateral symmetrical hyperintensity in middle cerebellar peduncles
on T2-weighted image (Fig. 1 C). Development of symmetrical hyperintensity in the middle cerebellar peduncles
following basis pontis infarction or hemorrhage is consistent with Wallerian degeneration
of pontocerebellar fibers, and should not be confused with additional infarctions.
As these fibers cross the midline at the basis pontis, this phenomenon develops bilaterally,
even if the initial pontine lesion is unilateral [
]. Wallerian degeneration of pontocerebellar tracts can also occur after pontine hemorrhage
and central pontine myelinolysis. Bilateral symmetric involvement of cerebellar peduncles
is not limited to Wallerian degeneration and has been reported in several other neurological
disorders, including Wilson's disease, hepatic encephalopathy, extrapontine myelinolysis
and toluene abuse. Mild diffuse abnormal signal intensity in bilateral middle cerebellar
peduncles has been also reported in neurodegenerative diseases such as multiple system
atrophy and spinocerebellar degeneration. Bilateral middle cerebellar peduncle lesions
are also found in bilateral anterior inferior cerebellar territory infarction, encephalitis
and gliomas of the brainstem; however, the involvement is usually asymmetric in these
entities [
]. Male carriers of the fragile X premutation who develop progressive intention tremor
and ataxia accompanied by progressive cognitive and behavioral difficulties can also
demonstrate bilateral symmetric signal abnormality in cerebellar peduncles [
