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    <div class="highwire-article-citation highwire-citation-type-highwire-article node14140--5" data-node-nid="14140" id="top-node-14140--61913562954" data-pisa="ajnr;36/8/E58" data-pisa-master="ajnr;ajnr.A4446" data-apath="/ajnr/36/8/E58.atom" data-hw-author-tooltip-instance="highwire_author_tooltip"><div class="highwire-cite highwire-cite-highwire-article highwire-citation-jcore-article-title-complete clearfix has-author-tooltip highwire-citation-highwire-article-top-a">
  
  
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      <h1 class="highwire-cite-title" id="page-title">Injury of the Contralateral Lower Ascending Reticular Activating System by an Intracerebral Hemorrhage</h1>  
    	<div class="highwire-cite-authors"><span  class="highwire-citation-authors"><span class="highwire-citation-author first" data-delta="0">S.H. Jang</span> and <span class="highwire-citation-author" data-delta="1">Y.S. Seo</span></span></div>
  
    	<div class="highwire-cite-metadata"><span  class="highwire-cite-metadata-journal highwire-cite-metadata">American Journal of Neuroradiology </span><span  class="highwire-cite-metadata-date highwire-cite-metadata">August 2015,  </span><span  class="highwire-cite-metadata-volume highwire-cite-metadata">36 </span><span  class="highwire-cite-metadata-issue highwire-cite-metadata">(8) </span><span  class="highwire-cite-metadata-pages highwire-cite-metadata">E58-E59; </span><span  class="highwire-cite-metadata-doi highwire-cite-metadata">DOI: https://doi.org/10.3174/ajnr.A4446 </span></div>
  
  
  
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<div id="hw-article-author-popups-top-node-14140--61913562954" style="display: none;"><div class="author-tooltip-0"><div class="author-tooltip-name">S.H. Jang </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>a</span>Department of Physical Medicine and Rehabilitation
College of Medicine, Yeungnam University
Daegu, Republic of Korea</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=S.H.%2BJang%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Jang%20S&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link last"><a href="/search/author1%3AS.H.%2BJang%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li></ul></div><div class="author-tooltip-1"><div class="author-tooltip-name">Y.S. Seo </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>a</span>Department of Physical Medicine and Rehabilitation
College of Medicine, Yeungnam University
Daegu, Republic of Korea</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=Y.S.%2BSeo%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Seo%20Y&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link last"><a href="/search/author1%3AY.S.%2BSeo%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li></ul></div></div></div>  </div>

  
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    <div class="highwire-markup"><div xmlns="http://www.w3.org/1999/xhtml" data-highwire-cite-ref-tooltip-instance="highwire_reflinks_tooltip" class="content-block-markup" xmlns:xhtml="http://www.w3.org/1999/xhtml"><div class="article fulltext-view "><span class="highwire-journal-article-marker-start"></span><p id="p-1">A 56-year-old female patient underwent decompressive craniectomy for removal of an intracerebral hematoma in the right temporoparietal lobe and spontaneous subarachnoid hemorrhage due to a ruptured right middle cerebral artery bifurcation aneurysm at the department of neurosurgery of a university hospital (<a id="xref-fig-1-1" class="xref-fig" href="#F1">Fig 1</a><em>A</em>). At 3 weeks after onset, she was transferred to the rehabilitation department. The patient exhibited impaired consciousness, with a Glasgow Coma Scale score of 8 (eye opening, 3; best verbal response, 1; and best motor response, 4). Seven age-matched control subjects (3 men; mean age, 55.28 years) were recruited. All subjects provided signed, informed consent, and the study protocol was approved by our institutional review board.</p><div id="F1" class="fig pos-float  odd"><div class="highwire-figure"><div class="fig-inline-img-wrapper"><div class="fig-inline-img"><a href="http://ajnr-stage2.stage.highwire.org/content/ajnr/36/8/E58/F1.large.jpg?width=800&amp;height=600&amp;carousel=1" title="A, Brain CT images at onset show an intracerebral hemorrhage in the right frontotemporal lobes and subarachnoid hemorrhage. B, Brain MR images obtained at 3 weeks after onset show a malactic lesion in the right frontotemporal lobes. C, Results of diffusion tensor tractography. The left lower ascending reticular activating system is thinner than the right one of the patient and those of a control subject (a 54-year-old woman)." class="highwire-fragment fragment-images colorbox-load" rel="gallery-fragment-images-983120515" data-figure-caption="&lt;div class=&quot;highwire-markup&quot;&gt;&lt;div xmlns=&quot;http://www.w3.org/1999/xhtml&quot;&gt;&lt;em&gt;A&lt;/em&gt;, Brain CT images at onset show an intracerebral hemorrhage in the right frontotemporal lobes and subarachnoid hemorrhage. &lt;em&gt;B&lt;/em&gt;, Brain MR images obtained at 3 weeks after onset show a malactic lesion in the right frontotemporal lobes. &lt;em&gt;C&lt;/em&gt;, Results of diffusion tensor tractography. The left lower ascending reticular activating system is thinner than the right one of the patient and those of a control subject (a 54-year-old woman).&lt;/div&gt;&lt;/div&gt;" data-icon-position="" data-hide-link-title="0"><span class="hw-responsive-img"><img class="highwire-fragment fragment-image lazyload" alt="Fig 1." src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" data-src="http://ajnr-stage2.stage.highwire.org/content/ajnr/36/8/E58/F1.medium.gif" width="440" height="391"/><noscript><img class="highwire-fragment fragment-image" alt="Fig 1." src="http://ajnr-stage2.stage.highwire.org/content/ajnr/36/8/E58/F1.medium.gif" width="440" height="391"/></noscript></span></a></div></div><ul class="highwire-figure-links inline"><li class="download-fig first"><a href="http://ajnr-stage2.stage.highwire.org/content/ajnr/36/8/E58/F1.large.jpg?download=true" class="highwire-figure-link highwire-figure-link-download" title="Download Fig 1." data-icon-position="" data-hide-link-title="0">Download figure</a></li><li class="new-tab"><a href="http://ajnr-stage2.stage.highwire.org/content/ajnr/36/8/E58/F1.large.jpg" class="highwire-figure-link highwire-figure-link-newtab" target="_blank" data-icon-position="" data-hide-link-title="0">Open in new tab</a></li><li class="download-ppt last"><a href="/highwire/powerpoint/44513" class="highwire-figure-link highwire-figure-link-ppt" data-icon-position="" data-hide-link-title="0">Download powerpoint</a></li></ul></div><div class="fig-caption" xmlns:xhtml="http://www.w3.org/1999/xhtml"><span class="fig-label">Fig 1.</span> <p id="p-2" class="first-child"><em>A</em>, Brain CT images at onset show an intracerebral hemorrhage in the right frontotemporal lobes and subarachnoid hemorrhage. <em>B</em>, Brain MR images obtained at 3 weeks after onset show a malactic lesion in the right frontotemporal lobes. <em>C</em>, Results of diffusion tensor tractography. The left lower ascending reticular activating system is thinner than the right one of the patient and those of a control subject (a 54-year-old woman).</p><div class="sb-div caption-clear"></div></div></div><p id="p-3">Diffusion tensor imaging data were acquired at 3 weeks after onset by using a 6-channel head coil on a 1.5T Gyroscan Intera scanner (Philips Healthcare, Best, the Netherlands). For each of the 32 noncollinear diffusion-sensitizing gradients, we acquired 67 contiguous sections. Imaging parameters were as follows: TR = 10,726 ms, TE = 76 ms, <em>b</em>=1000 s/mm<sup>2</sup>, NEX = 1, section thickness = 2.3 mm. Fiber tracking was performed by using a probabilistic tractography method based on a multifiber model (FSL, <a href="http://www.fmrib.ox.ac.uk/fsl">http://www.fmrib.ox.ac.uk/fsl</a>; 5000 streamline samples; 0.5-mm step lengths; curvature thresholds = 0.2). The seed ROI was placed at the reticular formation of the pons, and the target ROI was placed at the intralaminar nuclei of the thalamus.<sup><a id="xref-ref-1-1" class="xref-bibr" href="#ref-1">1</a><a id="xref-ref-2-1" class="xref-down-link" href="#ref-2"><span>⇓</span></a>–<a id="xref-ref-3-1" class="xref-bibr" href="#ref-3">3</a></sup> Fractional anisotropy (FA) and tract volume (TV) of the lower portion of the ascending reticular activation system (ARAS) were measured. In the patient, TV of the left ARAS was decreased &gt;2 SDs compared with that of control subjects. The left lower ARAS was thinner than the right one of the patient and those of control subjects.</p><p id="p-4">In this study, by using diffusion tensor tractography, we evaluated the lower portion of the ARAS between the pontine reticular formation and the thalamus in a patient with brain injury. Only the TV of the left lower ARAS was decreased compared with that in the control group. The TV is determined by the number of voxels contained within a neural tract; therefore, the decrement of the TV without a change of FA value appears to indicate injury of the left lower ARAS. On the configuration of diffusion tensor tractography, thinning of the left lower ARAS appears to coincide with the decrement of the TV of the left lower ARAS. It appears that the left lower ARAS might have been injured by the Kernohan notch phenomenon similar to an injury mechanism following transtentorial herniation by the right intracerebral hematoma.<sup><a id="xref-ref-4-1" class="xref-bibr" href="#ref-4">4</a></sup> Our results suggest that analysis of the ARAS by using DTT would be helpful in elucidating the cause of impaired consciousness in patients with brain injury.</p><div class="section ack" id="ack-1"><h2 class="">Acknowledgments</h2><p id="p-5">This work was supported by the National Research Foundation of Korea Grant funded by the Korean Government (NRF-2015R1A2A2A01004073).</p></div><div class="section ref-list" id="ref-list-1"><h2 class="">References</h2><ol class="cit-list ref-use-labels"><li><span class="ref-label">1.</span><a class="rev-xref-ref" href="#xref-ref-1-1" title="View reference 1. in text" id="ref-1">↵</a><div class="cit ref-cit ref-journal" id="cit-36.8.E58.1" data-doi="10.3174/ajnr.A4203"><div class="cit-metadata"><ol class="cit-auth-list"><li>
</li><li><span class="cit-auth"><span class="cit-name-surname">Jang</span>  <span class="cit-name-given-names">SH</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Kim</span>  <span class="cit-name-given-names">HS</span></span></li></ol><cite>. <span class="cit-article-title">Aneurysmal subarachnoid hemorrhage causes injury of the ascending reticular activating system: relation to consciousness</span>. <abbr class="cit-jnl-abbrev">AJNR Am J Neuroradiol</abbr> <span class="cit-pub-date">2015</span>;<span class="cit-vol">36</span>:<span class="cit-fpage">667</span>–<span class="cit-lpage">71</span></cite></div><div class="cit-extra"><a href="/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiYWpuciI7czo1OiJyZXNpZCI7czo4OiIzNi80LzY2NyI7czo0OiJhdG9tIjtzOjE5OiIvYWpuci8zNi84L0U1OC5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=" class="cit-ref-sprinkles cit-ref-sprinkles-ijlink"><span><span class="cit-reflinks-abstract">Abstract</span><span class="cit-sep cit-reflinks-variant-name-sep">/</span><span class="cit-reflinks-full-text"><span class="free-full-text">FREE </span>Full Text</span></span></a></div></div></li><li><span class="ref-label">2.</span><a class="rev-xref-ref" href="#xref-ref-2-1" title="View reference 2. in text" id="ref-2">↵</a><div class="cit ref-cit ref-journal" id="cit-36.8.E58.2" data-doi="10.1007/s00234-014-1419-y"><div class="cit-metadata"><ol class="cit-auth-list"><li>
</li><li><span class="cit-auth"><span class="cit-name-surname">Jang</span>  <span class="cit-name-given-names">SH</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Kim</span>  <span class="cit-name-given-names">SH</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Lim</span>  <span class="cit-name-given-names">HW</span></span>, <span class="cit-etal">et al</span></li></ol><cite>. <span class="cit-article-title">Injury of the lower ascending reticular activating system in patients with hypoxic-ischemic brain injury: diffusion tensor imaging study</span>. <abbr class="cit-jnl-abbrev">Neuroradiology</abbr> <span class="cit-pub-date">2014</span>;<span class="cit-vol">56</span>:<span class="cit-fpage">965</span>–<span class="cit-lpage">70</span></cite></div><div class="cit-extra"><a href="/lookup/external-ref?access_num=10.1007/s00234-014-1419-y&amp;link_type=DOI" class="cit-ref-sprinkles cit-ref-sprinkles-doi cit-ref-sprinkles-crossref"><span>CrossRef</span></a><a href="/lookup/external-ref?access_num=25119256&amp;link_type=MED&amp;atom=%2Fajnr%2F36%2F8%2FE58.atom" class="cit-ref-sprinkles cit-ref-sprinkles-medline"><span>PubMed</span></a></div></div></li><li><span class="ref-label">3.</span><a class="rev-xref-ref" href="#xref-ref-3-1" title="View reference 3. in text" id="ref-3">↵</a><div class="cit ref-cit ref-journal" id="cit-36.8.E58.3" data-doi="10.1097/PHM.0000000000000274"><div class="cit-metadata"><ol class="cit-auth-list"><li>
</li><li><span class="cit-auth"><span class="cit-name-surname">Jang</span>  <span class="cit-name-given-names">SH</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Kim</span>  <span class="cit-name-given-names">SH</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Lim</span>  <span class="cit-name-given-names">HW</span></span>, <span class="cit-etal">et al</span></li></ol><cite>. <span class="cit-article-title">Recovery of injured lower portion of the ascending reticular activating system in a patient with traumatic brain injury</span>. <abbr class="cit-jnl-abbrev">Am J Phys Med Rehabil</abbr> <span class="cit-pub-date">2015</span>;<span class="cit-vol">94</span>:<span class="cit-fpage">250</span>–<span class="cit-lpage">53</span></cite></div><div class="cit-extra"><a href="/lookup/external-ref?access_num=10.1097/PHM.0000000000000274&amp;link_type=DOI" class="cit-ref-sprinkles cit-ref-sprinkles-doi cit-ref-sprinkles-crossref"><span>CrossRef</span></a><a href="/lookup/external-ref?access_num=25700167&amp;link_type=MED&amp;atom=%2Fajnr%2F36%2F8%2FE58.atom" class="cit-ref-sprinkles cit-ref-sprinkles-medline"><span>PubMed</span></a></div></div></li><li><span class="ref-label">4.</span><a class="rev-xref-ref" href="#xref-ref-4-1" title="View reference 4. in text" id="ref-4">↵</a><div class="cit ref-cit ref-journal" id="cit-36.8.E58.4"><div class="cit-metadata"><ol class="cit-auth-list"><li>
</li><li><span class="cit-auth"><span class="cit-name-surname">Jang</span>  <span class="cit-name-given-names">SH</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Lim</span>  <span class="cit-name-given-names">HW</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Yeo</span>  <span class="cit-name-given-names">SS</span></span></li></ol><cite>. <span class="cit-article-title">Injury of the ascending reticular activating system by transtentorial herniation in a patient with intracerebral haemorrhage: a diffusion tensor tractography study</span>. <abbr class="cit-jnl-abbrev">J Neurol Neurosurg Psychiatry</abbr> <span class="cit-pub-date">2015</span> 
<span class="cit-month">Jan</span> 
<span class="cit-day">30</span>. <span class="cit-comment">[Epub ahead of print]</span></cite></div><div class="cit-extra"></div></div></li></ol></div><ul class="copyright-statement"><li class="fn" id="copyright-statement-1">© 2015 by American Journal of Neuroradiology</li></ul><span class="highwire-journal-article-marker-end"></span></div><span class="related-urls"></span></div></div>  </div>

  
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