Severe ataxia due to injuries of neural tract detected by diffusion tensor tractography in a patient with pontine hemorrhage

RATIONALE We examined injuries of the dentato-rubro-thalamic tract (DRTT), cortico-ponto-cerebellar tract (CPCT), dorsal spinocerebellar tract (SCT), and inferior cerebellar peduncle (ICP) in a patient with severe ataxia following bilateral tegmental pontine hemorrhage (PH), using diffusion tensor tractography (DTT). PATIENT CONCERNS A 75-year-old female patient underwent conservative management for bilateral tegmental PH. She presented with moderate motor weakness, severe resting and intentional tremor on both hands, and severe truncal ataxia (Scale for Assessment and Rating of Ataxia [25 points/0-40 points: a higher score indicates a worse state]), and she was not able to sit independently. DIAGNOSES AND OUTCOMES On DTT taken at 2 weeks after initial presentation, both DRTTs and the left dorsal SCT were not reconstructed, whereas the CPCTs showed thinning of the entire pathways between the primary sensorimotor cortex and cerebellum in both hemispheres. The right ICP was discontinued at the transverse cerebellar branch of the ICP and thinning of the left ICP was observed in the vertical and transverse cerebellar branch of the ICP. LESSONS Using DTT, concurrent injuries of the DRTT, CPCT, dorsal SCT, and ICP were demonstrated in a patient with severe ataxia following PH. Our result suggests the necessity of evaluation of these neural tracts in patients who develop ataxia after brain injury.