Neural reorganization between injured cingula and the brainstem cholinergic nuclei in a patient with cerebral concussion

RATIONALE We report on a patient who showed neural reorganization between injured cingula and the brainstem cholinergic nuclei following cerebral concussion. PATIENT CONCERNS The main concern of the patient is memory impairment. DIAGNOSES Cerebral concussion. OUTCOMES When she visited our hospital at 2 years after onset, cognitive function was evaluated using 2 scales; the Wechsler Intelligence Scale, and the Seoul neuropsychological screening battery: total IQ 97, verbal immediate recall 5.70 percentile, visual immediate recall 30.75 percentile, verbal delayed recall 3.13 percentile, visual delayed recall 11.00 percentile, verbal recognition <0.01 percentile, and visual recognition 13.70 percentile. Conventional brain magnetic resonance imaging did not show any abnormality. On 2-year diffusion tensor tractography for the cingulum, both anterior cingula were discontinued over the genu of the corpus callosum. One neural fiber bundle originating from the middle portion of the left cingulum descended through the left subcortical white matter, and connected to the left pedunculopontine nucleus (Ch 5) in the midbrain and the left laterodorsal tegmental nucleus (Ch 6) in the upper pons. LESSONS Reorganization of cholinergic innervations between cholinergic nuclei in the basal forebrain and brainstem following injury of the anterior cingulum was demonstrated in a patient with cerebral concussion.