Significant functional improvement in published case series
Reserved for patients failing comprehensive pharmacologic trials
Secondary prevention evidence base
Hypertension control strongest modifiable risk factor
ACE inhibitor plus thiazide combination reduces recurrent stroke
PROGRESS trial underpins combination treatment
Statin therapy for secondary prevention
SPARCL trial: atorvastatin 80 mg reduced recurrent stroke by 16%
Benefit extends to posterior circulation ischemic stroke
Atrial fibrillation anticoagulation
ARISTOTLE and ROCKET AF support direct oral anticoagulants
Reduced intracranial hemorrhage versus warfarin
Class I recommendation for non-valvular atrial fibrillation
Patient Discharge Instructions
copy discharge instructions
What happened to you
You had a stroke affecting the brainstem affecting a region called the midbrain
This caused weakness and coordination problems on one side of your body
This also caused eye movement problems on the other side
You may develop a tremor weeks or months from now
This is called Holmes tremor and is related to your stroke
It is treatable so report it immediately to your doctor
Medications
Take all medications exactly as prescribed
Blood thinners or aspirin to prevent another stroke
Blood pressure medications every day
Cholesterol medications every day
Do not stop any stroke medication without calling your doctor first
Missing doses increases stroke recurrence risk
If prescribed levodopa for tremor
Take with food to reduce nausea
Do not stop suddenly without medical advice
Activity and safety
Do not drive until cleared by your neurologist
Eye movement problems and tremor affect driving safety
Fall prevention measures at home
Remove trip hazards
Use assistive devices if recommended
Grab bars in bathroom
Swallowing precautions if applicable
Follow diet texture recommended by speech therapist
Sit upright for all meals
Take small bites and eat slowly
Warning signs to return to ER
Sudden new weakness or numbness on either side of the body
New or worsening vision problems or double vision
Sudden severe headache unlike any before
Difficulty speaking or understanding speech
Sudden loss of balance or inability to walk
Loss of consciousness or confusion
New difficulty swallowing or repeated choking
Sudden worsening of tremor or new tremor developing
Follow-up appointments
Neurology appointment within 2 weeks
Bring medication list
Report any new tremor or movement changes
Rehabilitation appointments
Physical therapy for balance and strength
Occupational therapy for daily activities
Speech therapy if swallowing or speech affected
Primary care appointment within 1 week
Blood pressure check
Medication review
References
Guidelines and key sources
Stroke guidelines
AHA/ASA Guidelines for the Early Management of Patients with Acute Ischemic Stroke 2019
Thrombolysis and thrombectomy eligibility criteria
Blood pressure management targets
AHA/ASA Secondary Prevention of Stroke Guidelines 2021
Antithrombotic therapy recommendations
Risk factor modification targets
European Stroke Organisation ESO Guidelines
Posterior circulation stroke specific guidance
Mechanical thrombectomy for basilar artery occlusion
Benedikt syndrome clinical references
Benedikt syndrome original description and anatomic localization literature
Topographic correlation of CN III palsy hemiataxia and hemiparesis
Differentiation from Weber and Claude syndromes
Holmes tremor mechanistic and treatment studies
Duprez et al and Raina et al on levodopa response rates in Holmes tremor
DaTscan utility for predicting levodopa response
Deep brain stimulation outcomes in refractory Holmes tremor
Evidence summaries
BASICS trial: endovascular therapy for basilar artery occlusion
New England Journal of Medicine 2021
No significant benefit over medical management in primary analysis
BEST trial: basilar artery occlusion endovascular trial
Trends toward benefit in pre-specified subgroups
POINT and CHANCE trials supporting dual antiplatelet therapy
21-day dual antiplatelet for high-risk TIA and minor stroke
SPARCL trial statin therapy for secondary stroke prevention
Atorvastatin 80 mg daily reduces recurrent stroke
Coding and classification
ICD-10 G46.3 brain stem stroke syndrome
ICD-10 I63.9 cerebral infarction unspecified
ICD-10 G25.2 essential tremor applied to Holmes tremor classification
SNOMED CT midbrain infarction disorder concept
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.