Hypersomnolence as the Presenting Feature of Thalamic Stroke

To analyze the characteristics of acute ischemic stroke (AIS) resulting from moyamoya disease (MMD) and intracranial large artery atherosclerotic stenosis (LAS). This real-world case control study enrolled imaging-confirmed AIS patients owing to MMD or LAS hospitalized from January 2015 through September 2020 consecutively. The features of risk factors, peripheral blood, and imaging presentations were compared between the two cohorts. A total of 191 eligible patients entered into final analysis, including 70 cases with MMD stroke and 121 with LAS stroke. LAS stroke vs. MMD stroke, the ratios of hyperlipidemia, hypertension, diabetes, and hyperhomocysteinemia were higher in the former (65.3 vs.12.9%, 65.3% vs. 4.3%, 39.7% vs. 2.9%, and 43.8% vs.12.9%; all p < 0.01) as well as baseline plasma arachidonic acid (AA) and adenosine diphosphate (ADP)-stimulated maximum platelet aggregation rates (75.3% vs. 60.8% and 73.1% vs.64.9%, respectively, all p < 0.01), which were positively correlated with triglycerides and cholesterol levels, blood glucose, age, and platelet counts (all p < 0.01). Classical watershed infarction (WSI) accounted for 87.14% in MMD stroke and 40.49% in LAS stroke, respectively (p < 0.01). Almost all of the patients with LAS showed plaques in arterial walls on CTA maps and non-homogeneous thickening with irregular luminal narrowing on HRMRI, while plaques were seldom found in MMD besides homogeneous thickening with regular luminal narrowing. Differing from LAS stroke, MMD stroke mainly presents with WSI and does not feature with platelet hyper-aggregation and fragmentation of ulcer plaque. Whereby, focusing on perfusion improvement rather than antiplatelets and statins may be the predominant step in MMD-stroke correction.

BackgroundMore patients with left-hemispheric than right-hemispheric strokes are admitted to hospitals. This is due to the easier recognition of cortical symptoms of the dominant-hemisphere. The thalamus constitutes a “micro-model” of the brain cortex with structure-function relationships known to be asymmetric, especially for language, memory, and visuo-spatial neurocognitive functions. The goal of this study was to characterize clinical symptoms and lesion distribution patterns of patients with acute isolated thalamic stroke (ITS) and to evaluate whether left-sided lesions are overrepresented in the hospital.MethodsWe performed a radiological database search including all brain scans performed in the Center of Neurology and Neurosurgery of the University Hospital Frankfurt between 2010 and 2019. A total of 5733 patients presenting with acute ischemic stroke were screened for ITS. Based on the MRI data, a lesion-overlap map was then generated to visualize the ITS lesion distribution.ResultsFifty-eight patients with unilateral ITS were identified. A majority of 38 patients (65.5%) showed left-sided ITS, whereas only 20 patients (34.5%) had right-sided ITS (p = 0.012). A particular difference was found for ITS lesions in the anterior thalamus of the anterolateral (n = 10) and anteromedian (n = 3) vascular territory, which were located in the left thalamus in 85% of patients (p = 0.011). No distribution difference was found for ITS lesions in the inferomedial (n = 7), central (n = 8), inferolateral (n = 23) and posterior (n = 7) vascular territories. The neuropsychological symptoms of thalamic aphasia (n = 8), neurocognitive impairment (n = 6), behavioral changes (n = 2), neglect (n = 2) and memory deficits (n = 3) were described predominantly in patients with left-sided ITS (p < 0.01). In contrast, other stroke symptoms (e.g., sensorimotor hemi-syndromes) did not reveal a side preponderance.ConclusionsThe better recognizability of left anterior compared to right anterior thalamic stroke symptoms may have an impact on the frequency in which ITS patients are admitted to the hospital. Clinical characteristics of right anterior thalamic stroke should therefore be further investigated, and diagnostic instruments towards their detection be identified.

Chapter 62 - Sleep and stroke

Ischemic thalamic infarction in children: clinical presentation, etiology, and outcome

The thalamus plays an important role in different brain functions including memory, emotions, sleep-wake cycle, executive functions, mediating general cortical alerting responses, processing of sensory (including taste, somatosensory, visual, and auditory) information and relaying it to the cortex, and sensorimotor control. Thalamic stroke, both in isolation and in combination with infarcts involving other structures, are not rare. The functional complexity of the thalami nuclei and the not uncommon normal variations of arteries supply the thalamus induce wide variations in presentation of thalami infarcts. In patients with an unusual collection of deficits difficult to explain by a single lesion, in particular where there is impaired vigilance, thalamic disease should be considered which may mimic several different neurological conditions. By researching the literature, we found that the characteristic stroke syndrome of paramedian thalamic infarction is probably underdiagnosed. In addition to thalamic infarct, thalamic lesions can be caused by deep cerebral venous thrombosis with neuropsychological and radiological features that should be considered in the differential diagnosis of intracranial artery occlusion or bleeding, especially in young patients.

Acute Childhood Arterial Ischemic and Hemorrhagic Stroke in the Emergency Department

Aphasia is an important presenting symptom of acute stroke. With increasing reliance on electronic communication, incoherent texting or “dystextia,” which is a subset of aphasia that is reflected in text messages, can be a useful tool for symptom recognition and analysis. It can be a red flag for the family and therefore can help in early identification of an acute neurological deficit. It is also useful for providers to reliably analyze the deficit as well as establish a timeline of evolution of symptoms. There have been case reports where dystextia has been the presenting feature of stroke or complicated migraine and in one case of meningioma. We present the case of a teenage patient that in our knowledge is the youngest reported case of dystextia, whose aphasia recorded in a text message assisted with stroke localization. This also adds to the literature of dystextia which so far has only seven other cases reported.

Thalamic stroke accounts for 2%-3% of total cerebrovascular diseases. Thalamus contains multiple complex nuclei with variant blood supplies, therefore thalamic ischemic stroke presents various clinical manifestations which will emerge difficulties in precise clinical diagnosis at acute stage. This review summarizes and integrates thalamic anatomical structure, blood supplies and corresponding clinical manifestations, aiming to provide overview of thalamic ischemic stroke and to improve efficacy of early diagnosis and treatment. DOI: 10.3969/j.issn.1672-6731.2018.12.011

A stroke is a clinical syndrome characterized by a focal neurologic deficit that can be attributed to a vascular territory within the brain. The presenting features of an acute stroke depends on the area of the brain affected. Although unusual, the presenting feature may include psychosis with auditory and/or visual hallucinations. A 56-year-old female was admitted to the psychiatric unit after threatening her husband with a knife. She reported experiencing altered sensorium for one week with suicidal and homicidal command hallucinations. Given the acute onset, brain images were obtained to rule out an organic etiology. A brain MRI revealed an acute right occipital lobe infarct with hemorrhagic transformation. The patient's symptoms were self-limited, resolving without antipsychotic medications. Psychosis with auditory hallucinations is not commonly reported following stroke. Since histologic and functional alterations in the occipital lobe appear to play a significant role in psychosis of schizophrenics, it is likely that ischemia in the same area may cause similar changes. Familiarity with this rare presentation is important, as it prevents a delay in diagnosis, which may negatively impact the outcome.

Arterial ischaemic stroke in the paediatric population is considered a rare disease, and its diagnosis is often delayed due to the subtlety and variability of clinical symptoms, especially in younger patients. The clinical presentation and imaging features of ischaemic stroke in the paediatric population are variable depending on the underlying cause, affected artery and patient's age. Literally, acute occlusion of the middle cerebral artery shows significant clinical signs and symptoms, and riotous imaging findings due to the size of the territory. Here, we present a case of a 15-year-old boy who unusually had subtle and intermittent clinical symptoms in spite of a complete acute occlusion in his right middle cerebral artery.

BackgroundChildhood stroke is a neurological emergency and an important cause of acquired brain injury and mortality in children. This retrospective study aimed to investigate the clinical presentation and neuroimaging features of arterial ischemic stroke (AIS) in children.MethodsWe retrospectively reviewed the records of pediatric AIS including neonates and children under 18 years of age from January 2008 to December 2023. Then we analyzed the gender and age distribution of AIS, as well as the clinical and neuroimaging characteristics and risk factors of AIS in different age groups. The study was approved by the Ethics Committee of the host institution.ResultsMale patients predominated in both the neonatal AIS (NAIS) group and the pediatric AIS (PAIS) group. The majority of AIS children (73, 60.33%) were diagnosed after 24 h of symptom onset. Seizures (82.35%) and limb weakness (77.88%) were the most common initial neurologic symptoms of NAIS and PAIS, respectively. Anterior circulation AIS alone was much more common than posterior circulation AIS alone in childhood AIS (79.34% vs. 9.92%). However, the NAIS group had a higher rate of infarctions that solely involved the cortex (52.94% vs. 20.19%). Perinatal hypoxia or asphyxia (23.5%) and minor head injury (28.85%) were the most common possible risk factors in NAIS and PAIS, respectively.ConclusionAIS in children is male-predominant, and there is significant diagnostic delay in both NAIS and PAIS. NAIS and PAIS differ in clinical and neuroimaging manifestations, and risk factors. Notably, we also noted that the actual prevalence of AIS in children, and the diagnosis of certain risk factors, may be underestimated. Education and training will be necessary in both layperson and healthcare settings. Furthermore, prospective studies are required to explore this hypothesis.

The artery of Percheron (AOP) is a rare variant of thalamic vasculature and is a single dominant thalamoperforating artery supplying bilateral paramedian thalamic territories. Occlusion of the AOP results in a characteristic pattern of bilateral paramedian thalamic infarcts and is estimated to represent between 0.1%-0.3% of all ischemic strokes and 4% to 35% of all thalamic strokes. Four distinct ischemic patterns of AOP infarcts have been identified: bilateral paramedian thalamic region with midbrain (43%), bilateral paramedian thalamic without midbrain (38%), bilateral paramedian thalamic with anterior thalamus and midbrain involvement (14%), and bilateral paramedian thalamic with anterior thalamus without midbrain involvement (5%).Despite our knowledge of the characteristic radiologic features of an AOP stroke, the true incidence of AOP strokes is challenging to estimate due to non-specific clinical symptoms and subtle findings on computed tomography (CT) and/or magnetic resonance imaging (MRI). Here, we present a case series of three patients seen within a 3-month span at one community hospital seen by one single neurologist with confirmed AOP stroke by radiologic imaging. The frequency of these cases suggests that the incidence of AOP infarctions may be higher than previously estimated and instead are underreported due to broad differential on clinical and imaging presentation.

Sudden-onset ptosis as a presenting feature of thalamic stroke.

Hypokinetic and hyperkinetic movement disorders can occur post-stroke. Of these, dystonia is known to occur in the chronic stage of stroke. Rarely, acute dystonia can present as a symptom of acute ischemic stroke or develop during hospitalization for ischemic stroke. In this article, we present a case of acute focal dystonia as a presenting symptom of acute ischemic stroke, review the literature to summarize previous reports, and provide more insight into the pathophysiologic mechanisms related to this presentation.

Background:Stroke is the most common neurologic disease and an important cause of morbidity and mortality. Headache is an initial presenting feature of ischemic stroke and sometimes precedes the development of stroke and thus, provides an opportunity for offering preventive measures. The aim of the present study was to determine the association of new onset headache with stroke.Methods:A total of 263 consecutive patients with stroke entered the study. Development of headache 24 have prior to admission lasting <3 days was considered the new onset headache. The intensity of headache was graded as mild, moderate and severe. Stroke was classified with respect to the localization of brain damage using magnetic resonance image (MRI). Chi-square test was applied for comparison of proportions. Results:One hundred thirty-nine males and one hundred twenty-four females with mean age of 76.4±10 (40-89) years were analyzed. Ischemic stroke involving anterior circulation was diagnosed in 210 (79%) patients and vertebrobasilar ischemia in the remaining population. Diabetes, hypertension, hyperlipidemia and coronary artery disease were observed in 36%, 52%, 38% and 42%, respectively. New onset headache was found in 49 (18.9%) patients in who 81.6% was mentioned as new onset. Six out of 9 patients with severe headache had involvement of posterior circulation, whereas in the remaining population, anterior circulation was involved.Conclusion:The findings of this study indicate no association of new onset headache with stroke. There was only a trend for severe headache toward the involvement of vertebrobasilar ischemia.