Bilateral Infarction Research Articles

Evaluation of Clinical Features and Stroke Etiology in Patients with Bilateral Middle Cerebellar Peduncle Infarction

Objective: The aim of this study was to characterize clinical features, etiologies, and mechanisms of strokes due to bilateral middle cerebellar peduncle infarction (BMCPI). Methods: Cases diagnosed as BMCPI in our hospital were retrieved, and a literature review was performed. Data on clinical features and brain MRI were obtained. Extracranial and intracranial segments of the vertebrobasilar artery were assessed by using digital subtraction angiography, magnetic resonance angiography, or computed tomography angiography. Results: Thirteen cases (11 men and 2 women) of BMCPI were identified. A high-intensity signal of diffusion-weighted imaging sequence involving the bilateral middle cerebellar peduncle was observed in all patients. Most patients experienced vertigo, dysarthria, ataxia, and hearing disorders. Eleven of these cases were classified as large artery atherosclerosis, one as traumatic vertebral artery (VA) dissection, and one as giant cell arteritis. Conclusion: BMCPI is a rare cerebrovascular disease characterized by vertigo, ataxia, and dysarthria, which may also be accompanied by a hearing deficit or clinical signs of brainstem damage. BMCPI may be associated with hypoperfusion secondary to occlusive disease of the bilateral VA or proximal basilar artery.

Severe COVID-19 with debut as bilateral pneumonia, ischemic stroke, and acute myocardial infarction

Severe COVID-19 with debut as bilateral pneumonia, ischemic stroke, and acute myocardial infarction

Heart sign in Neurology - A Radiological sign

Bilateral medial medullary infarction is a rare stroke syndrome. The common symptoms are quadriparesis, dysarthria and hypoglossal palsy. However, the early diagnosis of bilateral medial medullary infarction may be difficult as it may mimic other conditions like Guillain Barre syndrome and brainstem encephalitis. With the advent of magnetic resonance imaging, it can be easily diagnosed, as the diffusion weighted sequences demonstrate hyperintensity involving bilateral medulla in a heart shaped pattern, described as the “Heart sign”. We hereby report a patient who presented with progressive quadriparesis, and dysarthria, progressing to respiratory failure, whose MRI brain showed the characteristic “heart sign” on diffusion sequences and was diagnosed to have bilateral medial medullary infarction.

Multiple Acute Ischemic Strokes in a COVID-19 Patient: a Case Report.

We describe a case of a 47-year-old Italian, immunocompromised, and obese woman infected by COVID-19 presenting with fever (39.6 °C) and respiratory symptoms. Neurological examination was normal. Chest CT findings consist of bilateral interstitial pneumonia (visual score extension: 30%). The patient was treated with antiviral drugs and anti-inflammatory drugs with supportive care. Seven days after admission to Covid-19 Unit, the patient rapidly developed worsening respiratory failure and acute respiratory distress syndrome (ARDS). She suddenly developed partial left hemispheric syndrome. A new HRCT scan of her thorax revealed diffuse ground-glass opacities in both lungs (visual score extension: 90%). Brain CT performed 2 h after sudden-onset left-sided weakness showed subtle low attenuation within the right insular ribbon and frontal lobe (ASPECT Score 8). Multiphasic CT angiography (MCTA) demonstrated occlusion of both the dominant inferior division of the right middle cerebral artery and the A2 segment of the right anterior cerebral artery. After 24 h, her pupils became dilated and unreactive, and brain CT demonstrated large bilateral infarctions of both the cerebellar and cerebral hemispheres. She had a rapid progression of interstitial pneumonia from COVID-19, developed multiple strokes, and died 1 day later. SARS-CoV-2 infection seems to predispose pluripathological subjects to cerebrovascular complications.

Stanford type a aortic dissection with cerebral infarction: a rare case report

BackgroundAortic dissection (AoD) is a disease with a high mortality rate. Its clinical manifestations are diverse and covert, which makes diagnosis and treatment challenging. Here, we report a very rare case of aortic dissection leading to bilateral cerebral cortex ischaemia and epilepsy.Case presentationA 54-year-old man was admitted to the hospital with acute onset of right limb weakness accompanied by slurred speech. He had a history of hypertension as well as tobacco and alcohol use. The patient was found to have aphasia and right hemiplegia on physical examination. No bleeding was seen on the skull CT. Acute cerebral infarction was considered after admission, and rt-PA was administered for intravenous thrombolysis. During intravenous thrombolysis, the patient suddenly developed epilepsy, and diazepam was given immediately by intravenous injection to control the symptoms. Emergency skull diffusion-weighted imaging (DWI) was performed, and the results showed a small, patchy, high signal that was scattered throughout the left brain hemisphere, right frontal parietal lobe and centrum semiovale. Head and neck CT angiography (CTA) was performed; dissection was found in the ascending aorta, aortic arch, bilateral common carotid artery, proximal part of the internal carotid artery, and initial segment of the left external carotid artery. The laceration was located in the upper part of the ascending aorta. AoD complicated by acute cerebral infarction and epilepsy was considered, and the patient was immediately transferred to the cardiovascular surgery specialist hospital for surgical treatment.ConclusionsSome aortic dissections have no typical manifestations of chest pain, and the onset is covert. Atypical clinical manifestations of epilepsy secondary to bilateral cerebral hemisphere infarction may appear. AoD with cerebral infarction is a contraindication for intravenous thrombolysis; surgical treatment is the best way to reduce mortality.

Bilateral corpus callosum and corona radiata infarction due to cerebral venous sinus thrombosis presenting as headache and acute reversible aphasia: a rare case report

BackgroundCerebral venous sinus thrombosis (CVST), a rare cause of cerebral infarction, is often unrecognized at initial presentation. We report the case of a patient with bilateral corpus callosum and corona radiata infarction due to cerebral venous sinus thrombosis presenting as headache and acute reversible aphasia.Case presentationA 30-year-old female patient presented with headache, vomiting, and motor aphasia. She was 20 days post-partum and had a lower than normal food intake following a normal vaginal delivery. Brain magnetic resonance images revealed a bilateral corpus callosum and corona radiata infarction. MR venography (MRV) and digital subtraction angiography (DSA) images showed a signal void in the anterior aspect of the superior sagittal sinus and inferior sagittal sinus, ophthalmic vein expansion, and the reversed direction of venous flow. In addition, images showed non-visualization of the left transverse sinus. The left slender sigmoid sinus and small internal jugular vein were also noted. The diagnosis of cerebral venous thrombosis was considered based on the above findings. The patient was managed with anticoagulation therapy, and recovered substantially after treatment.ConclusionsBilateral corpus callosum and corona radiata infarction is very rare. However, for patients who clinically show cranial hypertension and neurological deficits during the puerperium period, the possibility of CVST should be considered. Furthermore, DSA plays an important role in the diagnosis of CVST, and should be routinely checked. Early diagnosis is crucial for the patient suffering from CVST.

Acute Onset Asymmetric Sensorimotor Paraparesis: Not Always Spinal!

Objective: To report an atypical case of acute onset sensorimotor paraparesis secondary to bilateral cerebral stroke. Background: Acute onset paraparesis or paraplegia is usually secondary to a spinal cord disease. Central or cerebral causes of paraparesis are rare and include parasagittal and bilateral precentral lesions. Design/Methods: Case report and literature review. Results: A 65-year-old man presented with acute onset weakness of both lower limbs, associated with pins and needle sensation. On examination, he was found to have paraparesis (grade 2/5, both legs) and an asymmetric sensory loss in both legs and thighs. Spinal magnetic resonance imaging ruled out any compressive or noncompressive etiology. Magnetic resonance imaging of the brain showed an acute infarction in the bilateral cerebral hemisphere in both the pre- and postcentral gyrus. An angiogram of the brain revealed an aplastic right ACA-A1 with left ACA-A1 feeding bilateral A2. There was distal left ACA-A1 stenosis seen, the probable cause of bilateral stroke in this patient. The patient was treated conservatively and showed symptomatic improvement during the course of stay at the hospital. Conclusion: This case of acute paraparesis secondary to bilateral cerebral infarction demonstrates the need to always look for a cerebral cause. In patients with cerebral infarction, who present early to a hospital, it may provide a window for thrombolytic or endovascular therapy.

Heart in the brain: classical imaging sign in bilateral medial medullary infarction

Bilateral medial medullary infarction is a rare type of posterior fossa stroke due to occlusion of blood supply to the anteromedial aspect of the medulla. It can be diagnosed by its classical imaging appearance - the "heart sign".

Improvement of activities of daily living in a patient with bilateral medullary infarction: A case report

Improvement of activities of daily living in a patient with bilateral medullary infarction: A case report

Fabry disease presenting as bilateral medial medullary infarction with a \u201cheart appearance\u201d sign: a case report

BackgroundThe etiologic determinants of cryptogenic stroke remain a diagnostic challenge in clinical practice. Fabry disease (FD) is one of the monogenic causes of stroke that may remain unrecognized as a potential contributing causative factor, because of its rarity and difficulty in diagnosis. We report a case with rare bilateral medial medullary infarction manifesting as “heart appearance” who was diagnosed with FD.Case presentationA 51-year-old Chinese man presented with acute dysarthria and mild tetraparesis. In the 24 h following admission, the patient rapidly developed progressive flaccid quadriplegia and tongue weakness, necessitating ventilator support. Immediate magnetic resonance imaging of the brain showed heart-shaped appearance of bilateral medial medullary infarction. The patient suffered two new subcortical infarcts 40 days after the first. Detailed Family history and physical examination indicated symptoms consistent with FD, which was confirmed by very low alpha galactosidase A levels and a missense mutation of the alpha-galactosidase A gene.ConclusionsWe report what appears to be the first case of FD manifesting as bilateral medial medullary infarction. Our case suggests that clinicians should consider the possibility of FD in patients with cryptogenic stroke, especially when combined with infarction in the vertebrobasilar artery system, renal insufficiency, or cardiomyopathy. A detailed analysis of subtle historical clues and performing a complete physical examination on stroke patients would help promote earlier diagnosis of FD.

SAT-182 Bilateral Adrenal Hemorrhage with Clinically Preserved Adrenal Function Leading to the Diagnosis of Antiphospholipid Syndrome

Background: Spontaneous bilateral adrenal hemorrhage (BAH) is a rare complication of antiphospholipid syndrome (APS), which is the most common identifiable risk factor for BAH. Although adrenal dysfunction is generally irreversible, adrenal function might be preserved or even recover in rare cases1.Clinical case: A 48 year-old man with history of hypertension and gout presented with right upper quadrant abdominal pain following trauma to his left leg. He was found to have a left lower extremity deep vein thrombosis and bilateral pulmonary emboli (PE) and was started on anticoagulation therapy. He continued to have abdominal pain and a CT abdomen revealed BAH. Three am cortisol level was 21 mcg/dL (8–25 mcg/dL), ACTH 37 pg/mL (6–59 pg/mL), aldosterone <3 ng/dL (4–31 ng/dL), renin 2.6 ng/mL/hr (0.2–1.6 ng/mL/hr), sodium 130 mmol/L (135–146 mmol/L) and potassium 4.3 mmol/L (3.6–5.3 mmol/L). Patient was hemodynamically stable and did not report symptoms of adrenal insufficiency. Hypercoagulable work-up was consistent with APS and Lupus. Despite normal cortisol levels, he was started on hydrocortisone in the setting of anticoagulation and recent hemorrhage. Given low aldosterone with slightly high renin he was also started on fludrocortisone. Six weeks after discharge, his morning cortisol was 6 mcg/dL and ACTH was elevated at 76 pg/mL which was concerning for adrenal insufficiency. However, 250 mcg IM ACTH stimulation test showed peak cortisol of 17 mcg/dL which is considered adequate. Aldosterone and renin levels normalized so fludrocortisone was discontinued.Patient subsequently self-discontinued all medications for 1 month with no symptoms of adrenal insufficiency, and later restarted hydrocortisone on his own. Repeat ACTH stimulation test showed baseline ACTH 57 pg/mL with peak cortisol of 17 mcg/dL. Patient was tapered off hydrocortisone and displayed no subsequent symptoms of adrenal insufficiency.Conclusion: This case highlights the need to consider APS in patients with spontaneous BAH. Additionally, patients with BAH may have relatively preserved adrenal function. There is limited data to guide when steroid replacement is necessary for patients without clear adrenal insufficiency. It may be reasonable to monitor these patients off hydrocortisone replacement with close monitoring.1. Ramon I, Mathian A, Bachelot A, et al. Primary adrenal insufficiency due to bilateral adrenal hemorrhage-adrenal infarction in the antiphospholipid syndrome: long-term outcome of 16 patients. J Clin Endocrinol Metab. 2013;98(8):3179–3189.

A case of Trousseau\u2019s syndrome due to intrahepatic cholangiocarcinoma with an extremely high level of CA19-9

BackgroundTrousseau’s syndrome is a cancer-associated thrombosis. Trousseau’s syndrome with cholangiocarcinoma is a rare condition with poor prognosis.Case presentationA 59-year-old female was admitted to our hospital with abdominal pain, headache, and nausea. Abdominal enhanced computed tomography revealed liver tumor, splenic infarction, and bilateral renal infarction. Multiple acute cerebral infarctions were also detected by magnetic resonance imaging. Her preoperative serum levels of carbohydrate antigen 19-9 (CA19-9) and carcinoembryonic antigen (CEA) were > 120,000 U/mL and 589.6 ng/mL, respectively, which were extremely high. Histopathology after right hepatectomy revealed moderately differentiated adenocarcinoma consistent with intrahepatic cholangiocarcinoma. Her serum levels of CA19-9 were trending down to 9029.2 and 2659.8 U/mL at 1 and 3 weeks after surgery, respectively. However, at 7 weeks after surgery, her CA19-9 levels increased in the presence of positive imaging findings in the remnant liver, hilar lymph nodes, and peritoneal cavity. The initiation of combination chemotherapy including gemcitabine and cisplatin had a significant effect. The patient was doing well at 6 months after the surgery.ConclusionThis rare case of Trousseau’s syndrome due to cholangiocarcinoma suggests that extremely high CA19-9 levels might be a pathogenic factor of this syndrome.

Cerebral blindness resulting from bilateral optic radiation infarction; a case report (2627)

Cerebral blindness resulting from bilateral optic radiation infarction; a case report (2627)

Spontaneous intracranial hemorrhage and acute multiple bilateral subcortical infarcts, a case of possible CADASIL (5123)

Spontaneous intracranial hemorrhage and acute multiple bilateral subcortical infarcts, a case of possible CADASIL (5123)

Giant \u201cheart appearance-like sign\u201d on MRI in bilateral ponto-medullary junction infraction: case report

BackgroundBilateral medial medullary infarction (MMI) is uncommon and bilateral medial pons infarction (MPI) is even rarer. “Heart appearance” on magnetic resonance imaging (MRI) is a characteristic presentation of bilateral medial medullary infarction (MMI).Case presentationWe present 67-year-old Chinese diabetic and hypertensive female patient affected with “heart appearance-like” infarction in bilateral ponto-medullary junction on MRI. Abnormal signal was observed in the bilateral ponto-medullary junction on T1, T2, fluid-attenuated inversion recovery and apparent diffusion coefficient (ADC). The whole brain digital subtraction angiography (DSA) showed the basilar artery and vertebral artery remained intact. Therefore, we speculated that the bilateral ponto-medullary junction infarction might be caused by the deep perforating branch of the basilar artery.ConclusionsAs far as we know, the “heart appearance-like” infraction in bilateral ponto-medullary junction was not reported. Our case also suggests that bilateral ischemic infraction involvement of the medulla and pon is possible even in the context of an intact basilar artery.

Catastrophic stroke burden in a patient with uncontrolled psoriasis and psoriatic arthritis: a case report

BackgroundPsoriasis is the most common chronic inflammatory condition involving the T helper cell system. Population studies have demonstrated that patients with psoriasis and/or psoriatic arthritis have an increased risk of developing vascular risk factors, including diabetes, hypertension, and obesity, and increased risk of adverse vascular events, including myocardial infarction and stroke. Population studies have generally investigated the individual contributions of psoriasis and psoriatic arthritis to development of vascular risk factors; fewer studies have investigated the additive contribution of comorbid inflammatory disorders. We present a case of a woman with psoriasis, psoriatic arthritis, and comorbid vascular risk factors.Case presentationA 49 year-old Caucasian woman with a history of severe psoriasis and psoriatic arthritis since adolescence presented with bilateral lower extremity weakness. She was found to have acute bilateral watershed infarcts and multifocal subacute infarcts. Her evaluation revealed vascular risk factors and elevated non-specific systemic inflammatory markers; serum and cerebral spinal fluid did not reveal underlying infection, hypercoagulable state, or vasculitis. Over the course of days, she exhibited precipitous clinical deterioration related to multiple large vessel occlusions, including the bilateral anterior cerebral arteries and the left middle cerebral artery. Autopsy revealed acute thrombi and diffuse, severe atherosclerosis.ConclusionPatients with early onset inflammatory disease activity or comorbid inflammatory disorders may have an even higher risk of developing metabolic syndrome and adverse vascular events compared to patients with late-onset disease activity or with a single inflammatory condition. The described case illustrates the complex relationship between inflammatory disorders and vascular risk factors. The degree of systemic inflammation, as measured by severity of disease activity, has been shown to have a dose-response relationship with comorbid vascular risk factors and vascular events. Dysregulation of the Th1 and Th17 system has been implicated in the development of atherosclerosis and may explain the severe atherosclerosis seen in such chronic inflammatory conditions. Further research will help refine screening and management guidelines to account for comorbid inflammatory disorders and related disease severity.

Bilateral macular infarction in a patient with metastatic breast carcinoma.

Bilateral macular infarction in a patient with metastatic breast carcinoma.

P171 Catastrophic systemic multiple embolism from a giant atrial mixoma: a case report

Abstract Atrial mixoma represents the most common cardiac tumour. The diagnosis is usually accidental since it is benign and usually asymptomatic. Nevertheless, life-threathening complications such as embolization may seldom occur. In these cases emergent multispecialistic approach is deemed. We describe the case of a 46 year old man without cardiovascular risk factors and whose previous clinical history was not significant. At home, the patient abruptly presented a right hemiplegia, deviation of the buccal commissure to the left and loss of consciousness. On arrival at the emergency department GCS was 5. Routine blood tests, gas analysis and ECG were unremarkable. An urgent CT scan showed a left fronto-parietal subarachnoid hemmorhage. Soon after admission in the stroke unit the patient showed sign of acute limb ischaemia. A high-resolution 3D-angio CT revealed multiple bilateral renal and splenic infarcts and a massive thrombosis of the abdominal aorta below the renal bifurcation, with extensive involvement of the iliac arteries. Unexpectedly, a bulky mass (max diameter 8 cm) was detected in the left atrium. Transthoracic echocardiography confirmed the presence of an irregularly oval (8x3cm) mobile peduncolate mass with fringed edges, suspected for mixoma, with phasic impingement of the mitral valve and protrusion into the left ventricle. Considering the age of the patient and the very early presentation, after Heart Team discussion the patient underwent an urgent embolectomy with Fogarty catheter followed by cardiac surgery for myxoma resection. After full sternotomy, with an interatrial groove approach, a large tumor with myxoid appearance implanted in the left atrial roof was discovered (8 cm maximum diameter). A complete excision of the mass was successfully performed. The macroscopic examination revealed a tumor with a gelatinous and friable surface, very irregular edges and narrow base of implantation, suggestive of atrial myxoma. The day after a CT revealed multiple new ischemic and hemorragic lesions in the left frontal and parietal lobes, in the right occipital lobes, in the cerebellar emispheres, thalamus and hypotalamus and in the mesencephalus. Multiple thrombosis of the main branches of the Willis polygon were detected as well. The patient remained comatous (GCS 3) with bilateral midriasis and was intubated in the intensive care unit. The anatomopathological study confirmed the diagnosis of atrial myxoma. Despite the general belief that atrial mixoma present a benign course, clinicians should carefully consider the possibility of dramatic complications, due to the risk of embolization. High resolution imaging techniques are of pivotal relevance for the diagnosis of the tumor and the complications, in which case emergent surgery may be required. Early surgery could be considered in asymptomatic patients because the evolutionary course and the prognosis can unexpectedly be ominous. Abstract P171 Figure. Multiple embolism from atrial myxoma

Bithalamic Infarct Revisited: Clinical, Imaging, Neuropsychological Profile and Prognosis

The bilateral thalamic infarcts are a particular entity by their clinical presentations, neuropsychological, etiologic and prognostic. We report here the presentations of 19 consecutive cases collected at University Teaching Hospital of Limoges. All patients underwent clinical evaluation, neuropsychological (only some of them), a diagnostic imaging and a full workup. A follow-up was performed for certain patients These 19 patients including 11 women, mean age 65.6 years (+/- 14.0 years), 13 were hypertensive. Clinically 84.2% had oculomotor disorders and 73.7% of vigilance disorders. Seven patients had motor problems that have persisted for two days in one. In territorial terms, 17 had bilateral paramedian infarction including 10 with a stem associated injury; 1 patient had a heart attack in the paramedian and tubero-thalamic territory and the last patient had tubero-thalamic and thalamo-geniculated infarction. On the etiological among the stroke patients bithalamique paramedian, 9 patients had a disease of the small arteries and March 1 cardioembolic infarction. Neuropsychological disorders in patients examined were marked by disorder of episodic memory, working, executive dysfunction, speech disorders. After a mean follow up of 35 months and among all patients with bilateral thalamic stroke 5 patients had died. Our series confirms some data in the literature on the evolution of these heart attacks and suggests that they are mainly topography paramedian, due to small artery disease and have a particular neuropsychological outcome.

Frontal bone infarctions masquerading as bilateral orbital cellulitis in a patient with sickle cell disease

Repeated vaso-occlusive crises (VOCs) are the hallmark of sickle cell disease (SCD). These repeated crises can lead to bone infarcts, necrosis, and, over time, degenerative changes in the bone marrow. Orbital complications in SCD patients are infrequent and usually present as orbital cellulitis. We report the appearance of orbital bone infarction intraoperatively in the case of an 18-year-old Saudi male patient who has been diagnosed with SCD and presented with severe headaches and generalized body aches. He was admitted with a case of SCD with acute VOC and started on the hospital sickle cell protocol. During the admission, the patient developed bilateral periorbital swelling and left inferior dystopia secondary to bilateral frontoparietal bone infarction, which was evident on the magnetic resonance imaging.