Left Basal Ganglia Research Articles

Basal ganglia hemorrhage secondary to scorpion sting: a fatal presentation

IntroductionCerebrovascular manifestations are uncommon presentations of scorpion sting in the Indian subcontinent. Encephalopathy, cerebral edema, subarachnoid hemorrhage, non-hemorrhagic strokes, and cortical necrosis are a few CNS complications described in the medical literature due to scorpion envenomation.Case descriptionWe report a rare case of scorpion envenomation in a 40-year old, non-hypertensive farmer, who presented in an unconscious state. Non-contrast CT head revealed intracerebral hemorrhages in left temporoparietal lobe extending into left basal ganglia with intraventricular extension.Discussion and evaluationToxin-induced autonomic storm is mostly responsible for the acute hypertensive crisis in affected individuals leading to stroke (commonly cerebral infarct) as a CNS complication.ConclusionBasal ganglia bleed following scorpion sting is an extremely rare scenario which is usually fatal as was in our case. Early suspicion and prompt institution of treatment (prazosin) is crucial in the management of intracranial bleed secondary to scorpion sting.

In Reply: Endoscopic Evacuation of Intracerebral Hematoma Utilizing a Side-Cutting Aspiration Device.

Background Intracerebral hemorrhage (ICH) is associated with a significant mortality of up to 50%, with almost all survivors suffering from debilitating functional compromise. In most cases, open craniotomy has failed to yield significant survival benefit. However, emerging evidence suggests that minimally invasive surgery (MIS) may yield clinically significant improvements in patient survival and quality of life in cases where open craniotomy has not shown benefit. Case presentation We report the first documented usage of a side-cutting-aspiration device via an endoscopic approach for the evacuation of a 56cc hematoma, which was a technical modification on previous MIS techniques. The patient is a 50-yr-old female who was transferred emergently to our center with a National Institutes of Health Stroke Scale score of 27 and found to have a large hematoma involving her left basal ganglia. A minimally-invasive approach was elected due to evidence on the risks and suboptimal outcomes of open craniotomy in ICH evacuation. Neuronavigation was used to plan the surgical trajectory for ICH access. Evacuation took place in three main steps: 1) beginning at the center of the clot to remove bulk; 2) mobilizing clots from parenchymal walls to a safe zone via aspiration, followed by clot homogenization; and 3) re-expansion of the cavity via continuous irrigation to allow visualization of further clots. A final inspection was performed to ensure removal of all clots that could be safely removed. The dual functionalities of the device, namely, suction only and suction plus side-cutting functions, enabled key maneuvers, such as clot homogenization and controlled aspiration strength, to be safely performed. A near-total evacuation of the hematoma was achieved without damage to surrounding parenchyma. The patient experienced a rapid clinical course from comatose to discharge-ready in 5 d. At 30-d follow-up, the patient had residual expressive aphasia and was able to ambulate with the assistance of a quad cane. There are no radiographical signs of recurrent hemorrhage or parenchymal injury. Clinical follow-up with this patient is ongoing. Conclusion This is the first ICH evacuation with a side-cutting-aspiration device via an endoscopic approach. In our patient, this technique proved to be safe and efficacious, suggesting that this technique may be a promising addition to the armamentarium of MIS for ICH evacuation.

Structural Characteristic of the Arcuate Fasciculus in Patients with Fluent Aphasia Following Intracranial Hemorrhage: A Diffusion Tensor Tractography Study.

This study investigated the relationship between the structural characteristics of the left arcuate fasciculus (AF) reconstructed using diffusion tensor image (DTI) and the type of fluent aphasia according to hemorrhage lesions in patients with fluent aphasia following intracranial hemorrhage (ICH). Five patients with fluent aphasia following ICH (three males, two females; mean age 55.0 years; range 47 to 60 years) and with sixteen age-matched heathy control subjects were involved in this study. The ICHs of patients 1 and 2 were located in the left parietal lobe and the left basal ganglia. ICHs were located in the left anterior temporal of patient 3, the left temporal lobe of patient 4, and the left frontal lobe of patient 5. We assessed patients’ language function using K-WAB (the Korean version of the Western Aphasia Battery) and reconstructed the AF using DTI. We measured DTI parameters including the fractional anisotropy (FA), tract volume (TV), fiber number (FN), and mean diffusivity (MD). All patients showed neural tract injury (the decrement of FA, TV, and FN and increment of MD). The left AFs in patients 1 and 2 were shifted from Broca’s and Wernicke’s territories. The destruction of Wernicke’s territory resulted in conduction or transcortical sensory aphasia in patients 3 and 4. The structural difference of the AF in patients following ICH in the left hemisphere was associated with various types of fluent aphasia.

Analysis of Magnetic Resonance Imaging Findings in Patients with Migraine

Background: Migraine is a common disabling brain disorder. Headache accounts for 4.4% of all consultations in general practice, approximately 5% of all medical admissions to hospital, and approximately 20% of neurology outpatient consultations. Hence, the present study was undertaken for assessing the MRI findings in patients with migraine. Subjects and Methods: A total of 5 patients with migraine headache were included in the present study. Complete demographic details of all the patients were obtained. Thorough clinical examination was carried out and routine hematological and other biochemical investigations were also done. Patients underwent MRI investigations. Imaging was performed using a head coil with patient in a supine position. All the MR imaging examination were performed on a Seimen’s Avento 1.5 Tesla Magnet MR System, slice thickness was 4-5mm with an inter slice gap of 0.5mm. MR imaging findings were compiled as per proforma and subjected to analysis using SPSS software. Results: Out of 5 migraine patients, significant abnormal MRI findings were present in 40 percent of the patients. One patient showed T2and T2 FLAIR Hyperintensities in subcortical white matter in frontal region. In the second patient with migraine, MRI finding revealed an area of diffusion restriction in left basal ganglia region which was hypointense on T1, T2 FLAIR and Hyperintense on T2 consistent with chronic infarct. Conclusion: Migraine headache patient occasionally have abnormal MRI findings to explain their headaches. Neuroimaging of headache sufferers in the general population yields few findings of clinical importance.

The Infectious Headache- A Case of Neurocysticercosis

A 50-year-old Hispanic female presented to her primary care physician with a progressively worsening headache over a week, associated with visual disturbances, prosopagnosia and episodes of disorientation. Outpatient workup with head CT showed abnormality in the ventral aspect of the left thalamus showing 1.2 1 cm low density cyst with approximately 2-3 mm right-left midline shift locally. Left basal ganglia showed multiple well-defined foci of low density measuring up to 3 mm reflecting edema.

Motor abnormalities and basal ganglia in first-episode psychosis (FEP).

Motor abnormalities (MAs) are the primary manifestations of schizophrenia. However, the extent to which MAs are related to alterations of subcortical structures remains understudied. We aimed to investigate the associations of MAs and basal ganglia abnormalities in first-episode psychosis (FEP) and healthy controls. Magnetic resonance imaging was performed on 48 right-handed FEP and 23 age-, gender-, handedness-, and educational attainment-matched controls, to obtain basal ganglia shape analysis, diffusion tensor imaging techniques (fractional anisotropy and mean diffusivity), and relaxometry (R2*) to estimate iron load. A comprehensive motor battery was applied including the assessment of parkinsonism, catatonic signs, and neurological soft signs (NSS). A fully automated model-based segmentation algorithm on 1.5T MRI anatomical images and accurate corregistration of diffusion and T2* volumes and R2* was used. FEP patients showed significant local atrophic changes in left globus pallidus nucleus regarding controls. Hypertrophic changes in left-side caudate were associated with higher scores in sensory integration, and in right accumbens with tremor subscale. FEP patients showed lower fractional anisotropy measures than controls but no significant differences regarding mean diffusivity and iron load of basal ganglia. However, iron load in left basal ganglia and right accumbens correlated significantly with higher extrapyramidal and motor coordination signs in FEP patients. Taken together, iron load in left basal ganglia may have a role in the emergence of extrapyramidal signs and NSS of FEP patients and in consequence in the pathophysiology of psychosis.

Bradycardia and syncope as sole manifestations of a\xa0cranial lesion: a case report

BackgroundBradycardia and syncope are known sequelae of brain lesions. However, in the absence of neurological signs and symptoms, bradycardia and syncope are often investigated purely from the cardiovascular perspective and central nervous system-related causes may be easily overlooked during differential diagnosis.Case presentationHere we report a case of a 69-year-old Caucasian man who presented to the emergency department after a fall. He had 1-year history of syncope and bradycardia with frequent ectopic beats shown on his electrocardiogram. He had no neurological symptoms. He was previously investigated as an out-patient and a diagnosis of idiopathic bradycardia with ventricular ectopic beats was made. On admission, cardiovascular investigations could not reveal the cause of his bradycardia. Computed tomography and magnetic resonance imaging scans of his head showed a localized mass in left basal ganglia consistent with infiltrating glioma.ConclusionTo the best of our knowledge this is the first case report demonstrating central nervous system-related bradycardia and syncope without other neurological symptoms. This case will serve as a useful reminder to general practitioners, accident and emergency doctors, and cardiologists.

Altered topological organization of functional brain networks in drug-naive patients with paroxysmal kinesigenic dyskinesia

BackgroundPrevious neuroimaging studies have revealed aberrant basal ganglia-thalamocortical circuit in patients with paroxysmal kinesigenic dyskinesia (PKD) with drug treatment. This study aims to investigate the topological organization of functional networks in drug-naive PKD. MethodsResting-state functional magnetic resonance imaging (rs-fMRI) was performed in 24 drug-naive PKD patients and 24 age, gender and mean framewise displacement (FD)-matched healthy controls (HCs). The network topological properties (including global and nodal measures) were analyzed between two groups by using graph-based theoretical approaches. Pearson's correlation analysis was performed between significant metrics and duration of disease and the age of onset of patients with PKD. ResultsCompare to HCs, the drug-naïve PKD patients showed increased nodal centralities mainly in left precentral gyrus, basal ganglia and limbic regions and decreased nodal centralities in the temporal pole. Our results showed that drug-naïve PKD patients presented the small-world topology and at the global level no significant differences were found between PKD and HCs. In the correlation analysis, the increased nodal efficiency in the left pallidum was positively correlated with the onset of age. ConclusionsOur findings supported the previous observation of the disruptive cortical-basal ganglia circuitry in PKD patients, but difference in that the prominent change of precentral area and temporal pole were also observed in our study when the potential impact of drug was excluded. These findings may provide a novel insight into further delineation of the pathophysiological genesis and possible target for PKD.

Reorganized functional connectivity of language centers as a possible compensatory mechanism for basal ganglia aphasia

ABSTRACTPrimary Object: To investigate the functional connectivity (FC) of cortical language centers in patients who have regained fluent speech after basal ganglia aphasia and identify the possible compensatory mechanism.Methods & Procedures: A retrospective cohort of 12 patients and 17 healthy controls were studied using resting-state functional MRI (rs-fMRI). All patients suffered from an ischemic stroke with lesions confined to the basal ganglia and showed impaired language functions at admission. Seven patients had lesions in the left basal ganglia, three in the right, and two in both sides. The rs-fMRI was performed after the patients regained fluent speech. Broca’s area, Wernicke’s area, and their contralateral homologues were selected as the region-of-interest (ROI) for both voxel-wise and ROI-wise FC studies.Results: We discovered that the interhemispheric FC of the language centers (i.e. Broca’s area and Wernicke’s area) decreased and the intrahemispheric FC of the language centers increased in these patients who regained fluent speech after basal ganglia aphasia.Conclusions: We speculated that damages to the basal ganglia disrupted the cortico-subcortical circuits that facilitated the transhemispheric communications of language functions, resulting in decreased interhemispheric FC. Consequently, the intrahemispheric FC increased as a possible compensatory mechanism to restore the language functions.

Stroke transcranial Doppler in children with human immunodeficiency virus.

To describe stroke syndromes and transcranial Doppler (TCD) findings in children with human immunodeficiency virus (HIV) and examine the associations between TCD and clinical and laboratory data. We enrolled 42 children (24 males, 18 females) with HIV (median age=7y 6mo; 2y 7mo-15y 6mo), with and without stroke who underwent a TCD examination of the anterior and posterior circulations to derive time-averaged maximum mean velocity (TAMMV) measurements for comparison with previous studies. Clinical and laboratory variables were extracted from the medical records. Of the 42 children with HIV, five had right-sided hemiparesis, three had chronic lung disease, two occurred post-varicella infection, one after herpetic oral ulceration, and one had a poorly functioning left ventricle. Neuroimaging showed middle cerebral artery (MCA) TAMMV greater than 200cm/s, moyamoya-like arteriopathy, left basal ganglia infarction with ipsilateral stenosis, hygroma consistent with venous thrombosis, and a hyperdense left MCA. Eight neurologically asymptomatic children had atypical TCD. The CD4 cell count was non-significantly lower in 6 out of 30 children with atypical TCD (median=21.5; interquartile range=16.1-26.5) compared with the remainder (median=29; interquartile range=21.3-35.0; p=0.09). A variety of stroke syndromes occur in children with HIV. TCD suggests atypical intracranial vessels and/or haemodynamics in some children with HIV infection, consistent with vasculopathy, possibly related directly to immunodeficiency and/or infection. A range of stroke syndromes are found in children with human immunodeficiency virus (HIV). Transcranial Doppler (TCD) velocities in HIV are commonly outside the range for typically developing children. TCD and neuroimaging data in children with HIV suggest intracranial vasculopathy as one mechanism for stroke. CD4 cell count is non-significantly lower in children with HIV and atypical TCD.

The Impact of Pediatric Basal Ganglia Stroke on Mental Health in Children: Report of 2 Cases

Background:The impact of basal ganglia stroke on mental health is better described in adults than in children. We report 2 children with significant mental health issues after basal ganglia stroke.Case Reports:Patient 1, an 8-year-old boy, had mild anxiety before his left basal ganglia stroke. Post-stroke, he developed severe anxiety, obsessions, depression, and attention deficit hyperactivity disorder, in addition to a right hemiplegia and some mild chorea. He gradually improved over 3 years with psychiatric care and medication but continued to have residual symptoms. Patient 2, a 10-year-old boy, had no history of mental health issues before his right basal ganglia stroke. Post-stroke, he developed significant anxiety and mild depression, along with a left hemiplegia. He improved over 9 months and returned to his mental health baseline.Conclusions:Mental health issues after basal ganglia stroke in children can be significant, and recovery can take months to years.

ML-05 A CASE OF NEUROLYMPHOMATOSIS ARISED SECONDARILY FROM PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA

A woman in her 40s. A biopsy of multiple intracranial lesions was performed, and the patient was diagnosed with DLBCL. As an initial treatment, 6 courses of high dose MTX therapy were performed and CR was achieved. Radiation therapy was not desired by the patient. On the 19th month after initial treatment, tumor recurrence was confirmed by MRI and added 2 courses of HD-MTX. On the 23rd month, second recurrence around the left basal ganglia were observed. One additional course of HD-MTX was performed, but due to the appearance of renal damage that was thought to be acute tubular necrosis, additional HD-MTX was not performed and whole brain irradiation was performed. She began complaining of pain in the trunk and extremities during radiation. When MRI and FDG-PET were performed in the 25th month, multiple lesions were found in the ganglia, plexus, and peripheral nerves from the cervical spinal cord to the sacral spinal cord. Cerebrospinal fluid cytology revealed atypical lymphocytes and lymphoma dissemination in the spinal cord. When intrathecal administration of the anticancer agent was performed nine times weekly, the CSF cytology was negative. Imaging findings showed that the lesions relapsed, although the lesions were temporarily reduced. After confirming that the renal function had recovered, two additional courses of HD-MTX were performed. Accumulation of FDG-PET in the lesion disappeared in the 29th month. However, peripheral neuropathic pain and paraplegia remained. Discussion: Neurolymphomatosis is considered to be a clinically rare disease that presents invasion of lymphoma into peripheral nerves including the cranial nerves, nerve roots or plexus. Diagnosis of NL has been required to be proved by nerve biopsy or autopsy, but noninvasive FDG-PET has been reported to be effective. In this case, CR was not obtained with anticancer drug intrathecal injection, and HD-MTX therapy was successful.

BT-10 A RARE CASE OF RADIATION-INDUCED GLIOBLASTOMA 29 YEARS AFTER TREATMENTS OF GERMINOMA

BACKGROUNDGerminoma is one of the most radiosensitive tumors. Although radiotherapy (RT) can lead to long term-survival, it has the possibility to cause adverse effects. One of the more serious side effects include radiation-induced tumors that can contribute to a life-long prognosis.Case presentationA 40-year-old man was diagnosed with left basal ganglia germinoma at the age of 11 years old. Postoperatively, he received whole-brain radiotherapy 40Gy, focal radiotherapy 9.26Gy, and craniospinal irradiation. After these treatments, he was free from tumor recurrence or a secondary tumor during the long-term follow up. However, after 29 years, he began experiencing aphasia. A Magnetic Resonance Imaging (MRI) showed a developing 4.5cm round mass in the left parietal lobe with marked surrounding edema. He underwent surgical resection of the tumor at the left partial lobe. Pathological examination showed the tumor to consist of unclear pleomorphism, and the diffuse proliferation of heterocyst. Therefore, the pathologic diagnoses concluded as glioblastoma (Ki-67 labeling index was 50%). Conclusion: The tumor developed in the previously irradiated field, and it was not present prior to the RT. He did not suffer from pathologies favoring the development of the tumor. The interval between the radiation exposure and the onset of the second tumor was approximately 29 years, and the histotype of the tumor differed from the original tumor. Considering these clinical features, we diagnosed the glioblastoma as a radiation-induced tumor. Radiation-induced malignant glioma occurs frequently in patients after the treatment for acute lymphoblastic leukemia. Therefore, the radiation-induced malignant glioma after the treatment for germinoma is rare. Regardless of age, histology, and RT dosages, the patient has the possibility to develop radiation-induced malignant glioma. In conclusion, it is necessary to have careful monitoring even after 20–30 years of RT.

Diabetic striatopathy- rare case of Chorea associated with Non-ketotic hyperglycemia

Non-ketotic hyperglycemia (NKHG) has been reported to increase the probability of seizures and movement disorders especially in elderly population. Here we report a case of long standing diabetes who presented with poor glycemic control and choreoathetoid movements of right upper limb, with Magnetic resonance imaging showing hyperintense lesion on T1 sequence in left basal ganglia suggestive of Diabetic striatopathy. These patients may get frequently misdiagnosed to have neurological disease, however recognition of this association is important as the condition may quickly resolve when NKHG is controlled.

Focused ultrasound enhanced intranasal delivery of brain derived neurotrophic factor produces neurorestorative effects in a Parkinson\u2019s disease mouse model

Focused ultrasound-enhanced intranasal (IN + FUS) delivery is a noninvasive approach that utilizes the olfactory pathway to administer pharmacological agents directly to the brain, allowing for a more homogenous distribution in targeted locations compared to IN delivery alone. However, whether such a strategy has therapeutic values, especially in neurodegenerative disorders such as Parkinson’s disease (PD), remains to be established. Herein, we evaluated whether the expression of tyrosine hydroxylase (TH), the rate limiting enzyme in dopamine catalysis, could be enhanced by IN + FUS delivery of brain-derived neurotrophic factor (BDNF) in a toxin-based PD mouse model. Mice were put on the subacute dosing regimen of 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP), producing bilateral degeneration of the nigrostriatal pathway consistent with early-stage PD. MPTP mice then received BDNF intranasally followed by multiple unilateral FUS-induced blood-brain barrier (BBB) openings in the left basal ganglia for three consecutive weeks. Subsequently, mice were survived for two months and were evaluated morphologically and behaviorally to determine the integrity of their nigrostriatal dopaminergic pathways. Mice receiving IN + FUS had significantly increased TH immunoreactivity in the treated hemisphere compared to the untreated hemisphere while mice receiving only FUS-induced BBB opening or no treatment at all did not show any differences. Additionally, behavioral changes were only observed in the IN + FUS treated mice, indicating improved motor control function in the treated hemisphere. These findings demonstrate the robustness of the method and potential of IN + FUS for the delivery of bioactive factors for treatment of neurodegenerative disorder.

Effects of cannabidivarin (CBDV) on brain excitation and inhibition systems in adults with and without Autism Spectrum Disorder (ASD): a single dose trial during magnetic resonance spectroscopy

Autism spectrum disorder (ASD) is a high cost neurodevelopmental condition; and there are currently no effective pharmacological treatments for its core symptoms. This has led some families and researchers to trial alternative remedies – including the non-intoxicating Cannabis sativa-derived compound cannabidivarin (CBDV). However, how CBDV affects the human brain is unknown. Previous (pre)clinical evidence suggests that CBDV may modulate brain excitatory-inhibitory systems, which are implicated in ASD. Hence, our main aim was to test, for the first time, if CBDV shifts glutamate and/or GABA metabolites – markers of the brain’s primary excitatory and inhibitory system - in both the ‘typical’ and autistic brain. Our subsidiary aim was to determine whether, within ASD, brain responsivity to CBDV challenge is related to baseline biological phenotype. We tested this using a repeated-measures, double-blind, randomized-order, cross-over design. We used magnetic resonance spectroscopy (MRS) to compare glutamate (Glx = glutamate + glutamine) and GABA + (GABA + macromolecules) levels following placebo (baseline) and 600 mg CBDV in 34 healthy men with (n = 17) and without (n = 17) ASD. Data acquisition from regions previously reliably linked to ASD (dorsomedial prefrontal cortex, DMPFC; left basal ganglia, BG) commenced 2 h (peak plasma levels) after placebo/CBDV administration. Where CBDV significantly shifted metabolite levels, we examined the relationship of this change with baseline metabolite levels. Test sessions were at least 13 days apart to ensure CBDV wash-out. CBDV significantly increased Glx in the BG of both groups. However, this impact was not uniform across individuals. In the ASD group, and not in the typically developing controls, the ‘shift’ in Glx correlated negatively with baseline Glx concentration. In contrast, CBDV had no significant impact on Glx in the DMPFC, or on GABA+ in either voxel in either group. Our findings suggest that, as measured by MRS, CBDV modulates the glutamate-GABA system in the BG but not in frontal regions. Moreover, there is individual variation in response depending on baseline biochemistry. Future studies should examine the effect of CBDV on behaviour and if the response to an acute dose of CBDV could predict a potential clinical treatment response in ASD.

RARE-14. STRUCTURAL BRAIN PLASTICITY OF THE GRAY MATTER IN PATIENTS WITH BASAL GANGLIA GERM CELL TUMORS: A VBM STUDY

Abstract OBJECTIVE To assess the whole brain structural plasticity in case of unilateral basal ganglia germ cell tumors (BGGCTs). METHODS To detect changes in gray matter volume of the whole brain from structural Magnetic Resonance Imaging (MRI), we used voxel-based morphometry (VBM) in a sample of 41 patients with BGGCTs invading the left basal ganglia (BasalG_L group; n = 22) or the right basal ganglia (BasalG_R group; n = 19) and a sample of 16 patients with GCTs arising in pineal or suprasellar regions, comparing these groups with 16 age-matched normal controls (NCs) by two-sample t test after that. RESULTS To left BGGCTs patients, the regions of whole brain VBM analysis emphasized a large cluster of voxels with gray matter volume increase in left para hippocampal (k = 529 voxels, T=4.18, p< 0.01) and decrease in left thalamus (k = 527 voxels, T=-4.88, p< 0.01). At the same time, the cluster of voxels with gray matter volume increase in right middle cingulate cortex (rMCC) (k = 172 voxels, T=3.96, p< 0.01), and decrease in right inferior frontal gyrus (rIFG), pars opercular (k = 495 voxels, T= -4.29, p< 0.01) in right BGGCTs patients. Furthermore, gray matter volume showed no significant difference between groups of patients with GCTs arising in pineal or suprasellar regions and NCs by two-sample t test. And the results were corrected by family-wise-error correction. CONCLUSIONS The revealed results demonstrate that slow-growing but destructive lesion of the BGGCTs markedly and asymmetrically atrophies the gray matter volume in specific brain regions and shows compensatory plasticity in each side of cerebral hemisphere. Our findings direct focus on the whole cerebral adaptation that perhaps be a physiologic basis for the high level of functional compensation and partially explain the relationships between gray matter remodeling and cognitive disturbances observed in patients with BGGCTs.

OA11.02 Changes of Brain Structure in Advanced NSCLC Patients Receiving EGFR-TKIs: Dynamic Analysis Based on Series MRI Images

EGFR-TKI was the standard care for metastatic NSCLC patients harboring positive EGFR mutation, which might inhibit EGF signaling pathway and consequently have effect on differentiation, maturation and rehabilitation of neural cells. For the first time, we evaluated the dynamic changes of white matter lesion (WML) and gray matter volume (GMV) among such patients based on series of MRI images. We retrospectively identified 778 patients with pathologically diagnosed advanced NSCLC receiving first-generation EGFR-TKIs in our hospital from 2010 to 2017, and 75 patients without brain metastasis and else comorbidity (hypertension, etc.) were analyzed. The modified Scheltens visual scale were performed to evaluate the changes of WML based on the series (baseline, 12 months' point and 24 months' point) of MRI images, and CBM (cluster-based morphometry) method based on SPM12 were adopted to identify GMV loss. The statistical methods were performed using SPSS software 22.0. During the 24-month EGFR-TKI treatment, the patient's WML visual scores showed a progressive worsen. Comparing to the baseline (6.680±3.636), the scores were significantly changed at the 12 months' point (8.650±3.857; Mean scores increasing 1.973, 95% CI 1.595-2.352, p<0.001) and changed more obviously at the 24 months' point (10.110±3.854; Mean scores increasing 3.427, 95% CI 2.979-3.874, p<0.001), respectively. Also, the significant GMV loss were found in subregions of the right occipital lobe (mean decrease 76.714, 95% CI 40.739-112.690), left occipital lobe (mean decrease 93.476, 95% CI 37.483-149.469) and left basal ganglia (mean decrease 37.571, 95% CI 21.576-53.567), respectively (all p<0.005, the cluster level FDR<0.05). Dynamic structural analysis of series brain MRI images showed the significant worsen of the WML and GMV loss in patients with advanced NSCLC receiving EGFR-TKIs chronically. Perspective studies are warranted to verify its impact on the cognitive deficiency and hypomnesis among these patients in future.

COCAINE-INDUCED THROMBOTIC STORM

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Cocaine is associated with a wide array of complications through a number of different mechanisms. Although majority of cocaine related morbidity has been attributed to complications in arterial vasculature, the deleterious impact of venous complications appears to be largely unrepresented in current literature as well as clinical practice despite emerging evidence of the high prevalence and annual incidence of DVT in illicit drug users CASE PRESENTATION: 27-year-old previously healthy male presented to the ED with new onset difficulty speaking and facial droop hours after using cocaine. He was afebrile with vitals 98.5 °F, BP 142/97, HR 94 and RR 16. Examination was remarkable for expressive aphasia and right facial droop with no other focal neurological finding. CT scan of head showed thrombosed left MCA with infarct in left frontal lobe and basal ganglia. Labs were significant for a troponin of 14 md/dl and CK-MB 34. CBC and metabolic panel were unremarkable. Urine toxicology was positive for cocaine and opiates. EKG showed T wave inversion with ST depression in V1-V4 II and aVF. CTA of chest revealed bilateral segmental and subsegmental PE without any acute pulmonary disease. CTA of head and neck showed complete abrupt occlusion of proximal left internal carotid artery with distal reconstitution at the segment M1 of MCA and an intraluminal thrombus in the M1 segment. A doppler of lower extremities revealed deep venous thrombosis in left peroneal and posterior tibial veins. An ECHO failed to reveal an intracardiac shunt precluding the possibility of paradoxical thrombosis. He was continued on heparin for 10 days before being switched to Xarelto. He experienced improvement in word finding ability and is currently in rehab. Hypercoagulability work-up including prothrombin gene mutation, factor V Leiden deficiency, APLA and anti-thrombin deficiency was negative. DISCUSSION: This case illustrates an uncharacteristic presentation of cocaine-related widespread thrombotic cascade involving both arterial and venous circulations causing significant morbidity. The complex pathophysiology of widespread prothrombotic state caused by cocaine includes endothelial damage promoting increase of fibrinogen and Von Willebrand factor to platelet aggregation and clot formation. It is important to identify the impact cocaine induced venous thrombosis can mount, especially in the form of potentially fatal complications like pulmonary embolism. CONCLUSIONS: Although recent studies have focused on increased incidence and prevalence of venous thrombosis in setting of cocaine abuse, ours is the first case of documented pulmonary embolism caused by cocaine related venous thrombosis. Further studies are needed to identify patients at higher risk for this complication like rare thrombotic disorders Reference #1: 1. Substance Abuse and Mental Health Services Administration, Drug Abuse Warning Network, 2011: National Estimates of Drug-Related Emergency Department Visits. HHS Publication No. (SMA) 13-4760, DAWN Series D-39. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013. Reference #2: Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality (formerly the Office of Applied Studies). The DAWN Report: Highlights of the 2009 Drug Abuse Warning Network (DAWN) Findings on Drug-Related Emergency Department Visits. Rockville, MD, December 28, 2010. Reference #3: . Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. Drug Abuse Warning Network: Detailed Tables: National Estimates, Drug-Related Emergency Department Visits for 2004–2009. Rockville, MD, December 28, 2010. DISCLOSURES: no disclosure on file for Erika Cappelluti; No relevant relationships by Manish Kumar, source=Web Response No relevant relationships by Alain Rizkallah, source=Web Response No relevant relationships by Nihar Shah, source=Web Response No relevant relationships by Toishi Sharma, source=Web Response

Ischemic stroke in a case of Koyanagi Harada syndrome

Vogt-Koyanagi-Harada (VKH) syndrome is a rare multisystem inflammatory disorder characterized by uveitis associated with neurological, cutaneous, and auditory manifestations. The neurological symptoms described are headaches, aspeptic meningoencephalitis and meningismus. Strokes can also occurred and were described in few reports. A 57-year-old man, who had bilateral visual disturbance due to VKH disease, was admitted to our hospital because of headache and speech disorder. On examination at entry, no abnormalities except for loss of bilateral visual acuity, patches of vitiligo and dysarthria were found. Laboratory data were normal and the cerebral magnetic resonance imaging showed ischemic lesions of the left basal ganglia in the territory of lenticulostriate arteries and a lesion in the left internal capsule. Our patient improved after treatment with intravenous and oral steroids. Only a few previous reports have described cerebral ischemic lesions in VKH syndrome. Our patient’s history of uveitis, the absence of other cause of stroke and response to steroid treatment suggest an inflammatory mechanism. In fact, this vascular event was probably related to inflammatory arteriopathy. Based on our patients and on previous reports, we emphasize the fact that cerebral ischemic episodes could be included in the neurological symptoms of VKH syndrome.