Left Hemiparesis Research Articles

A 10 Years Old Child Presented with Hemiparesis and Moyamoya Disease – A Case Report

Introduction: In Moyamoya disease there is long standing, continuous developing occlusion of the arteries of Circle of Willis which leads to development of typical collateral vessels seen on cerebral angiogram. Moyamoya Disease was diagnosed on performing the MR Angiography. Child with Moyamoya disease presents with recurrent episodes of sudden hemiplegia that might occur at alternative sides. The disease is progressive and dynamic in children. Acute management of this disease is symptomatic. MR Angiography clinches the diagnosis and neurosurgical intervention with physiotherapy which may be required as a part of definitive management. Objectives: Our case brings forth the significance of considering Moyamoya Disease to be classic etiology for acute ischemic strokes in children.
 Case Report: We report a rare case of 10 year old female child who was admitted at our medical center for the complaints of transient ischemic attack & left side hemiparesis with left facial palsy. In respect to our case, surgical intervention was not considered due to having satisfactory response on the commencing medical management.
 Conclusion: Our case brings forth the importance of considering MMD to be classic etiology for acute ischemic strokes in children .MMD is main diagnosis when we evaluate the children with cerebrovascular events. To asses this non operative MR angiography is investigation of choice. For favourable outcome in children with Moyamoya disease the key is early diagnosis and management.

Expressive aphasia and horizontal gaze palsy following a right internal capsular and globus pallidal ischaemic stroke: A case report

Expressive (non-fluent) aphasia is commonly attributed lesions involving the dominant posterior inferior frontal cortex which includes the Broca’s area. Horizontal gaze palsies are mainly due to lesions either in the contralateral frontal cortex or the ipsilateral pons. A gaze palsy with ipsilateral paraparesis is usually due to a lesion in the frontal eye field. Gaze palsies are not described in subcortical infarcts whereas subcortical aphasia is a field under evaluation. We describe a case of acute ischaemic stroke involving the right internal capsule and the globus pallidum which resulted in left hemiparesis, left gaze palsy and expressive aphasia.

The management of a patient with multiple infarcts with different etiologies

72 yo male, presents for abdominal pain and motor deficiency of the left upper limb. Clinical examination reveal severe general condition, left brachial hemiparesis, right arm blood pressure (BP) 240/120 mmHg, left arm BP 210/100 mmHg, heart rate (HR) 110 bpm, arrhythmic, abdominal pain at superficial palpation, without other abnormalities. Biological: negative hs troponin I, positive D-dimers, positive CRP, GFR 38 ml/min/m2, potassium 2.97 mmol/l. ECG: Atrial fibrillation. Abdominal ultrasound: abdominal dilated aorta, dissection flap. Abdominal and pelvic CT scan: right renal infarction, multiple splenic infarction, abdominal aortic aneurysm with dissection. Underwent interventional treatment of the abdominal aortic dissection (EVAR). Particularity of the case: concomitant diagnosis of multiple infarction with different etiologies, for which therapeutic decision was challenging.

Conservative Management of Severe Medication-Related Osteonecrosis of the Jaw With Pathological Fracture.

Medication-related osteonecrosis of the jaw (MRONJ) is a well-known risk following dental extraction in patients taking certain medications. Pathological fracture secondary to MRONJ often requires complex operative intervention.This case demonstrates the conservative management of pathological fracture secondary to MRONJ in a patient with multiple comorbidities. The patient developed MRONJ with pathological fracture following extraction of the mandibular second molar. The patient presented with significant surgical risk factors, having hypertension and a recent stroke, causing dense left hemiparesis, subsequently resulting in transition to high-level nursing care. Given the high risk of reconstructive surgery, nonoperative management was undertaken. Following a course of long-term antibiotics with resolution of signs of infection, the case was managed conservatively with chlorhexidine-based mouthwash and soft diet.With routine clinico-radiographic assessment and optimal oral health care, the pathological fracture did not require operative intervention. Healing progressed well with no clinical complications and radiographic evidence of good healing at 6- and 12-month follow-up on orthopantomogram.A role for conservative management of pathological fractures secondary to MRONJ yet exists, especially in the elderly population. This case highlights the importance of developing treatment plans based on individual patient context and clinical assessment.

Persistent Primitive Hypoglossal Artery with Ipsilateral Symptomatic Carotid Artery Stenosis and Cerebral Aneurysm

ObjectivePersistent primitive hypoglossal artery (PPHA) is a rare type of persistent carotid-basilar anastomosis sometimes associated with other vascular lesions. We treated an extremely rare case of PPHA with concomitant ipsilateral symptomatic cervical internal carotid artery (ICA) stenosis and unruptured aneurysm. Case presentationA 67-year-old woman visited our institution with acute onset of diplopia. Magnetic resonance imaging revealed multiple acute infarctions in the right anterior and posterior circulations. Digital subtraction angiography demonstrated the right PPHA concomitant with ipsilateral cervical ICA stenosis and an unruptured ICA aneurysm with maximum diameter of 8 mm. The multiple infarctions were considered to result from artery-to-artery embolism due to microthrombi from the ICA plaque passed along the PPHA, so carotid endarterectomy was performed as the first step with preoperative modified Rankin Scale (mRS) grade 1. During the operation, the patient had impaired ICA perfusion due to internal shunt catheter migration into the PPHA followed by acute infarction in the right hemisphere causing mild left hemiparesis. The patient was transferred to the rehabilitation hospital with mRS grade 3. After 3 months of rehabilitation, the patient recovered to mRS grade 1 and clipping surgery for the unruptured right ICA aneurysm was performed as the second step with uneventful postoperative course. ConclusionThe treatment strategy should be carefully considered depending on the specific blood circulation for such cases of PPHA with unique vasculature.

THE EFFECT OF TASK ORIENTED FUNCTIONAL TRAINING PROGRAMME IN ELDERLY WITH HEMORRHAGIC STROKE- A CASE STUDY

BACKGROUND- A 70 year old unknown male patient was found unconscious on road and was brought to tertiary care hospital. On investigations and clinical correlation, patient was diagnosed as a case of left hemiparesis secondary to acute middle cerebral artery infarct. Patient regained consciousness on next day and was in state of complete dependence for bed mobility and daily living activities. He was managed conservatively and was referred to occupational therapy department for further management. METHOD- Patient was evaluated by using uniform terminology. Modied Barthel index, Modied Rankin Scale, Basic MOCA scale and Stroke Specic QOL scales were administered. Patient was given intervention for 5 weeks. Enabling activities with self-care functional activities were practised. Accident prevention, activity promotion, Compensatory strategies and environmental modications were done. Scales were administered post intervention and comparative data was obtained. RESULT- Change of pre-intervention and post- intervention score indicates improvements in performing activities of daily living, reduced disability, improved cognition and quality of living. There were signicant improvement in activities like eating, drinking milk, in bed mobility dressing and coming to sit. Minimum to moderate improvement was seen in activities like toileting, walking, stair climbing and use of wheelchair. Despite his age and lack of family support, signicant functional improvements were documented in this elderly stroke patient, and he was discharged to old age home. CONCLUSION- Supplementing enabling activities with task oriented functional training is feasible and effective in improving independence for activity of daily living in elderly stroke

Plantar Pressure and Contact Area Measurement of Foot Abnormalities in Stroke Rehabilitation.

Background: Evaluation of plantar pressure in stroke patients is a parameter that could be used for monitoring and comparing how the timing of starting a rehabilitation program effects patient improvement. Methods: We performed the following clinical and functional evaluations: initial moment (T1), intermediate (T2), and final evaluation at one year (T3). At T1 we studied 100 stroke patients in two groups, A and B (each 50 patients). The first group, A, started rehabilitation in the first three months after having a stroke, and group B started after three months from the time of stroke. Due to the impediments observed during rehabilitation, we made biomechanic evaluation for two lots, I and II (each 25 patients). Assessment of the patient was carried out by clinical (neurologic examination), functional (using the Tinetti Functional Gait Assessment Test for classifying the gait), and biomechanical evaluation (maximal plantar pressure (Pmax), contact area (CA), and pressure distribution (COP)). Results: The Tinetti scale for gait had the following scores: for group A, from 1.34 at the initial moment (T1) to 10.64 at final evaluation (T3), and for group B, 3.08 at initial moment (T1) to 9 at final evaluation (T3). Distribution of COP in the left hemiparesis was uneven at T1 but evolved after rehabilitation. The right hemiparesis had uniform COP distribution even at T1, explained by motor dominance on the right side. CA and Pmax for lot I increased more than 100%, meaning that there is a possibility for favorable improvement if the patients start the rehabilitation program in the first three months after stroke. For lot II, increases of the parameters were less than lot I. Discussions: The recovery potential is higher for patients with right hemiparesis. Biomechanic evaluation showed diversity regarding compensatory mechanisms for the paretic and nonparetic lower limb. Conclusions: CA and Pmax are relevant assessments for evaluating the effects on timing of starting a rehabilitation program after a stroke.

A-60 Case of Moyamoya Syndrome in Haitian Female without Known Risk Factors

Abstract Objective Moyamoya is a rare, progressive cerebrovascular disorder characterized by carotid artery stenosis or occlusion. Tiny “moyamoya” blood vessels open at the brain base to compensate, often resulting in large vessel ischemic strokes or from hemorrhage of moyamoya vessels. Peak incidence in adults is 30 to 50 years old and 30% progress bilaterally. 54 year-old right-handed Black Haitian female with 13 years of education presented with new stroke, now diagnosed with bilateral moyamoya syndrome. Premorbid history includes hypertension, Type II Diabetes Mellitus, patent foramen ovale, and malignant phyllodes breast tumor treated by resection and local radiation. Presents with no traditional risk factors for moyamoya (e.g., brain radiation, sickle cell disease, neurofibromatosis). Method Five years previously patient experienced multi-focal embolic MCA strokes from left internal carotid occlusion attributed to hypercoagulability of malignancy, returning to previous activities except driving. Present perfusion CT showed complete occlusion of bilateral cavernous carotid arteries. Diagnostic angiogram showed collateral system via PCA-MCA pial-pial collaterals in parieto-occipital-temporal regions, and leptomeningeal collaterals to ACA territory. She underwent bilateral STA-MCA direct bypass. Results Acute neuropsychological testing conducted in Haitian Creole by native-speaking trainee showed expressive aphasia, orientation to person and situation, ability to follow 1-step commands, moderately impaired naming of familiar objects, reduced sustained attention. Also left hemiparesis, right gaze preference, and left homonymous hemianopsia. Conclusions The present case study delineates development of secondary moyamoya in a Black Haitian woman without known risk factors, resulting in significant cognitive-linguistic deficits consistent with brain findings. Limitations include lack of validated measures in Haitian Creole.

Treatment of a Giant Thrombotic M1 Segment Middle Cerebral Artery Aneurysm With Radial Artery Bypass and Distal Occlusion to Create a "Blind Sac" Following Endovascular Failure: 2-Dimensional Operative Video.

The case is of a 36-yr-old male with a previously coiled aneurysm arising from the proximal M1 segment of the middle cerebral artery (MCA) just beyond the internal carotid artery (ICA) bifurcation who presented to our institution with subjective left hemiparesis, headache, and vomiting. Physical exam revealed a left facial droop, but neurological exam was otherwise normal, including full motor strength. Neuroimaging showed a large partially thrombosed aneurysm recurrence, measuring 5.2 cm, with obstructive hydrocephalus. Cerebral angiogram showed filling within a small portion of the aneurysm and marked stenosis of the MCA beyond the neck. A ventriculostomy was placed, and he underwent a pterional craniotomy for high-flow radial artery bypass from the common carotid artery to an M2 branch of the MCA and clip placement. This case demonstrates the creation of a blind sac by placing a clip on the MCA distal to the aneurysm and proximal to the lenticulostriate arteries for the treatment of a giant proximal M1 segment aneurysm. Postoperative digital subtraction angiography shows the MCA distribution, including the lenticulostriate arteries, filling through the radial artery bypass, and anterograde flow through the ICA, which perfuses up to and including the anterior choroidal artery. There is no residual filling of the aneurysm. The patient remained at his neurological baseline postoperatively and required ventriculoperitoneal shunt placement for hydrocephalus. At outpatient follow-up, computed tomography imaging showed decreased size of the thrombosed aneurysm, measuring 4.5 cm, and he had no neurological deficits. The patient gave informed consent for surgery and deidentified video recording of this case.

Acute prolonged motor aura resembling ischemic stroke after COVID \u2212\u200919 vaccination (CoronaVac): the first case report

BackgroundWe report the first case of a patient who suffered transient focal neurological deficit mimicking stroke following CoronaVac vaccination. However, instead of an ischemic stroke, motor aura was suspected.Case presentationsA 24 year-old Thai female presented with left hemiparesis fifteen minutes after receiving CoronaVac. She also had numbness of her left arm and legs, flashing lights, and headaches. On physical examination, her BMI was 32.8. Her vital signs were normal. She had moderate left hemiparesis (MRC grade III), numbness on her left face, arms, and legs. Her weakness continued for 5 days. A brain CT scan was done showing no evidence of acute infarction. Acute treatment with aspirin was given. MRI in conjunction with MRA was performed in which no restricted diffusion was seen. A SPECT was performed to evaluate the function of the brain showing significant hypoperfusion of the right hemisphere. The patient gradually improved and was discharged.DiscussionsIn this study, we present the first case of stroke mimic after CoronaVac vaccination. After negative imaging studies had been performed repeatedly, we reach a conclusion that stroke is unlikely to be the cause. Presumably, this phenomenon could possibly have abnormal functional imaging study. Therefore, we believed that it might be due to cortical spreading depression, like migraine aura, which we had conducted a literature review.

Migrainous Infarction with Adjacent Cortical Enhancement

A 26-year old woman developed left homonymous superior quadrantanopia followed by severe pulsating headache with vomiting. Thereafter, she experienced recurrent left hemiparesis and paresthesia with or without headache. Brain magnetic resonance imaging showed diffusion restriction in the territory of the right posterior cerebral artery and contrast enhancement in the right lingual gyrus adjacent to the diffusion-restricted region. This case suggests an occurrence of cerebral infarction and blood-brain barrier disruption associated with migraine with aura.

Large hemorrhagic stroke after ChAdOx1 nCoV‐19 vaccination: A case report

BackgroundThe anti‐COVID‐19 vaccines are new, and we should be alert of potential adverse effects of them.Aims of the StudyTo report a case of a large hemorrhagic stroke 5 days after ChAdOx1 nCoV‐19 vaccination.MethodsClinical, imaging, and laboratory data of a patient with stroke admitted to our emergency department.ResultsA woman, 57 years old, took the first dose of the ChAdOx1 nCoV‐19 vaccine and shortly thereafter presented mild systemic symptoms and started on aspirin. On day 5, she had a sudden onset of sweating and paleness, which has followed by left hemiparesis, vomiting, and somnolence. Computed tomography showed a large right deep frontal lobe parenchymal hematoma with the inundation of the entire ventricular system. Platelets count, fibrinogen, prothrombin time, and D‐dimer were normal. Digital subtraction angiography did not show any signs of thrombosis or aneurysms in brain circulation.ConclusionsClinicians should be aware of cerebrovascular adverse effects of ChAdOx1 nCoV‐19, including out‐of‐context of vaccine‐induced immune thrombotic thrombocytopenia.

P-MD009. A neurophysiological characteristic of holme’s tremor with thalamic lesion

Introduction. Holme’s tremor (HT) is defined as a slow frequency tremor with irregular amplitude that mostly occurs at rest and worsens with voluntary movements. Dystonia can be occurred with HT and almost all patients had thalamic lesions. The neurophysiological characteristics of HT are limited. The objective of this case report is to highlight the neurophysiological finding of HT with co-occurrence of dystonia from the thalamic lesion. Results. We reported a 46-year-old female patient with 13-year-history of left cerebellar infarction with bilateral vertebral artery dissection post left cerebellar hemispherectomy with full recovery. Recently she presented with left hemiparesis, hemiataxia and left hemianesthesia, diagnosed as the right thalamic hemorrhage. Seven months later, she developed irregular jerky movement of the left hand as well as dystonic posture. The neurophysiological test was done to distinguish among HT, myorhythmia and dystonic tremor. The one-axis accelerometer (ACC) was put on the left thumb and surface EMG was placed on the abductor pollicis brevis (APB), the flexor digitorum superficialis of the left index (FDS 2) and the left extensor indicis proprius (EIP). The ACC and EMG data showed regular sinusoidal movement of left hand at the peak frequency of 3 Hz with synchronous contractions of the antagonist pairs at rest. The similar pattern with larger amplitude of movement was demonstrated during postural holding at several positions. These findings were consistent with the definition of HT with concomitant dystonia rather than myorhythmia or dystonic tremor. The functional imaging also revealed hypometabolism of right thalamus, cerebral peduncle, medulla and left cerebellum. Botulinum toxin injection was done with good benefit. Conclusion. The neurophysiological test is capable to differentiate HT from mimics. Sinusoidal rhythmic slow oscillation with co-contraction of the antagonist pairs at rest with worsening at voluntary movements might indicate HT with concomitant dystonia.

P-OT006. Vertebro-basilar dolichoectasia: A case report of recurrent stroke with treatment dilemma

Introduction. Vertebro-basilar dolichoectasia (VBD) has been associated with stroke and all- cause mortality. Subsequent stroke risk is also higher in patients with VBD. The incidence of the disease is low, and most patients are asymptomatic. Howbeit this disease carries significant mortality and disability rate in symptomatic patients. We report a case of recurrent ischemic stroke in a patient with VBD in Hospital Sultanah Maliha. Results. A 79-year-old man with underlying hypertension suffered from two strokes within six months duration. His first stroke was lacunar infarction with left hemiparesis and he was commenced on antiplatelet. He had modified Rankin Scale (mRS) score of 3 upon discharge. Six months later, he was readmitted for generalised tonic clonic seizure with worsening left hemiparesis. His computed tomography (CT) brain revealed hypodensity in right basal ganglia and right occipital, in line with recurrent ischemic stroke. His CT angiography of brain showed tortuous, elongated and dilated vertebral and basilar arteries with wall calcification which are consistent with VBD. Family members opted for conservative management and he was discharged with mRS score of 5. Discussion. VBD is recognized as an important independent risk factor for recurrent stroke. There are currently no effective measures to manage patients with VBD who present with ischemic symptoms. Dolichoectasia is an arteriopathy rather than an atherosclerosis; thus, the role of antiplatelet or anticoagulant therapy is unclear, but it may increase the risk of VBD rupture. Conclusion. VBD is considered a challenging lesion without an ideal treatment modality. Despite the unfavourable course of VBD, there is still uncertainty in the optimal treatment of VBD.

Editors' Note: Teaching NeuroImages: Pseudopathologic Brain Parenchymal Enhancement due to Vascular Compression in Parotid Tumor

In “Teaching NeuroImages: Pseudopathologic Brain Parenchymal Enhancement due to Vascular Compression in Parotid Tumor,” Teixeira et al. present a CT angiogram (CTA) obtained through right antecubital vein injection that shows intracranial vascular reflux in the cortical veins and pseudopathologic enhancement of the right brain parenchyma in a patient with a right-sided parotid gland tumor who had transient left hemiparesis but had a normal digital subtraction angiogram (DSA) and a normal repeat CTA obtained through left-sided vein injection. The authors initially described the enhancement as being in the distribution of the right middle cerebral artery territory, but they subsequently agreed with Chen et al. that the involvement of the occipital lobe suggests the enhancement pattern is more consistent with the drainage territory of the right superficial cerebral veins. Chen et al. note the mechanism for this finding is unclear and question (1) whether the DSA showed any anomalies in the venous sinuses; and (2) whether the pseudopathologic enhancement could have been related to the fact that the initial injection was performed through a right-sided vein, suggesting there could be severe stenosis of the right brachiocephalic vein. On further review, Teixeira et al. reported the DSA showed a hypoplastic right anterior cerebral artery, occlusion of the right internal jugular vein, and critical stenosis of the right vertebral artery origin. They suspect the patient's symptoms were the result of compression of the right internal carotid artery by the tumor in the setting of right vertebral artery stenosis, which led directly to either compensatory vasodilation or precipitated blood-brain barrier disruption. Although there was also occlusion of the right internal jugular vein, the patent right external jugular vein may have led to rapid spread of contrast into the right hemisphere and retrograde flow into the dilated capillary bed. They postulated that the CTA obtained through left-sided injection was normal because either the patent left internal jugular vein reduced the contrast velocity or vascular autoregulation was reestablished. In “Teaching NeuroImages: Pseudopathologic Brain Parenchymal Enhancement due to Vascular Compression in Parotid Tumor,” Teixeira et al. present a CT angiogram (CTA) obtained through right antecubital vein injection that shows intracranial vascular reflux in the cortical veins and pseudopathologic enhancement of the right brain parenchyma in a patient with a right-sided parotid gland tumor who had transient left hemiparesis but had a normal digital subtraction angiogram (DSA) and a normal repeat CTA obtained through left-sided vein injection. The authors initially described the enhancement as being in the distribution of the right middle cerebral artery territory, but they subsequently agreed with Chen et al. that the involvement of the occipital lobe suggests the enhancement pattern is more consistent with the drainage territory of the right superficial cerebral veins. Chen et al. note the mechanism for this finding is unclear and question (1) whether the DSA showed any anomalies in the venous sinuses; and (2) whether the pseudopathologic enhancement could have been related to the fact that the initial injection was performed through a right-sided vein, suggesting there could be severe stenosis of the right brachiocephalic vein. On further review, Teixeira et al. reported the DSA showed a hypoplastic right anterior cerebral artery, occlusion of the right internal jugular vein, and critical stenosis of the right vertebral artery origin. They suspect the patient's symptoms were the result of compression of the right internal carotid artery by the tumor in the setting of right vertebral artery stenosis, which led directly to either compensatory vasodilation or precipitated blood-brain barrier disruption. Although there was also occlusion of the right internal jugular vein, the patent right external jugular vein may have led to rapid spread of contrast into the right hemisphere and retrograde flow into the dilated capillary bed. They postulated that the CTA obtained through left-sided injection was normal because either the patent left internal jugular vein reduced the contrast velocity or vascular autoregulation was reestablished.

Thromboembolic and Vascular Complications in Patients with Secondary Erythrocytosis Caused By High Oxygen Affinity Variant Hb Coimbra

There are 99 hemoglobin (Hb) variants with increased oxygen affinity inducing compensatory erythrocytosis (Globin Gene Server Web Site: http://globin.cse.psu.edu). One of these mutations, named Hb Coimbra, was described in 1991 in Portugal by Tamagnini et al. (HBB c.300T>A, p.Asp100Glu). Limited amount of published clinical and laboratory data of this condition and the absence of specific guidelines for its management suggest it would be a very benign condition. Here we report clinical and laboratorial findings of carriers of Hb Coimbra with some unexpectedly more severe clinical presentations.We collected peripheral blood venous samples from 10 patients (6 female), aged 31-72 years, upon signed informed consent. All of them were diagnosed with erythrocytosis, with hematocrits in the 46.9-78.1% range at the time of diagnosis, and were heterozygous for the Hb Coimbra mutation as confirmed by direct sequencing of the β-globin gene. The β-globin cluster haplotypes were determined by TaqMan SNP Genotyping Assay (rs7482144, rs968857, rs16911905) and other polymorphisms in the β-globin gene by direct sequencing (rs713040, rs10768683, rs7480526, rs7946748). We were able to identify a common haplotype for the Hb Coimbra allele, which strongly suggests a common origin despite the patients belonging to 5 different unrelated families.Three patients had complications possibly associated with the disease. Patient 1, male, 64 years old, presented with pulmonary embolism in July 2012. Patient 2, male, 60 years old, suffered a left lower limb amputation due to complicated venous thromboembolism in 2010 before he was diagnosed with Hb Coimbra and, in January of 2015, he also developed right pulmonary artery thromboembolism. Patient 3, male, 72 years old, presented with left hemiparesis in 2016 due to intraparenchymatous hemorrhage in the right basal ganglia.Differently from the other patients, elevated levels of serum erythropoietin were observed only in patients 1, 2, and 3 (81.1 mUI/mL, 423.5 mUI/mL, and 35.4 mUI/mL, respectively, reference range 2.6-18.5 mUI/mL). We speculate this abnormality could be associated with the therapeutic phlebotomy treatment performed in these cases.Oxygen affinity was evaluated by determining the p50 in whole blood samples without Hb isolation. O2 dissociation and saturation curves demonstrated that samples containing Hb Coimbra had considerably high affinity for oxygen in comparison to wild type (p50deoxi and p50oxi for Hb Coimbra were, 8.22 [SD 0.64] and 7.94 [SD 0.98], respectively, vs. wild type p50deoxi = 15.56 [SD 0.50] and p50oxi = 15.56 [SD 0.77]). Heme-heme cooperativity was also significantly reduced, tending to a non-cooperative event. Hill coefficients were ndeoxi - Hb Coimbra= 1.51 (SD 0.19) and noxi - Hb Coimbra = 1.48 (SD 0.32), ndeoxi - wild type = 2.52 (SD 0.22) and noxi - wild type = 2.41 (SD 0.32). In spite of the very high O2 affinity of Hb Coimbra, no significant difference was observed between samples from patients with clinical complications and from the remaining Hb Coimbra carriers.Alterations in the α1β2 interface, such as the one in Hb Coimbra, promote conformational changes in the structure of the hemoglobin, and tend to promote O2 binding, reducing oxygen supply to peripheral tissues and resulting in compensatory erythrocytosis (Wajcman et al, 2005). Mutations that generate hemoglobin variants are very rare, but should be considered in the context of familial erythrocytosis or in cases in which more frequent hematological diseases such as polycythemia vera have been excluded.In general, hemoglobin variants with high oxygen affinity manifest exclusively with erythrocytosis and a benign clinical course; however, our data suggest that this might not be the case in some patients, particularly in carriers of Hb Coimbra. Our experience supports that some patients may benefit from the prophylactic use of aspirin or therapeutic phlebotomy as attempts to reduce the incidence of thromboembolic or other vascular complications.Taken together, our data underscore that larger and multicentric studies of the clinical complications secondary to high oxygen affinity hemoglobins are necessary to define guidelines for the optimal management of this type of erythrocytosis. DisclosuresFertrin:Alexion Pharmaceuticals: Consultancy.

The Possible Associaton Between Cerebral Venous Thrombosis and COVID-19 Infecton in a Patent WithSickle Cell Disease: A Case Report

Background: The most common symptom of the novel Coronavirus Disease 2019 (COVID-19) infection is fever and dyspnea that leads to hypoxia in severe cases. Some COVID-19 patients experience neurological symptoms, including ischemic stroke and intracerebral hemorrhage. Sickle Cell Disease (SCD) is a hypercoagulable state, however, it has not been approved as a significant cause of Cerebral Venous Thrombosis (CVT). Case presentation: In this case report, we described CVT in an SCD patient who had COVID-19, as well. We reported a 32-year-old man with a history of sickle cell anemia presented with left hemiparesis, headache, and seizure. After evaluation of the patient, CVT accompanied by COVID-19 infection was diagnosed. He was treated with intravenous unsaturated heparin, antiepileptic drugs, and antiviral agents with a favorable outcome. Based on our knowledge, this is the first case study to describe an association between CVT and COVID-19 infection in a patient with SCD. Conclusion: During the recent pandemic, vaso-occlusive attacks in SCD patients can be evaluated for COVID-19 as an etiological factor.

PSEUDOTUMORAL PRESENTATION OF NEURO-BEHÇET DISEASE: A CONFUSING DIAGNOSIS

A 35-year-old man was referred to the internal medicine department for acute hemiplegia with oral aphthous ulcers. The patient reported recurrent oral and genital ulcers more than 3 times a year. He also experienced one episode of peripheral thrombosis 1 year ago. The physical examination showed left hemiparesis with positive Babinski sign, hyperreflexia, and pseudofolliculitis in legs and trunk. The pathergy test was positive. Cerebral MRI showed a large mass hyperintense in T2 sequence in the regions of basal ganglia and corpus callosum with peripheral contrast enhancement and intensive edema around the lesion. The diagnosis of pseudotumoral neuro-Behçet disease was made on the basis of clinical history, the cerebral MRI result, and the exclusion of other tumoral and infectious diseases. The patient was treated with corticosteroids and cyclophosphamide with favorable outcome.

Endovascular treatment of concomitant innominate and subclavian artery injury with pseudoaneurysms from a gunshot wound in a polytrauma patient

Introduction Injury of the innominate artery (IA) is associated with high mortality and morbidity, such as a major neurologic event. The aim of this case report was to describe an example of prioritization in polytrauma management by applying endovascular intervention in a difficult case with impending uncal herniation, extensive cerebral infarction, and large pseudoaneurysm from concomitant innominate and right subclavian artery injuries. Case Report A 34-year-old woman sustained a gunshot wound to her upper chest that lodged in the anterior triangle of her neck and presented with tension pneumothorax and cardiac arrest, which was successfully resuscitated. Subsequently she developed drowsiness and left hemiparesis, and computerized tomography demonstrated a large right cerebral hemisphere and left cerebellar region infarction with impending uncal herniation and pseudoaneurysms from the IA and proximal right subclavian artery. After emergency craniectomy to avert herniation, endovascular treatment was performed to facilitate vessel repair due to anatomical difficulty and the patient’s unstable condition. She was discharged home 3 weeks after operation, and 2 months postoperatively, she was neurologically intact with no evidence of endoleakage or pseudoaneurysm. Conclusion In such a complex polytrauma case, correct prioritization of interventions is crucial to obtaining the best outcomes, and the Endovascular Resuscitation and Trauma Management protocol can be applied as an alternative treatment protocol with good results.

Unilateral Tension Pneumocephalus of the Sylvian Fissure: A Rare Neurosurgical Complication

Tension pneumocephalus is an uncommon complication of neurosurgical procedures. We report a patient who presented with headache, vomiting, left hemiparesis and rhinorrhea 30 days after correction of a recurrent nasal cerebrospinal fluid fistula and shunt placement. A computed tomography scan revealed a massive collection of air with air-fluid level in the right sylvian fissure and midline shift. A right pterional craniotomy was performed and a small corticectomy resulted in evacuation of air from the sylvian fissure. A dural graft from the previous surgery was recognized to be acting as a ball-valve mechanism, trapping air from the nasal cavity. It was removed and the cranial defect was corrected with a split calvarial bone graft. Follow-up brain computed tomography revealed complete resolution of pneumocephalus. After surgery there was progressive improvement of neurological symptoms over 10 days, and the patient was asymptomatic after 1 month of follow-up.