Left Homonymous Hemianopia Research Articles

Case 302.

History A 21-year-old immunocompetent man who was a long-term resident of Qatar presented to the emergency department with recurrent episodes of unprovoked generalized tonic-clonic seizures lasting 2-3 minutes that spontaneously resolved and were associated with postictal confusion. The patient also had progressive mild diplopia, intermittent dizziness, and numbness in the left arm over the course of 3 months. The patient did not have any other systemic symptoms or chronic medical diseases. He did not have any history of intake of illicit drugs, supplements, or regular medications; he had not received any recent vaccinations; and he had not undergone any surgical procedures. He had no history of travel. At presentation, vital signs were normal. Neurologic examination showed mild left homonymous hemianopia, normal gait with no cerebellar signs, and preserved sensations, power, tone, and reflexes in all four limbs. An electroencephalogram showed no epileptiform discharges. Chest CT and extensive laboratory work-up, including viral, fungal, bacterial, and parasite work-up, thyroid function tests, and immunologic blood tests yielded normal results. Those included normal complete and differential blood counts and normal serum chemistry. Serum analysis was negative for antinuclear antibody, Sjögren syndrome antigens A and B, cytoplasmic antineutrophil cvtoplasmic antibody, and paraneoplastic profile. Serum evaluation was also negative for human immunodeficiency virus type 1 and type 2 RNA, and Brucella, Schistosoma, and toxoplasma antibodies. Venereal Disease Research Laboratory (VDRL) and rapid plasma regain (RPR) test results were negative. Cerebrospinal fluid (CSF) analysis revealed clear fluid and normal pressure and biochemistry, except for elevated protein concentration (0.48 g/L) (normal range, 0.15-0.45 g/L). There were 43 leukocytes/µL (99% lymphocytes) (normal range, 0-5 leukocytes/µL; lymphocytes range, 40%-80%), with no atypical or malignant cells. CSF Gram staining, acid-fast staining, cryptococcal antigen, varicella-zoster virus polymerase chain reaction (PCR), herpes simplex virus PCR, VDRL, and RPR test results were negative. CSF cultures did not show any evidence of growth of bacteria, fungi, or acid-fast bacillus. CSF flow cytometry did not show a monoclonal lymphoid population. No CSF oligoclonal bands were detected. Conventional brain MRI with intravenous administration of contrast material and a perfusion study were performed and included different sequences (Figs 1-3).

1401. Infliximab for Immune Reconstitution Inflammatory Syndrome (IRIS) in Tuberculous Meningitis; A Treatment Paradox

BackgroundTumor necrosis factor (TNF)-α inhibitors are known for the reactivation of latent tuberculosis (TB). As a paradox, it has been reported to have a role in the treatment of immune reconstitution inflammatory syndrome (IRIS) from anti-TB therapy.MethodsWe report a case of paradoxical worsening of central nervous system TB after initiation of anti-TB medications, which was treated successfully with infliximab (TNF-α inhibitor).ResultsA 34-year-old man from Nepal with a history of untreated latent TB presented with complaints of occipital headache, slurred speech, and witnessed seizure. His physical exam was consistent with hyperreflexia. MRI of the brain revealed multiple small contrast-enhancing lesions in cerebral hemispheres. CT Chest showed bilateral centrilobular nodules suggestive of miliary TB. Cerebrospinal fluid (CSF) analysis showed pleocytosis, high protein, and low glucose. He was started on isoniazid, rifampin, ethambutol, and pyrazinamide along with high-dose dexamethasone for TB meningitis. Later, MTB DNA probe from bronchioalveolar lavage and CSF detected Mycobacterium Tuberculosis which was pan-susceptible. Repeat MRI of the brain 6 months into therapy revealed worsening of brain lesions. Moxifloxacin and linezolid were added to the regimen given clinical progression on first-line therapy. 6-months into this enhanced regimen he started experiencing blurring of vision. Visual field mapping showed left homonymous hemianopia. Repeat MRI of the brain confirmed extensive changes of basilar meningitis completely enveloping the optic chiasm. IRIS from TB was suspected. His prednisone dose was increased, and 3-doses of infliximab infusion were, 2-weeks apart were administered which showed clinical and radiological improvement.MRI Brain MRI Brain (axial T2/flair sequence) shows hyperintensities in multiple locations including the involvement of the left optic nerve and the left occipital region.ConclusionExacerbation of pre-existing clinical symptoms, formation of new lesions, or cavitation of prior pulmonary infiltrates is known as tuberculosis IRIS or paradoxical reaction. Despite the clinical and radiological exacerbation, mycobacterial cultures usually stay negative. Continuation of anti-TB medications and high-dose corticosteroids are the backbone of treatment but in refractory cases, immune modulation is needed with anti-TNF-α agents.Disclosures All Authors: No reported disclosures

Trans-Sulcal Parafascicular Port-Based Resection of a Subcortical Occipital High-Grade Glioma: 2-Dimensional Operative Video.

Minimally invasive trans-sulcal parafascicular port-based approaches can provide safe access to a wide variety of deep brain lesions.1,2 This surgical video illustrates the use of a minimally invasive port-based approach for resection of a subcortical right medial occipital lobe lesion in a 63-year-old woman who presented with seizures and bilateral left homonymous hemianopia. MRI showed a 2.5-cm contrast enhancing lesion with a necrotic center and significant T2 and fluid-attenuated inversion recovery signal consistent with vasogenic edema. Diffusion tensor imaging revealed compromise of the right optic radiations and edema extending through the right corticospinal tract. A minimally invasive trans-sulcal parafascicular port-based approach to the deep occipital lobe and periatrial region was performed under full exoscopic visualization. A gross total tumor resection was achieved, and histopathology revealed an IDH1-mutant, MGMT-methylated-positive glioblastoma. The patient's presentation, rationale, key surgical steps, and outcomes are discussed, and informed consent for surgery was obtained. The participants and any identifiable individuals consented to the publication of their image. Images at 3:50 used with permission from Nico Corporation. All rights reserved.

Abstract 1122‐000200: Chiropractor Manipulation Leading to Bilateral Vertebral Artery Dissection and Acute Ischemic Stroke

Introduction : Traumatic cervical artery dissection is one of the leading causes of stroke in patients under the age of 45. Recent chiropractic neck manipulation is associated with risk of vertebral artery dissection (VAD). The V3 segment of the vertebral artery is highly susceptible to the bending forces during forced manipulation leading to intimal damage. Methods : N/A Results : This is a case presentation of a 44 year old male who was transferred from another emergency department for left homonymous inferior quadrantanopia noted on an optometrist visit. He reported sudden onset left homonymous hemianopia after receiving a high velocity cervical spine adjustment at a chiropractor appointment for chronic neck pain a few days prior. CT angiogram of the head and neck revealed bilateral vertebral artery dissection at left V2 and right V3 segments. MRI brain confirmed an acute infract in the right medial occipital lobe. His right PCA stroke was likely embolic from the injured right V3 but possibly from the left V2 as well. As the patient reported progression from a homonymous hemianopia to a quadrantanopia, he likely had a migrating embolus. Conclusions : Arterial dissection accounts for about 2% of all ischemic strokes, but may be between 8–25% in patients less than 45 years old. VAD can result from trauma of varying severities ‐ from sports, motor vehicle accidents, and chiropractor neck manipulations to violent coughing/sneezing. It is estimated that 1 in 20,000 spinal manipulation results in vertebral artery aneurysm/dissection. In the United States, patients who have multiple chronic conditions are reporting higher use of complementary or alternative medicine, including chiropractic manipulation. Education about the association of VAD and chiropractor maneuvers can be beneficial to the public as these are preventable acute ischemic strokes. In addition, vertebral artery dissection symptoms can be subtle and patients presenting to chiropractors may have distracting pain masking their deficits. Evaluating for appropriateness of cervical manipulation in high‐risk patients and detecting early clinical signs of VAD by chiropractors can be beneficial in preventing acute ischemic strokes in young patients.

The application of shotgun metagenomics to the diagnosis of granulomatous amoebic encephalitis due to Balamuthia mandrillaris: a case report

BackgroundGranulomatous amoebic encephalitis (GAE) is an infrequent and fatal infectious disease worldwide. Antemortem diagnosis in this condition is very difficult because clinical manifestations and neuroimaging are nonspecific.Case presentationA 60-year-old Japanese woman was admitted with a chief complaint of left homonymous hemianopsia. Brain-MRI showed extensive necrotizing lesions enhanced by gadolinium, in the right frontal lobe, right occipital lobe, and left parietal lobe. Epithelioid granulomas of unknown etiology were found in the biopsied brain specimens. Shotgun metagenomic sequencing using a next-generation sequencer detected DNA fragments of Balamuthia mandrillaris in the tissue specimens. The diagnosis of granulomatous amoebic encephalitis was confirmed using an amoeba-specific polymerase chain reaction and immunostaining on the biopsied tissues.ConclusionsShotgun metagenomics is useful for the diagnosis of central nervous system infections such as GAE wherein the pathogens are difficult to identify.

Restoring Moderate to Severe Loss of Upper Extremity Function Post-stroke with a Neuromotor Prosthesis: A Case Report

<h3>Research Objectives</h3> To study the effect of a wearable, powered exoskeleton orthosis controlled by a brain-computer interface (BCI) on upper extremity function in a single participant with moderate to severe hemiparesis. <h3>Design</h3> Single subject design with pretest, mid, and posttest. <h3>Setting</h3> Home and outpatient. <h3>Participants</h3> Participant was a 41-year old right-hand-dominant male with moderate to severe (Fugl-meyer upper extremity [FM-UE] 33/66) left-sided hemiparesis due to a stroke that occurred 18 months prior, with left homonymous hemianopsia, left hemi-neglect, left central VII nerve palsy, and spasticity in the weakened left upper extremity. The stroke lesioned the right lentiform nucleus and adjacent white matter. <h3>Interventions</h3> Brain implants were surgically placed within the right precentral gyrus region of the cortex, representing the left hand. The 12-week intervention consisted of neuromotor prosthesis training with BCI controlling the powered exoskeleton and biofeedback for controlling a game cursor; physical therapy once/week; occupational therapy twice/week. <h3>Main Outcome Measures</h3> Action Research Arm Test (ARAT), FM-UE, Motor Activity Log (MAL) domains of Amount of Use (AOU) and Quality of Movement (QOM) <h3>Results</h3> ARAT scores with the powered exoskeleton were greater with BCI (change: 10-point, 18%) than with myoelectric control (change: 5-points, 9%). Upper extremity outcomes exceeded the minimal clinically important difference thresholds for FM-UE (change: 8-point, 21%), MAL-AOU (change: 18.5-points, 12%), and MAL-QOM (Change: 17-point, 11%). <h3>Conclusions</h3> The results indicate promising outcomes of the neuromotor prosthesis on upper extremity function for a single participant with potential for future research with implanted systems combined with therapy. <h3>Author(s) Disclosures</h3> Drs. Serruya and Napoli are inventors on a US provisional patent application that has been filed by Thomas Jefferson University on the software methods used in this study to map neural activity into orthosis control.

Dichoptic visual field mapping of suppression in exotropia with homonymous hemianopia

The purpose of this study was to investigate which portions of the visual scene are perceived by each eye in an exotropic subject with acquired hemianopia. The pattern of suppression is predictable from knowledge of how suppression scotomas are organized in exotropic subjects with intact visual fields. Dichoptic perimetry was performed by having a subject wear red/blue goggles while fixating a cross that was either red or blue. Red, blue, or purple spots were presented briefly at peripheral locations. The subject's identification of the spot color revealed which eye was perceptually engaged at any given location in the visual fields. A 17-year-old female with a history of exotropia was evaluated after rupture of a right parietal arteriovenous malformation. Dichoptic perimetry showed a left homonymous hemianopia. All stimuli to the right of the right fovea's projection point were perceived via the right eye. Stimuli between the foveal projection points, which were separated horizontally by the 20° exotropia, were perceived by the left eye. Perception of the visual scene is shared by the eyes in hemianopia and exotropia. Suppression occurs only in the peripheral temporal retina of the eye contralateral to the brain lesion, regardless of which eye is engaged in fixation. Although exotropia expands the binocular field of vision in hemianopia, it is probably not an adaptive response, even when it develops after hemianopia.

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.

Diagnosis of Acute Promyelocytic Leukemia After Presentation to Neuro-Ophthalmology.

Acute promyelocytic leukemia (APML) is a medical emergency that can initially present with neuro-ophthalmologic signs. Early recognition is crucial, and immediate treatment with all-trans retinoic acid (ATRA) and arsenic trioxide (ATO) can be life-saving. The goal of this study was to describe patients who first presented to neuro-ophthalmology and were subsequently diagnosed with APML. We retrospectively reviewed consecutive patients seen at a tertiary neuro-ophthalmology centre. Patients with an unknown diagnosis of APML at presentation who subsequently went on to receive this diagnosis were included. Clinical characteristics, neuro-ophthalmologic findings, and outcome were retrieved. A total of 3 patients (2 women and 1 men) with a mean age of 30.7 (range 24-33) years were included in the study. Neuro-ophthalmologic diagnoses at presentation were severe hemorrhagic papilledema related to dural venous sinus thrombosis, hemorrhagic bilateral optic disc edema, and left homonymous hemianopia related to an occipital lobe hemorrhage. At diagnosis, the average hemoglobin was 83.7g/L (range 78-104), and the platelet count was 39.3 × 109/L (range 15-77). All patients were treated with ATRA and ATO. One patient developed papilledema and sixth nerve palsies related to this treatment, which resolved with acetazolamide. Clinical follow-up ranged from 6 to 12 months, and all patients were in clinical remission about systemic APML. Neuro-ophthalmologic symptoms may be the first manifestations of APML, and a complete blood count is an essential test in patients presenting with optic disc edema, especially if hemorrhagic.

EFFECT OF INDIVIDUALLY-TAILORED TDCS AND SYMBOLIC ART THERAPY FOR CHRONIC ASSOCIATIVE PROSOPAGNOSIA AFTER INFECTION BY SARS-COV-2, NEUROCOVID-19 AND ISCHEMIC STROKE

Background The rehabilitation of patients with chronic prosopagnosia that occurs following a stroke is a challenge for modern medicine. Dysfunction to the facial processing areas is permanent and standard rehabilitation brings only limited improvement. Therefore, therapists suggest reinforcing the compensatory strategies used by such patients such as voice, figure, and gait recognition to help with the identification of a particular person, which promotes their social functioning. New neurotechnologies, especially QEEG/ERPs, displays of functional brain impairment in prosopagnosia, may be helpful in developing an appropriate neurotherapy protocol and create the conditions for other forms of rehabilitation in such patients. The purpose of our study was twofold: 1) to evaluate QEEG/ ERPs shows of post-stroke functional impairment associated with prosopagnosia, 2) to construct a neurofeedback protocol based on these indices to sup- port the neuropsychological rehabilitation of the case study described herein. We present the case of a 23-year-old right-handed student of the Graphics Faculty of the Academy of Fine Arts, with chronic associative prosopagnosia after infection with SARS-CoV-2 followed by Covid-19 and a right hemisphere stroke. He was re- ferred in April 2021 for diagnosis and therapy at the Reintegration and Training Cen- ter of the Polish Neuropsychological Society (PTNeur). Six months earlier, in October 2020, the patient had been admitted to the Infectious Disease Hospital. COVID-19 was diagnosed based on coronavirus 2 (SARS-CoV-2) reverse transcrip- tion PCR (RT-PCR) on a nasopharyngeal swab. The neurological examination re- vealed muscle weakness on the left side of the body, slow and aprosodic speech, preserved comprehension, and acute left homonymous hemianopsia, as well as prosopagnosia and mirror symptom. The patient was sedated and mechanically ventilated for six days. The CT-scan showed foci in the posterior part of the superior temporal lobe and hyperintense changes in the blood supply area of the right middle cerebral artery. After 30 days of hospitalization, the patient was discharged from this hospital and referred to an outpatient rehabilitation center for five months. Ther- apy improved his general condition but did not remove the chronic prosopagnosia: a personal tragedy for the patient which prevented him from continuing his studies. He was diagnosed at the PTNeur Reintegration and Training Center within the next few weeks: (1). ophthalmologic examinations revealed no pathology; (2) neuropsy- chological testing confirmed the presence of chronic apperceptive prosopagnosia; (3) examination of event-related potentials (ERPs) revealed a large delay of the N170 wave, particularly on the right side, indicating a slowing of the rate of nerve impulses in early face processing and a cause of prosopagnosia. The patient was referred for rehabilitation: he participated in 20 sessions of individually tailored anodal transcranial direct current stimulation (tDCS) twice a week for ten weeks, and in parallel, for indi- vidualized Prosopagnosia Symbolic Art Therapy provided once a week for ten weeks. By the end of therapy, the patient was not only recognizing but also painting portraits of faces. He returned to college, finished and defended a master’s thesis in Artistic Drawing, in which facial presentation played an important role. Quantitative EEG (QEEG) and event-related potentials (ERPs) neuromarkers helped to understand the mechanism of prosopagnosia and to choose an individualized protocol, thus the appropriate application of tDCS in our patient, which accelerated the recovery of the ability to perform complex tasks and created the conditions for Symbolic Art Therapy. Modern medicine can successfully use such a management protocol in individuals with chronic prosopagnosia.

Reversible Homonymous Hemianopia in a Newly Diagnosed Diabetic Man

A 53-year-old healthy man presented with acute-onset left homonymous hemianopia (HH) suggestive of a right occipital lobe stroke. Serum glucose was severely elevated (999 mg/dl, normal 64–138), consistent with hyperosmolar hyperglycemic state (HHS). Perimetry revealed left HH (Humphrey field analyzer, Fig A). Magnetic resonance imaging (MRI) demonstrated right occipital lobe subcortical T2 hypointensity, without diffusion restriction (Fig B). This unique pattern is inconsistent with ischemic stroke and has been described in HHS, possibly secondary to hyperglycemia-induced cellular metabolic dysfunction or focal seizure activity.

Mitochondrial Diabetes: The Clinical Spectrum of MIDD and MELAS in Association With the A3243G Mutation

Abstract Introduction: Maternally inherited diabetes and deafness (MIDD) is a multisystem disorder characterized by insulinopenia and sensorineural hearing loss. This rare form of monogenic diabetes is most commonly associated with the A3243G mutation of mitochondrial DNA (mtDNA). The same mutation is seen in 80 percent of patients with MELAS (Mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes). MIDD and MELAS have overlapping features suggesting a continuum of expression for the A3243G mutation. Clinical Case: A 41-year-old male was referred for genetic testing and counseling by his ophthalmologist following detection of bilateral punched-out retinal pigment epithelium (RPE) lesions on routine exam. His medical history was significant for type 1 diabetes mellitus (T1DM) diagnosed at the age of 21 and bilateral sensorineural hearing loss diagnosed at the age of 38. The referral was triggered by patient reported family history of MELAS in two of his brothers who were both diagnosed at the age of 10 and died at the ages of 20 and 27. Whether the patient was previously tested during early childhood remains unclear. His medical history was negative for stroke-like episodes or seizures. Neurologic evaluation revealed mild fluent aphasia with paraphasic errors and some comprehension difficulties. MRI of the brain without contrast showed no focus of restricted diffusion. Mitochondrial DNA sequence analysis was performed. A pathogenic variant (m.3243 A&amp;gt;G) was detected in the MT-TL1 gene at approximately 25% heteroplasmy. The patient was advised to avoid metformin given increased risk for lactic acidosis. He was also instructed against use of statins. At the age of 45, the patient presented to the emergency department (ED) with a complaint of headache, vertigo and incoordination. Physical examination revealed left homonymous hemianopsia, right horizontal nystagmus and bilateral upper extremity dysmetria. MRI of the brain without contrast showed a large area of predominantly cortical restricted diffusion involving the right temporal and occipital region with associated T2/FLAIR hyper-intensity. Cross over between the PCA and MCA territories was suggestive of a stroke-like episode related to MELAS. The patient received a bolus of IV arginine at 0.5 g/kg followed by an IV infusion of 0.5 g/kg/day for 3 days. He was later transitioned to oral arginine 5g three times daily and was discharged to a rehab facility. Clinical Lesson: This case demonstrates the evolution of MIDD to MELAS, supporting the concept that both syndromes represent a spectrum of the same disease. A few case reports describe the progression of MIDD to MELAS. Why some patients develop MELAS and others develop MIDD is unclear but may be related to heteroplasmy. Early identification of MIDD and MELAS is crucial given associated comorbidities and unique management issues.

Giant Prolactinoma Presenting With Facial Nerve Palsy and Hemiparesis

BackgroundGiant prolactinomas are an exceedingly uncommon type of pituitary adenomas that usually occur in men, and cause extremely high prolactin levels and mass-related symptoms. Rarely, patients may experience neurological deficits resembling ischemic events.MethodsWe describe an unusual case of a young man who presented with stroke-like symptoms and was found to have a giant prolactinoma.Clinical CaseA 25-year-old man presented with left facial droop and gradually progressing upper and lower extremity weakness for evaluation of stroke. He reported recent weight gain and erectile dysfunction. Physical examination revealed left homonymous hemianopsia, left VII nerve palsy, and left hemiparesis. Magnetic resonance imaging of the brain showed an enormous mass in the sella turcica, which invaded the sphenoid sinus and right side of the skull base. Prolactin level was elevated at 13 580 ng/mL, and the testosterone level was low. The patient was started on cabergoline and had marked improvement in his symptoms in a few months. Fifteen months after starting treatment, he has had more than 90% reduction in tumor volume and a 93% reduction in prolactin level.ConclusionGiant prolactinomas are uncommon and present with compressive symptoms that can be mistaken for a stroke. Our case is a unique report of a facial nerve palsy and hemiparesis secondary to giant prolactinoma in the absence of stroke or pituitary apoplexy.

Ophthalmological symptoms in a patient\xa0with reversible cerebral vasoconstriction syndrome: a case report

BackgroundReversible cerebral vasoconstriction syndrome is characterized by severe headache with reversible segmental constriction of the cerebral arteries. We present details on a patient with reversible cerebral vasoconstriction syndrome who initially visited an ophthalmologist because of visual symptoms.Case presentationA 34-year-old Japanese woman complained of sustained headache and insomnia starting 2 days after her first childbirth. In addition to the severe headache, a visual field defect was also observed 10 days later. Best corrected visual acuity at the initial visit was 20/20 and 20/25 for the right and left eye, respectively. Exudative retinal detachment was noted surrounding both optic heads. Visual field testing revealed left homonymous hemianopsia, while magnetic resonance imaging demonstrated the presence of edema and infarction of the bilateral basal nuclei and right occipital lobe. The homonymous hemianopsia and exudative retinal detachment recovered immediately after treatment with a free-radical scavenger and anticoagulant. There has been no recurrence of symptoms during the 4 years of follow-up.ConclusionsWe report a case of reversible cerebral vasoconstriction syndrome with ophthalmological symptoms that were reversible, including serous retinal detachment and homonymous hemianopsia.

An interesting case of functional visual loss presenting as a left homonymous hemianopia

Functional visual loss is vision loss where a pathological or structural cause cannot be found and is commonly related to psychological issues.1,2 The purpose of this report is to discuss an intere...

LGG-21. MR-GUIDED LASER INTERSTITIAL THERMAL THERAPY FOR UNRESECTABLE AND SYMPTOMATIC PEDIATRIC LOW GRADE GLIOMA

BACKGROUNDPediatric low-grade gliomas (LGG) not amenable to resection, while often indolent, represent a significant source of cancer-related morbidity and an unmet therapeutic need. Standardly, these patients are treated with sequential lines of chemotherapy, while delaying as long as possible radiation. Magnetic resonance-guided laser interstitial therapy (LITT) is a minimally invasive procedure that utilizes real-time MR thermography to ablate brain lesions.METHODSA 15-year-old girl was diagnosed with a suprasellar, hypothalamic LGG, BRAF V600E mutation positive. The tumor was unresectable, and due to progressive vision loss and headaches, the patient underwent treatment. Despite sequential trials of thioguanine/procarbazine/lomustine/vincristine, carboplatin/vincristine, dabrafenib, and combination dabrafenib/trametinib, the patient continued to experience debilitating headaches, malnutrition, school absenteeism, and overall poor quality-of-life. Using real-time, sequential MRI-thermometry and the Neuroblate cooled directional laser catheter, the bulk of the enhancing tumor was heated to a killing temperature.RESULTSAt 1-year post LITT, the patient’s symptoms were dramatically improved, including greatly improved headaches, malnutrition, school absenteeism, and overall quality of life. LITT was generally well tolerated, though the patient had slight progressive left homonymous hemianopia, thought secondary to LITT impact on the optic tracts. The tumor progressively shrank over the year post-LITT to a peak of 42% volume reduction.CONCLUSIONWe report a case of a pediatric patient with an unresectable low grade glioma who underwent LITT with excellent clinical and radiographic effects. LITT should be considered for children with unresectable and morbid LGGs that fail to respond to more conventional therapies.

Visual Consequences of Optic Tract Damage

Background: Optic tract lesions can have devastating visual consequences. When insult is isolated to the optic tract, central acuity is typically spared and color vision is usually normal; the visual manifestation of damage is a visual field deficit. Optic tract damage as a cause for homonymous hemianopia is relatively rare compared to other visual pathway lesions producing such a field defect, and presents with characteristic features. These features include a relative afferent pupillary defect in the eye contralateral to the lesion and pallor of that optic disc in a “band” or “bow-tie” configuration. Case Reports: Two patients with optic tract damage of different etiologies were examined. The first patient presented with concerns about blackouts and peripheral field deficits. Neuroimaging demonstrated a supersellar meningioma compressing the left optic nerve and part of the optic tract. Prior to meningioma resection, threshold visual field testing revealed the presence of a right incongruous incomplete homonymous hemianopia. The second patient sustained severe brain injury during a motor vehicle accident which left him in a coma for over one month. Upon awakening, he reported left-sided vision loss. Magnetic resonance imaging revealed damage involving the right optic tract, corresponding with a left homonymous hemianopia found on threshold perimetry. Conclusions: The optometrist should bear in mind that homonymous hemianopic visual field deficits can be caused by lesions in the optic tract, although damage to this portion of the visual pathway occurs infrequently. The unique clinical presentation of optic tract lesions enables the optometrist to make a preliminary diagnosis as to the location of the insult. This is especially important since lesions of the optic tract may be difficult to detect with neuroimaging. CE Notification: This article is not available as a COPE accredited CE course. To view all the COPE accredited CE courses: Click here to Enroll (https://www.crojournal.com) Please check COPE course expiry dates prior to enrollment. The COPE course test must be taken before the course expiry date

NIMG-60. ATYPICAL POSTERIOR REVERSIBLE LEUKOENCEPHALOPATHY SYNDROME MIMICKING TUMOR IN 1ST TRIMESTER PREGNANCY-’DON’T BELIEVE EVERYTHING YOU SEE’

Abstract Posterior reversible encephalopathy syndrome (PRES) is a clinico-radiographic diagnosis characterized by headache, confusion, visual disturbances, seizures and most commonly bilateral vasogenic edema. PRES during first trimester gestation is exceptional and in our report mimicking CNS tumor. An 18-year-old G1P0 Hispanic woman was admitted with headache, left-sided hemiparesis and left-sided visual loss for 4 days. Exam was consistent for drowsiness, dysarthria, left homonymous hemianopia, left facial droop and left hemiplegia with left hemi-sensory loss. By pelvic ultrasound she had a single 9-week intrauterine pregnancy with no detectable fetal heart tone. MRI brain: large area of increased T2 signal in the right parietal occipital and upper temporal and posterior right frontal lobe white matter with mass effect of 6mm midline shift and no evidence of hemorrhage. There was high suspicion for a glial neoplasm. MRA of head and neck and EEG were unremarkable. IR cerebral angiogram had no evidence of vascular abnormalities. Eventual MR spectroscopy, choline/NAA ratio was (&amp;lt; 2/1), elevated lactate/fat peak suggestive of inflammatory versus infectious process. She had D&amp;C for missed abortion and pathology was negative for malignancy. Further brain biopsy on day 5 demonstrated reactive astrogliosis with microglial activation, scattered macrophages with white matter vacuolation. Biopsy specimen was negative for infections. TPO Ab, NMO/AQP4, Ttg IgA and rheumatologic panel were negative. The pathology was most compatible with PRES. Repeat MRI had decreasing mass effect and increased patchy subcortical restricted diffusion in the right occipital and temporo-parietal lobes. She had inpatient rehabilitation leading to complete recovery.

Left Homonymous Hemianopia: An Uncommon, Neuro-ophthalmological Presentation of Hyperglycemic Hyperosmolar State.

Spectrum of the neurological deficits in non-ketotic hyperglycemia and hyperosmolar hyperglycemic state (HHS) ranges widely among patients and can have any presentation from focal seizures, epilepsia partialis continua, chorea-hemiballismus syndrome, hemiparesis, hemianopia to mental obtundation and coma. Here we report a case of HHS which presented with Left Homonymous Hemianopia as the only initial presentation. Symptoms slowly resolved over the course of two weeks by administration of insulin and normalizing the glucose.

Acromegalia en Paciente con Cáncer Papilar de Tiroides

Introducción: El cáncer de tiroides es la neoplasia endocrina más frecuente y el Carcinoma Papilar de tiroides representa el 80% de los casos. Por otro lado, la acromegalia es un trastorno poco diagnosticado con una incidencia estimada anual de 4 casos por millón de personas. Presentamos un caso en el que se presentan las dos entidades al mismo tiempo en un paciente y la discusión del posible nexo bioquímico.&#x0D; Caso clínico: Mujer de 23 años, con masa nodular pétrea de 3 centímetros, en polo superior de lóbulo derecho de tiroides; sometida a tiroidectomía radical y linfadenectomía cervical bilateral, reporte histopatológico de carcinoma papilar. Evoluciona con cambios visuales en ojo izquierdo, cefalea, amenorrea de 1 año, galactorrea negativa, características morfo-anatómicas de acromegalia, campimetría hemianopsia homónima izquierda. IRM de cerebro lesión sellar y suprasellar hiperintensa en T2 en relación a macroadenoma hipofisario. Bioquímicos: Prolactina 131.20, GH 2.7, ACTH 18.5, IGF1 434, IGFBP 35.8, TTOG para GH que se informa: GH 0 min: 10.7, GH 30 min: 9.24, GH 60 min: 7.9.&#x0D; Evolución: La paciente fue sometida a hipofisectomía transesfenoidal endoscópica parcial. En tratamiento con cabergolina 0.5 mg bisemanal, levotiroxina 225 mcg día y octreótide 20 mg mensual.&#x0D; Conclusión: Se concluye que siendo la acromegalia una enfermedad rara se asocia a cáncer de tiroides, implicando posibles mutaciones en la subunidad ? de la proteína G.