Left-sided Hemiparesis Research Articles

Morphine overinfusion of intrathecal drug administration system under magnetic resonance evaluation for the diagnosis of stroke: a case report

BackgroundUntil recently, it is generally considered safe to perform magnetic resonance imaging (MRI) in patients with an intrathecal drug administration system (ITDAS) device. In this study, we presented a case of morphine overdose due to ITDAS malfunction during MRI evaluation for the diagnosis of stroke.Case presentationA 58-year-old woman was referred to the emergency department for left-sided hemiparesis and dysarthria. She had undergone ITDAS implantation 4 years ago because of intractable back pain. Her brain MRI examination did not show any abnormalities except an old hemorrhagic infarction in the right basal ganglia. After MRI was performed, her symptoms completely resolved. Approximately 3 h after the MRI scan, the patient showed progressive stuporous consciousness and decreased respiration with decreased peripheral oxygen saturation of 80%. Initial arterial blood gas analysis revealed respiratory acidosis with hypoxia and hypercapnia. We suspected the opioid overdose for her unconciousness, small and sluggish pupils, and slow respiration. The patient regained consciousness within 3 min after the administration of naloxone with severe anxiety and irritability, without any respiratory symptoms or focal neurological deficits. In the pump interrogation and actual reservoir checks performed 6 h after the MRI scan, there was no significant difference between the expected reservoir volume and actual reservoir volume. Follow-up MRI performed to rule out posterior circulation infarction showed no structural lesions. The patient was eventually discharged without further neurologic or functional deterioration, with diagnosis of transient ischemia attack for initial symptoms of focal neurologic deficits.ConclusionAlthough both ex vivo and in vivo studies have provided evidence that ITDAS devices are MRI-compatible, the pump is made of titanium and has ferromagnetic components. Since misdiagnosis of overinfusion could lead to mortality, early awareness of overinfusion of the intrathecal drug is needed to all clinicians in case of performing MRI in ITDAS implanted patients.

The Role of Angioplasty Alone in Intracranial Atherosclerosis: 2-Dimensional Operative Video

Intracranial atherosclerosis disease (IAD) is the cause of stroke in up to 10% of cases. Symptomatic IAD results mainly from hypoperfusion, embolic phenomenon, and occlusion. Treatment consists of conservative management with aggressive medical treatment, surgery, and endovascular therapy.1,2 This video is about a 62-yr-old male who presented with left-sided hemiparesis and right gaze preference secondary to an acute ischemic stroke in the right middle cerebral artery (MCA) territory treated initially with tissue plasminogen activator (tPA). Head computed tomography (CT) angiography (CTA) revealed occlusion of the extracranial and cavernous segments of the internal carotid artery (ICA). CT perfusion (CTP) showed hypoperfusion in the MCA territory and magnetic resonance imaging (MRI) revealed multifocal, wedge-shaped areas of restricted diffusion in the right hemisphere. During his hospitalization, he experienced worsening of his symptoms in the setting of hypoperfusion (hypotension). The patient underwent a cerebral angiogram with thrombectomy and submaximal angioplasty (SA). Successful revascularization of the right ICA was obtained. No procedure-related complications occurred, and the patient's neurological exam improved. SA can be as efficient and a safer option than conventional angioplasty or angioplasty and stenting for symptomatic IAD. The patient consented for the procedure and for the video production.

Chordoma and meningioma arising as a collision tumor in the petroclival region: Case report and literature review

The co-existence of two independent brain tumors at the same anatomical site is rare and occurs as a "collision tumor" or "tumor-to-tumor metastasis." In intracranial location, meningioma is the most common neoplasm in such coincidences. We present a case involving a 31-year-old woman with a complex tumor consisting of chordoma and meningioma in the petroclival region. The patient presented with left facial numbness, ataxia, and left-sided hemiparesis. Computed tomography and magnetic resonance imaging showed a well-demarcated, intradural, extra-axial tumor mass in the petroclival region. After complete total resection, histopathological examination revealed two different parts of the tumor, consisting of chordoma and meningioma. Therefore, additional radiation therapy and adjuvant chemotherapy were given. To the best of our knowledge, this is the first description of the simultaneous occurrence of chordoma and meningioma in the same anatomical location. In such a scenario, differential diagnosis of choroid meningioma and chordoma is required. The correct recognition of both components is important for treating this complex tumor, and its separate elements may require independent approaches.

Cerebral fat embolism in the absence of a long bone fracture: A rare case report

Background: The classic triad of fat embolism syndrome consists of pulmonary distress, mental status change, and petechial rash. Typically, symptoms manifest 24–48 hours after a long bone fracture, but case reports have demonstrated fat embolism syndrome without long bone fracture. These cases are initiated by a stress response, mobilizing free fatty acids into the circulation.Case Description: Herein, we present the case of a 70-year-old male who presented with the left-sided hemiparesis and was subsequently found to have tandem lesions of the right internal carotid artery (ICA) and right middle cerebral artery (MCA) warranting emergent mechanical thrombectomy (MT). The ensuing pathology report determined the source of ischemic stroke to be caused by fat embolism, a rare and intriguing case of cryptogenic large vessel occlusion (LVO) with unique features distinguishing it from other reports in the literature.Conclusion: According to the biochemical theory, a catecholamine surge can precipitate fat globules forming in the circulatory system, leading to tissue hypoxia, injury, and ischemia. While the majority of cerebral fat emboli cause reversible ischemia of small diameter vessels, our case presents with LVO and tandem lesions in both the ICA and MCA resulting in infarct and residual hemiparesis.

Ischemic stroke secondary to self-inflicted carotid sinus massage: a case report

BackgroundThe risk of stroke after carotid sinus massage is greater if there is preexisting carotid stenosis or carotid plaques. We present the case of a patient with underlying 40% carotid stenosis, who developed a watershed stroke after a self-neck massage in our stroke unit. We show a well-documented case with magnetic resonance images before and after the neck massage. We report a case of a watershed brain infarct after a self-massage of the carotid sinus, with preexisting carotid artery stenosis. Neck massage continues to be a significant cause of stroke and should therefore not be performed by patients. Clinicians must be aware of the implications of a carotid sinus massage in both the outpatient and inpatient settings.Case presentationWe admitted a 58-year-old white male patient, with no relevant medical history, to our department with a brain stem infarct. During his stay at our stroke unit, the patient performed a self-neck massage with consecutive bradycardia and asystole, resulting in left-side hemiparesis. The underlying cause of the hemodynamic stroke is believed to be secondary to this intensive neck massage performed by the patient. The patient also suffered from unknown right internal carotid artery stenosis. ConclusionClinicians and patients must be aware that neck massage can lead to ischemic stroke. We postulate that repetitive impaired cardiac output can lead to a hemodynamic (watershed-type) stroke.

Cryptic brain abscess ‐ do not forget hereditary hemorrhagic teleangiectasia!

Cryptic brain abscess ‐ do not forget hereditary hemorrhagic teleangiectasia!

Extensive hemicerebral damage after traumatic midterm amniocentesis

A 28-year-old right-handed man had suffered a traumatic amniocentesis at 17 weeks’ gestation, and subsequently was born with extensive right-sided cerebral, cerebellar and brainstem damage. The initial amniocentesis had been...

Multifocal glioblastoma multiform with \u201cencephalitis-like presentation\u201d : a case report

BackgroundGlioblastoma multiform is the most common and aggressive type of primary malignant tumor that affects the central nervous system in adults. It clinically presents with seizures, headache, and/or progressive focal neurological deficits. Radiologically, glioblastoma multiform appears as a single distinguishable, large heterogeneous lesion affecting the cerebrum with characteristic central necrosis, marginal enhancement, and surrounding vasogenic edema. This article describes a patient that exhibited an atypical clinical presentation of multifocal glioblastoma multiform with misleading early radiological features that simulated herpetic encephalitis.ResultsA 66-year-old female that presented with left-sided hemiparesis and left partial motor seizures underwent multi-slice computed tomography (MSCT) and magnetic resonance imaging (MRI) scans. A cerebrospinal fluid (CSF) polymerase chain reaction (PCR) test was also performed to screen for herpes simplex virus 1 (HSV-1).ConclusionsThe early stages of glioblastoma may manifest as symptoms typical to encephalitis, which can delay diagnosis and treatment. Therefore, early diagnosis and identification of atypical glioblastoma multiform presentations, as reported in this article, are essential.

A case of myocardial metastasis of bladder cancer

The case of metastatic heart damage manifesting by a clinical picture of acute myocardial infarction in a patient with urothelial carcinoma of the urinary bladder is described. A 69-year old patient was admitted with the symptoms of acute myocardial infarction from the neurological department, where he was hospitalized due to a space-occupying lesion of the right hemisphere of the brain, which manifested in a convulsive episode with the development of leftsided spastic hemiparesis. After coronary angiography, percutaneous coronary intervention was performed for the lesions of the anterior interventricular branch of the left coronary artery. Despite the complex of the therapeutic measures, the patient died. A pathological study revealed urothelial carcinoma of the bladder with distant metastases to the brain and myocardium. This clinical case demonstrates the situation of intravital diagnosis of metastatic myocardial lesions, which requires a determination of the treatment approach in the described category of patients.

Infantile hemiconvulsion-hemiplegia epilepsy syndrome associated with GRIN2A gene mutation

Introduction. Infantile hemiconvulsion?hemiplegia and epilepsy (IHHE) syndrome is defined as a specific syndrome in patients < 2 years of age, presenting as a new onset refractory status epilepticus with unilateral motor seizures and acute imaging abnormalities, fever, hemiparesis > 24 hours, and excluding infectious encephalitis. Case outline. We present the results of a follow-up in a 11-year-old girl with IHHE, associated with GRIN2A mutation. The girl had normal development until the first febrile hemiconvulsive status epilepticus at the age of seven months. Neuroimaging initially showed right hemisphere edema, followed by progressive right side hemiatrophy. The patient has resistant epilepsy, left side hemiparesis, and good language and cognitive development. Conclusion. Despite IHHE described many years ago, some syndrome?s features, including etiology, have remained unexplained. The association between IHHE and GRIN2A mutation stated in the current manuscript is described in scientific literature for the first time.

A Rare Complication of Burr Hole Drainage of Chronic Subdural Hematoma

Chronic subdural hematoma is a common neurosurgical problem, especially in the elderly, which is frequently treated by burr hole drainage. Recurrence is the most frequent complication of chronic subdural hematoma surgery reported in literature. However, cerebrospinal fluid leak resulting subgaleal pseudomeningooele has been reported. We report a 67-year-old man who had burr hole drainage of chronic subdural hematoma and subsequently developed cerebrospinal fluid fistula which was drained by subdural drain inserted intraoperatively. A 67-year-old right-handed man who presented with nine days' history of progressive pan-cranial persistent headache following a fall from the bathroom associated with irrational behavior and weakness of the left side of the body. His Glasgow Coma Score (GCS) was 12/15, with generalized hypertonia, left-sided hemiparesis, and left-sided grade + 3 deep tendon reflexes. Brain computed tomography scan [Figure 1] showed right-sided fronto-temporoparietal chronic subdural hematoma with midline shift and effacement of the ipsilateral lateral ventricle. He had right frontal and right parietal burr holes, such as subdural hematoma and insertion of nonnegative subdural drain through the parietal burr hole. He developed cerebrospinal fluid leak, which drained into the drainage bag and subsequently managed conservatively. Cerebrospinal fluid leaks can occur following burr hole drainage of chronic subdural hematoma. Subdural drain inserted intraoperatively is helpful in preventing the sequelae of cerebrospinal fluid accumulation in the subdural and subgaleal spaces.

Fatal cerebral haemorrhage after COVID-19 vaccine.

New vaccines against COVID-19 are being rolled out globally. AstraZeneca's vaccine ChAdOx1 nCoV-19 was not known to cause vaccine-induced immune thrombotic thrombocytopenia (VITT) at the time of this case. The patient was a previously healthy woman in her thirties with headaches that developed one week after vaccination with ChAdOx1 nCoV-19. Three days later, her condition deteriorated rapidly, and she presented to the emergency department with slurred speech, uncoordinated movements and reduced consciousness. Symptoms progressed to left-sided hemiparesis and her level of consciousness deteriorated. Computed tomography (CT) of the head showed a large right-sided haemorrhage and incipient herniation. She was found to have severe thrombocytopenia 37x109/l, (ref 145-390x109/l). In spite of efforts to reduce intracranial pressure, the patient died the following day. Post mortem examination revealed antibodies to PF4, and fresh small thrombi were found in the transverse sinus, frontal lobe and pulmonary artery. Severe thrombocytopenia and antibodies to PF4make a diagnosis of vaccine-induced immune thrombotic thrombocytopenia (VITT) likely.

Recombinant tissue plasminogen activator (rTPA) in young adult patient with acute ischemic stroke: a case report

Background: Stroke is one of the highest causes of morbidity and mortality in the world. The incidence rate of ischemic stroke is about 80% of all stroke incidents. The use of recombinant tissue plasminogen activator (rtPA) is recommended under 4.5 hours of stroke onset. Stroke in young adults are reported as being uncommon, compromising 10% -15% of all stroke patients. Many studies were reported the most common risk factor in young adults were obesity and dyslipidemia. This case report will discuss a 33-year-old men with ischemic stroke with obesity and dyslipidemia treated at dr. Kariadi Hospital Semarang.Case presentation: A 33-year old obese man with left-sided hemiparesis and central facial nerve palsy with an onset of 1 hour. On laboratory examination, it was obtained total cholesterol 179mg/dL, LDL level 123mg/dL, and HDL level 39mg/dL. The protocol code stroke was performed in emergency room with alteplase (r-TPA) 0.6 mg/kgBW, after his head MSCT shows there was no sign of blood in the brain parenchym.Conclusion: The increased risk of ischemic stroke in young patients is due to dyslipidemia, hypertension, obesity, physical inactivity, and smoking. Treatment of the hyperacute phase of ischemic stroke with thrombolysis can reduce the outcome of stroke due to the disability.

Management of Tumor- and Nontumor-related Aorto-esophageal and Aorto-bronchial Fistulas

This study aims to review and compare the clinical presentation, management, and outcome in patients with tumor-related (TR) and nontumor-related (NTR) aorto-esophageal fistula (AEF) and aorto-bronchial fistula (ABF) with particular focus on the thoracic endovascular aortic repair. We retrospectively reviewed a series of 16 consecutive patients with TR (n=8) and NTR (n=8), ABF (n=6), and AEF (n=10) admitted to our hospital from 2011 to2019. The median age was 62years (range 46-81), with 11 men. The most common predisposing factor was esophageal or gastric cardia cancer (n=6), followed by open repair of the thoracic aorta (n=5). Endoluminal vacuum therapy (Endo-SPONGE®) accounted for 3 cases of AEFs. Thoracic endovascular aortic repair (TEVAR) was applied in 13 patients (4 with ABFs and 9 with AEFs). The primary technical success of the TEVARs was 100%. One patient (8%) was complicated with postoperative middle cerebral artery syndrome and left-sided hemiparesis. The respective in-hospital, 6-month, and 1-year mortality rates were 0% (n=0), 25% (n=2), and 25% (n=2) for the NTR group and 63% (n=5), 88% (n=7), and 100% (n=8) for the TR group. After a mean period of 13months, 5 (31%) patients were still alive, and one patient lost to follow-up after 11months. The survivors (n=5) had all nontumor-related ABF. Progression of underlying cancer and hemodynamic shock were the most common causes of death. TEVAR represents a reliable option in the treatment of NTR ABFs. In the cases of TR fistulas and NTR AEFs, TEVAR should be applied more selectively. The associated mortality remains very high.

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 (< 2/1), elevated lactate/fat peak suggestive of inflammatory versus infectious process. She had D&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.

Acute necrotizing encephalopathy of childhood. Diagnostic and treatment challenges in COVID-19 pandemic

Acute necrotizing encephalopathy of childhood (ANEC) can occur in previously healthy children during a respiratory infection with fever and can manifest by epileptic seizures. Magnetic resonance imaging (MRI) typically shows bilateral lesions of the brainstem, cerebellum, thalamuses, basal neclei, and hemispheral white matter. We describe three clinical cases with an initial diagnosis of ANEC. In the first case, a 12-year old patient developed headache, leg weakness and high blood pressure during treatment of hepatitis C virus infection with PEG-interferon alfa2b. Later on she had myoclonic seizures with subsequent epileptic status, tetraparesis, confusion, and hyperthermia. Her clinical chemistry parameters showed a non-significant increase in liver enzymes levels. Cerebrospinal fluid was remarkable for increased protein level. The patient's brain MRI showed typical for ANEC bilateral thalamic lesions. The second case manifested with myoclonic seizures and subsequent epileptic status in a 17-months' old patient with a respiratory infection (vomiting, rhinitis, fever, and hyperthermia). His brain MRI showed bilateral lesions in the brainstem (dorsal part of the pons), thalamus, subcortical nuclei, white matter of the cerebral hemispheres, as well as lesions in the left hippocampus. The patient had increased urine levels of malic, 2-hydroxyisovalerianic, 3-hydroxy-isovalerianic, N-acetylaspartic, 3-hydroxybutyric, and lactic acids and increased blood levels of alanine, glutamic acid, glycine, and ornithine. By the time of the study, no hereditary metabolic disease was identified. In the third case, a 3-year old patient with a respiratory infection with vomiting and fever developed left-sided hemiparesis after she had fallen out of bed. The brain MRI revealed acute ischemic damage. Her cerebrospinal fluid was remarkable for a decreased protein level. Currently, ANEC is a diagnosis of exclusion. In the third patient, ANEC was obviously misdiagnosed. It is necessary to clarify the diagnostic criteria for the syndrome and to develop a management protocol for patients with ANEC.

Mystery Case: Clinical Reasoning

A 29-year-old G6P3023, left-handed woman presented with acute onset left-sided weakness and expressive aphasia. She was in her normal state of health while driving home from work when her mother noted symptom onset. She was taken immediately to the emergency department for further evaluation. On presentation, she was afebrile with blood pressure 136/99 mm Hg, regular heart and respiratory rates, and oxygen saturation 88% on room air. Neurologic examination was notable for left-sided hemiparesis and sensory disturbance. The aphasia had resolved. Emergent head CT did not demonstrate any abnormalities.

Cerebral Aspergilloma in Patient with Diabetes – A Case Report with Short Literature Review

BACKGROUND: In the recent years, the incidence of fungal brain abscess has been rising as a result of the increased use of corticosteroid therapy, broad-spectrum antimicrobial therapy, and immunosuppressive agents. Aspergillosis of the central nervous system (CNS) is reported in 10%–20% of the patients having invasive fungal disease. Commonly, the disease is observed in immunocompromised or immunosuppressed patients; also, patients who suffered traumatic head injury are reported as well to develop the infection due to due cranial defect accompanied by dural tearing. Symptoms are non-specific neurologic manifestations.
 CASE PRESENTATION: We presented a case of a 68-year-old man who had diabetes mellitus type II. He was admitted to in neurosurgery clinic due reported head trauma. Initially, he complained of a headache, dizziness, slurred speech, nausea, and pain in the right ear with tinnitus and pain in his right upper teeth – continuous for a month. The patient was conscious, adequate, Glasgow Coma Scale – 15 points, with left-sided hemiparesis, general symptomatic syndrome. An emergent computed tomography scan was performed, which showed tumorous formation in patient’s right temporal lobe that had mass effect and compression of the right lateral ventricle. The patient was discussed on a emergent clinical counsel and it was decided that he was shown for surgical treatment. An informed consent was signed by the patient and his relatives. After the surgery intervention – the histological result of the biopsy was aspergilloma of the brain and the microbiological result was Aspergillus fumigatus.
 CONCLUSION: The prognosis for CNS aspergillosis is poor, but the early diagnosis and effective medical and surgical treatments may reduce morbidity and mortality.

Spontaneous intracranial hypotension associated with cerebral venous thrombosis detected by a sudden seizure: a case report

BackgroundSpontaneous intracranial hypotension (SIH) is rare but can lead to life-threatening complications including cerebral venous thrombosis (CVT). The concurrence of CVT and SIH raises questions regarding priority.Case presentationWe present the case of a 52-year-old woman who developed sudden left-sided hemiparesis and generalized tonic-clonic seizures. She experienced progressive orthostatic headaches over the prior 2 weeks. Imaging showed thrombosis in the left transverse and sigmoid sinuses, bilateral subdural hematomas, and a cervicothoracic cerebrospinal fluid leak. Low molecular weight heparin was administered, but it was discontinued 2 days later due to subarachnoid hemorrhage. She was transferred to our hospital where an epidural blood patch was applied immediately, which resulted in complete symptom relief.ConclusionCVT is a rare complication of SIH that may result in devastating consequences. Treatment of SIH should be the primary focus. Prompt diagnosis and EBP application can result in a good outcome.

Treatment of cerebral vasospasm secondary to subarachnoid hemorrhage utilizing the Comaneci device

Delayed cerebral ischemia due to vasospasm following subarachnoid hemorrhage continues to have high morbidity and mortality despite current treatments. This report highlights the use of the Comaneci (Rapid Medical, Yokneam, Israel), a device FDA approved for temporary coil embolization assistance, for the treatment of symptomatic vasospasm. Ten days post subarachnoid hemorrhage, a patient developed acute left-sided hemiparesis with angiographic vasospasm. Through a Headway 17 microcatheter, a Comaneci 17 was deployed in the right ICA terminus, M1, M2, A1, and, A2 segments resulting in improvement of angiographic vasospasm and the patient's left-sided hemiparesis. On the following day, a repeat angiogram demonstrated no recurrence of vasospasm. The patient had complete return on neurologic function by post bleed day 18 continuing to her four-week follow-up appointment. This case demonstrates the feasibility of the Comaneci device as an effective tool in the treatment of vasospasm following subarachnoid hemorrhage.