Left V1 Research Articles

Anterior bilateral optic neuritis as a complication of Varicella‐Zoster virus (VZV)

Aims/Purpose: To shed light on optic neuritis as a potential ocular complication of Varicella‐Zoster virus (VZV) infection.Methods: Presentation of a clinical case.Results: We present the case of a 70‐year‐old woman, who arrived at the Emergency Room complaining of a bilateral acute loss of visual acuity. She had received treatment on several occasions for a recurring zoster involving the left V2 territory, the last episode being one month before her visit. She had a visual acuity of 0.3 on her right eye, and 0.6 on her left eye. Pupil examination evidenced a relative afferent pupillary defect (RAPD) on her right eye. Dyschromatopsia was documented by red desaturation and Ishihara tests. Fundus examination displayed an asymmetrical bilateral papillitis, predominant in her right eye. This finding was confirmed by an Optic Coherence Tomography (OCT). A cranial CT scan and a general blood analysis were performed, and both returned normal results. The patient was admitted to the Hospital to start treatment with intravenous steroids. Additional tests were performed, including blood serological tests, a temporal artery Doppler ultrasound, a cranial MRI, and a lumbar puncture. Blood serological tests showed positive high titles of IgG VZV, and came back negative for IgM VZV. Lastly, the polymerase chain reaction (PCR) test on the CSF sample turned out positive for VZV, shedding light on the diagnosis. Steroids were suspended and the patient was started on intravenous Acyclovir. Clinical evolution was favorable, and her visual acuity on the 2‐month follow‐up visit had climbed up to 0.6 on her right eye and 0.7 on her left eye.Conclusions: This case illustrates the relevance of ruling out infectious causes of optic neuritis, specifically VZV, in patients in which other causes are less likely, those who present a bad evolution on inflammatory treatment, or who have a recent episode of VZV infection. MRI demyelination is a frequent finding in both demyelinating and infectious diseases, therefore not ruling out the latter. Positive blood serology indicates previous contact with VZV, but has little sensibility for detecting an active infection. All these reasons justify the need to select patient who may benefit of a lumbar puncture, as an early diagnosis radically changes the therapeutical approach.

Inter- and Intrahemispheric Sources of Vestibular Signals to V1.

Head movements are sensed by the vestibular organs. Unlike classical senses, signals from vestibular organs are not conveyed to a dedicated cortical area but are broadcast throughout the cortex. Surprisingly, the routes taken by vestibular signals to reach the cortex are still largely uncharted. Here we show that the primary visual cortex (V1) receives real-time head movement signals - direction, velocity, and acceleration - from the ipsilateral pulvinar and contralateral visual cortex. The ipsilateral pulvinar provides the main head movement signal, with a bias toward contraversive movements (e.g. clockwise movements in left V1). Conversely, the contralateral visual cortex provides head movement signals during ipsiversive movements. Crucially, head movement variables encoded in V1 are already encoded in the pulvinar, suggesting that those variables are computed subcortically. Thus, the convergence of inter- and intrahemispheric signals endows V1 with a rich representation of the animal's head movements.

Abstract 315: Intraventricular hemorrhage due to bilateral vertebral artery dissection during treatment in drug intoxication patient: a case report

Introduction A vertebral artery dissection is a possible cause of stroke in young and middle‐aged adults without risk factors for cerebrovascular disease. It often occurs spontaneously for no particular reason, but it can also occur due to trauma or other causes. This study aims to report the treatment experience of bilateral vertebral artery dissection and intraventricular hemorrhage in a patient hospitalized for drug intoxication in our hospital. Methods A fifty‐six‐year‐old woman was found collapsed on the street and visited the emergency department of our hospital, complaining of comatose mentality and hypothermia. The Glasgow Coma Scale score measured at the visit was 3 points, and bradycardia and hypotension were present. A bag of medications prescribed by a psychiatrist was found in the patient's bag, and a drug screen test performed showed benzodiazepines positive. Brain CT performed in the emergency room did not reveal an acute lesion, so the patient was admitted to the intensive care unit at the department of emergency medicine under a drug intoxication impression. After four days of hospitalization, the patient's response started to improve, and on the 7th day, she showed a drowsy mentality. IVH was found in the bilateral lateral ventricles on diffusion MR performed on day 7, and dissection was confirmed in the bilateral distal V4 segment on additional CT angiography. Results Conservative treatment was performed in the intensive care unit, and a follow‐up CT showed that the hemorrhage was resolved. Still, dissecting aneurysms with an increased size was confirmed in both V4 segments. Emergency stent‐assisted coil embolization was performed for left V4 dissecting aneurysm with bleb. There were no complications during the procedure, and the right V4 dissecting aneurysm was decided to do embolization after a follow‐up examination. After the procedure, the patient showed an alert mentality, and there were no acute abnormal findings in the follow‐up examination. In the MRA performed one year after the procedure, the treated area on the left V4 dissecting aneurysm was well maintained. The right V4 dissecting aneurysm showed normal findings due to spontaneous healing. Conclusion In the case of vertebral artery dissection, which rapidly changes shape, careful observation is required, and appropriate treatment is required before new neurological symptoms develop. For treatment, stent‐assisted coil embolization can be a good option, and since spontaneous healing can occur in some cases, it is essential to determine an appropriate treatment method. In addition, appropriate follow‐up tests and identification of the cause are necessary for patients with decreased consciousness for which the cause is unclear.

Aberrant dynamic functional and effective connectivity changes of the primary visual cortex in patients with retinal detachment via machine learning.

Previous neuroimaging studies have identified significant alterations in brain functional activity in retinal detachment (RD) patients, these investigations predominantly concentrated on local functional activity changes. The potential directional alterations in functional connectivity within the primary visual cortex (V1) in RD patients remain to be elucidated. In this study, we employed seed-based functional connectivity analysis along with Granger causality analysis to examine the directional alterations in dynamic functional connectivity (dFC) within the V1 region of patients diagnosed with RD. Finally, a support vector machine algorithm was utilized to classify patients with RD and healthy controls (HCs). RD patients exhibited heightened dynamic functional connectivity (dFC) and dynamic effective connectivity (dEC) between the Visual Network (VN) and default mode network (DMN), as well as within the VN, compared to HCs. Conversely, dFC between VN and auditory network (AN) decreased, and dEC between VN and sensorimotor network (SMN) significantly reduced. In state 4, RD patients had higher frequency. Notably, variations in dFC originating from the left V1 region proved diagnostically effective, achieving an AUC of 0.786. This study reveals significant alterations in the connectivity between the VN and the default mode network in patients with RD. These changes may disrupt visual information processing and higher cognitive integration in RD patients. Additionally, alterations in the left V1 region and whole-brain dFC show promising potential in aiding the diagnosis of RD. These findings offer valuable insights into the neural mechanisms underlying visual and cognitive impairments associated with RD.

Brain Activation and Aberrant Effective Connectivity in the Mentalizing Network of Preadolescent Children at Familial High Risk of Schizophrenia or Bipolar Disorder

BackgroundSchizophrenia and bipolar disorder are characterized by social cognitive impairments, and recent research has identified alterations of the social brain. However, it is unknown whether familial high risk (FHR) of these disorders is associated with neurobiological alterations already present in childhood. MethodsAs part of the Danish High Risk and Resilience Study–VIA 11, we examined children at FHR of schizophrenia (n = 121, 50% female) or bipolar disorder (n = 75, 47% female) and population-based control children (PBCs) (n = 128, 48% female). Using functional magnetic resonance imaging and dynamic causal modeling, we investigated brain activation and effective connectivity during the social cognition paradigm from the Human Connectome Project. ResultsWe found similar activation of the mentalizing network across groups, including visual area V5, the dorsomedial prefrontal cortex, and the posterior superior temporal sulcus (pSTS). Nonetheless, both FHR groups showed aberrant brain connectivity in the form of increased feedforward connectivity from left V5 to pSTS compared with PBCs. Children at FHR of schizophrenia had reduced intrinsic connectivity in bilateral V5 compared with PBCs, whereas children at FHR of bipolar disorder showed increased reciprocal connectivity between the left dorsomedial prefrontal cortex and the pSTS, increased intrinsic connectivity in the right pSTS, and reduced feedforward connectivity from the right pSTS to the dorsomedial prefrontal cortex compared with PBCs. ConclusionsOur results provide first-time evidence of aberrant brain connectivity in the mentalizing network of children at FHR of schizophrenia or FHR of bipolar disorder. Longitudinal research is warranted to clarify whether aberrant brain connectivity during mentalizing constitutes an endophenotype associated with the development of a mental disorder later in life.

The impact of an anomalous third segment of the vertebral artery on bypass surgery: a case report and literature review.

The horizontal part of the third segment (V3) of the vertebral artery (VA) is a critical anastomotic site for bypass procedures involving either donor or recipient vessels. It is rare for the V3 segment to deviate from its typical course of passing through the atlanto-transverse foramen. V3 anomaly encountered in occipital artery (OA)-V3 bypass surgery has not been previously reported. Here, we present a case involving a patient undergoing bypass surgery due to recurrent post-stent occlusion at the first segment (V1) of the left VA. During the operation, it was noted that the V3 horizontal segment could not be identified within the left VA groove, leading to initial suspicion of left V3 disuse atrophy attributed to prolonged chronic ischaemia. Consequently, there was a need to modify the operative method and to transition from an OA-V3 bypass to an OA-posterior inferior cerebellar artery bypass. Post-operative computed tomography angiography confirmed that indeed, the left V3 did not traverse through the transverse foramen of the atlas and instead entered the dural membrane between the first cervical vertebra (C1) and the second cervical vertebra (C2).

Changes in primary visual and auditory cortex of blind and sighted adults following 10weeks of click-based echolocation training.

Recent work suggests that the adult human brain is very adaptable when it comes to sensory processing. In this context, it has also been suggested that structural "blueprints" may fundamentally constrain neuroplastic change, e.g. in response to sensory deprivation. Here, we trained 12 blind participants and 14 sighted participants in echolocation over a 10-week period, and used MRI in a pre-post design to measure functional and structural brain changes. We found that blind participants and sighted participants together showed a training-induced increase in activation in left and right V1 in response to echoes, a finding difficult to reconcile with the view that sensory cortex is strictly organized by modality. Further, blind participants and sighted participants showed a training induced increase in activation in right A1 in response to sounds per se (i.e. not echo-specific), and this was accompanied by an increase in gray matter density in right A1 in blind participants and in adjacent acoustic areas in sighted participants. The similarity in functional results between sighted participants and blind participants is consistent with the idea that reorganization may be governed by similar principles in the two groups, yet our structural analyses also showed differences between the groups suggesting that a more nuanced view may be required.

Altered functional connectivity strength of primary visual cortex in subjects with thyroid-associated ophthalmopathy.

Our objective was to explore the disparities in the intrinsic functional connectivity (FC) patterns of primary visual cortex (V1) between patients with thyroid-associated ophthalmopathy (TAO) and healthy controls (HCs) utilizing resting-state functional MRI. Twenty-one patients with TAO (14 males and 7 females; mean age: 54.17 ± 4.83 years) and 21 well-matched HCs (14 males and 7 females; mean age: 55.17 ± 5.37 years) underwent functional MRI scans in the resting-state. We assessed modifications in the intrinsic FC patterns of the V1 in TAO patients using the FC method. Subsequently, the identified alterations in FC regions in the analysis were selected as classification features to distinguish TAO patients from HCs through the support vector machine (SVM) method. The results indicated that, in comparison to HCs, patients with TAO exhibited notably reduced FC values between the left V1 and the bilateral calcarine (CAL), lingual gyrus (LING) and superior occipital gyrus, as well as between the right V1 and the bilateral CAL/LING and the right cerebellum. Furthermore, the SVM classification model based on FC maps demonstrated effective performance in distinguishing TAO patients from HCs, achieving an accuracy of 61.9% using the FC of the left V1 and 64.29% using the FC of the right V1. Our study revealed that patients with TAO manifested disruptions in FC between the V1 and higher visual regions during rest. This might indicate that TAO patients could present with impaired top-down modulations, visual imagery and vision-motor function. These insights could be valuable in understanding the underlying neurobiological mechanisms of vision impairment in individuals with TAO.

Abstract 089: A Case of Complicated Dissection: Vertebral Artery Sacrifice for Recurrent Stroke Prevention

Introduction Posterior circulation strokes account for 20% of ischemic strokes (1). Optimal management for posterior circulation strokes has been studied less than for anterior circulation strokes (2). Endovascular parent vessel sacrifice is an established technique used to treat vascular pathologies. There is limited evidence for parent artery sacrifice for recurrent strokes and there is no current guideline for standard of care. Methods '‐ Results 51‐year‐old gentleman with history of tobacco use presented with left homonymous hemianopsia, onset 1.5 hours prior to arrival. CT brain showed no bleed and patient received IV tissue‐plasminogen activator (tPA). CT angiography (CTA) demonstrated occlusion of the right posterior cerebral artery (PCA) and dissection of the left vertebral artery (V2 segment) with distal reconstitution. He underwent emergent thrombectomy for right P2 thrombus with complete reperfusion TICI 3 (Thrombolysis in Cerebral Infarction Score). Less than 24 hours later, he developed a right homonymous hemianopsia, and was found to have a new occlusion of the left P1 segment of the left PCA. Emergent thrombectomy was performed with complete reperfusion (TICI3). MRI brain demonstrated bilateral PCA territory infarcts. Within 12 hours of the second thrombectomy, his neurological exam deteriorated, and interval imaging revealed a basilar trunk thrombus, for which he underwent a successful endovascular thrombectomy complete reperfusion (TICI3). His antiplatelet regimen was optimized with Aspirin. Heparin was considered as treatment but was not provided because of the hemorrhagic conversion of his ischemic strokes. Given the persistent recurrence of thromboemboli in the posterior circulation despite being on optimal medical management, and evidence of hemorrhagic conversion, a decision was made to perform endovascular coil embolization of the left vertebral artery V2 segment at the site of dissection. Angiographic imaging demonstrated antegrade blood flow through the dissection as the source of recurrent embolic strokes. Six Stryker Target coils were deployed spanning the region of dissection within the left V2 segment via a right radial access with the guide catheter in the right vertebral artery. Post coil embolization angiographic runs demonstrated complete occlusion of the left vertebral V2 segment at the region of dissection which was confirmed via a left vertebral injection from a left femoral arterial access. There was preservation of ascending cervical collaterals beyond the dissection with patency of the contralateral vertebral artery supplying the intracranial circulation. Following embolization, repeat imaging showed no new infarcts and no new or worsening hemorrhage. He was continued on Aspirin monotherapy. It is notable that though his neurological exam deteriorated during each recurrent thromboembolic event, his neurologic exam at the time of discharge significantly improved with NIHSS of 3. He is currently being followed at our neuroscience institute. Conclusion Cervical arterial dissections pose increased risk for ischemic strokes (3). Vertebral artery dissection accounts for approximately 2%, of which, 10‐25% occur in middle‐aged and younger patients (4). This is a case of a young patient that exemplifies a successful role for vertebral artery sacrifice with coil embolization to prevent recurrent thromboembolic posterior circulation strokes. However controlled studies are needed for safety and efficacy of these interventions.

Abstract 286: Endovascular Management of Pediatric Vertebro‐Vertebral Arterio‐Venous Fistula: Case report

Introduction Vertebro‐vertebral arteriovenous fistula (VV‐AVF) is a rare vascular malformation with abnormal high flow shunt between extracranial vertebral artery and an adjacent vertebral vein plexus without intervening capillaries.1 While seen in both adult and pediatric populations, the majority of the VV‐AVFs seen in childhood are largely congenital, seen in the setting of connective tissue diseases such as Ehler‐Danlos Syndrome, Neurofibromatosis type 1, and Marfan’s syndrome, with abnormal involution of the proatlantal system also thought to be implicated.2,3,4 Approximately 70% of the presenting population are symptomatic at presentation, with a pulsatile mass over the side of the neck or pulsatile tinnitus. Additionally, symptoms of vertebrobasilar insufficiency including gait abnormalities, limb weakness, vertigo, recurrent vomiting, diplopia, and in severe cases, cardiac decompensation can also be seen.5 Methods This is a case report of a 2‐year‐old boy presented to our pediatric neurovascular center of excellence with a progressively enlarging pulsatile left neck mass appreciated a year ago. Further evaluation with neck MRA followed by catheter cerebral angiogram revealed an upper cervical AVF with primary arterial feeders from V3 segment of the left vertebral artery, enlarged left occipital artery, and retrograde filling via the right vertebral artery into the left V4 with a direct shunt into a large venous pouch which drained into the vertebral venous plexus. Results Given the progressive enlargement of the mass, location of AVF, and concern for detrimental subsequent venous congestion, decision was made to pursue elective endovascular embolization of the VV‐AVF. The goal was set to obtain complete occlusion of the venous pouch to obliterate all arterial inflow contribution and prevent further recruitment. Occipital artery catheterization was attempted however given the redundant anatomical loops; optimum microcatheter navigation was not feasible. Given the non‐dominant configuration of the left VA, along with the presence of left AICA‐PICA system off the basilar trunk, coil embolization of the venous pouch followed by sacrifice of the V3 segment left VA was achieved satisfactorily leading to obliteration of the AVF along with all the arterial contributions from bilateral vertebral arteries and left occipital artery (Figure‐1). Given the potential vertebrobasilar inadvertent embolization, the procedure was performed under continuous neurophysiological monitoring and post‐periprocedural therapeutic anticoagulation. The patient tolerated the procedure well without any intraoperative issues. He was monitored in the pediatric ICU for 24 hours after the procedure, and subsequently discharged home. Conclusion We report a successful endovascular coil embolization of a VV‐AVF. To our knowledge, this is the youngest reported case where endovascular technique was successfully utilized to achieve cure of such high flow VV‐AVF in this 2‐year‐old patient. Systematic and methodical angiographic analyses with close post‐procedural monitoring are pivotal in ensuring successful outcomes.

Abstract 159: Computed Tomography Angiography Negative Spinal Artery Dissection

Introduction Vertebral artery dissection (VAD) is a relatively common cause of ischemic stroke, especially after chiropractic neck manipulation. VAD usually can be diagnosed by noninvasive imaging studies such as CT angiography (CTA) of the head and neck with suggestive findings of an arterial string sign, arterial stenosis, a double lumen sign, a pseudoaneurysm, or an occlusion. However, in rare situations, CTA may display normal arterial caliber except for very subtle signs such as abnormal dorsal thickening of the arterial wall against adjacent fat at the V3 segment of the vertebral artery. This is referred to as the "suboccipital rind sign." Here we wish to report such a case as identified at our institution. Methods Electronic charts of a patient with acute spinal shock and strokes were reviewed. Results The patient is a 36‐year‐old female with chronic neck pain, status‐post C5‐T1 spinal fusion who presented emergently with quadriparesis that following chiropractic neck manipulation. She felt a “pop” at the neck during the neck manipulation. She shortly thereafter began experiencing persistent neck pain associated with tingling sensations of both upper extremities on her drive home. She then noted transient right‐hand weakness as she was attempting to open a package. Her symptoms then temporarily resolved with rest, but after some time the paresthesia and neck pain reoccurred, worsened, and quickly progressed to quadriplegia. Brain MRI was negative for acute stroke. However, MRI of the cervical spine demonstrated acute cervical spinal cord ischemia in addition to post‐surgical changes. CTA head and neck reported normal arterial caliber. A diagnostic angiogram was performed that showed no evidence of arterial dissection but did demonstrate absence of the anterior spinal artery. Subsequently, CTA was further reviewed on thin slice revealing a “suboccipital rind sign" of the left V3 segment, suggesting left vertebral artery V3 segment dissection. Hypercoagulable workup was negative, and the patient was treated with anticoagulation. Conclusion Arterial dissection is usually readily diagnosable by CTA with high sensitivity. However, a study with normal caliber vessels in the reconstituted images does not always exclude an arterial dissection. To our knowledge there have been six reported vertebral dissection cases with a normal appearing lumen on CTA or conventional angiography. However, similar to our case, they displayed “suboccipital rind” signs on CTA thin cross‐section due to the thickening of the dissected artery on the V3 segment. The V3 segment has a horizontal course which runs parallel to the axially acquired imaging plane, which makes it difficult to appreciate the classic crescentic wall hematoma associated with arterial dissection. We hope that increased awareness of the typical location and appearance of the “suboccipital rind” sign on CTA may increase the detection rates of subtle arterial dissections in the setting normal‐appearing arterial lumens.

Abstract 114: “Failing” DAPT? Think Again

Introduction Bow Hunter’s Syndrome (BHS) is a rare etiology of vertebrobasilar insufficiency that usually occurs with head turn, which causes compression of the vertebral artery by an osteophyte. There is subsequent hypoperfusion of brain tissue, but thromboembolism and ischemic stroke is rare. Timely diagnosis is imperative, as decompressive surgery can be curative. This unique case highlights the diagnostic and therapeutic challenges of a patient with multiple vascular risk factors who suffered from strokes secondary to BHS. Methods A 79‐year‐old man with a past medical history of peripheral artery disease, abdominal aortic aneurysm, myocardial infarction with drug eluding stents (on dual antiplatelet therapy (DAPT)), complete heart block with pacemaker, heart failure with reduced ejection fraction, hypertension, hyperlipidemia, and diabetes mellitus presented to an outside hospital with recurrent episodes of right‐sided weakness every 1‐2 days over the previous 3 weeks. Episodes always occurred after activity and only upon sitting. He had previously undergone non‐contrasted head computed tomography (NCHCT) (magnetic resonance imaging (MRI) was unable to be performed secondary to pacemaker), which did not reveal strokes. His initial computed tomography angiogram (CTA) of the head and neck was unremarkable. However, CTA head and neck 4 days later demonstrated 90 percent stenosis of the mid left V2 at the C3‐4 level and a 75‐90 percent stenosis of the left mid V2 segment at the C5‐6 level (hard and soft plaque in these areas). He was switched from DAPT to aspirin and warfarin because he was considered a “DAPT failure.” He continued to have episodes, so he was transferred to our institution for a second opinion. Results On arrival, the exam was notable for right‐sided hemiparesis and dysmetria. Repeat CTA head and neck demonstrated multifocal intracranial atherosclerosis with marked stenosis of the left V4 segment. However, marked stenosis at V2 appeared to be owed to external compression from facet arthrosis rather than atherosclerosis. He also had moderate stenosis of the right V4 segment. Eventually, he underwent an MRI brain, which demonstrated acute to subacute infarcts in the left pons. He was taken for a cerebral angiogram on the same day, which demonstrated stenosis of the distal V2 segment of the left vertebral artery (at the level of C3‐C4) with interval development of marked stenosis following neck flexion and occlusion of the left vertebral artery following leftward head rotation. Findings were most consistent with rotational occlusion of the left vertebral artery, which is also known as BHS. The patient underwent surgery, but suffered from a gastrointestinal bleed and developed post‐operative atrial fibrillation; after a risks/benefits discussion, he was discharged on anticoagulation only. He had no further strokes. Conclusion This patient suffered from ischemic strokes, which occur in less than 10% of BHS cases. Contralateral vertebral artery stenosis, which is unable to supply retrograde flow during compression, is the likely etiology of this patient's strokes. Recurrent posterior circulation strokes in the setting of optimal medical management should clue clinicians to consider other etiologies of stroke. Dynamic angiography is the gold standard for BHS and decompressive surgery is often curative.

Abstract 094: Sudden Onset Dysphagia: A Symptom To Be Aware of During Code Strokes

Introduction Lateral medullary infarction (LMI) can present with dysphagia, dysphonia, dysarthria, vertigo, nausea, skew deviation, and ipsipulsion. Patients may also exhibit sensory loss and ipsilateral Horner’s syndrome. LMS often develops because of an acute infarct from the vertebral arteries or posterior inferior cerebellar arteries (PICA). The most common mechanism of stroke usually is atherothrombosis, followed by cardioembolic, dissection and embolic source of undetermined source (ESUS). While dysphagia often accompanies the constellation of LMS symptoms, it is rarely the first symptom and has only been reported in a few cases in the literature. In this report we describe the case of a man in his 40s with acute onset dysphagia as the presenting finding ahead of an LMS diagnosis. Methods The patient was identified in routine clinical practice. Results A man in his 40s with medical history of HTN, type 2 DM and polycystic kidney disease, presented with sudden‐onset dysphagia which started while he was drinking alcohol. Later he noticed that he was unable to keep his balance. His National Health Institute Stroke Scale was 4. Neurologic exam was pertinent for left‐sided miosis, ptosis, and dysmetria. Pinprick and temperature sensation were decreased on the right arm and leg. Facial sensation to light touch was diminished on the left. Brain MRI showed an acute infarct in the left lateral medulla (Figure A). CTA showed calcified atherosclerosis of the V4 segment of left vertebral artery (Figure B). Mechanism of ischemic stroke was artery to artery thromboembolism from the left V4 segment of vertebral artery. For secondary prevention, dual antiplatelet therapy, high intensity statin, and optimization of his risk factors were initiated. Conclusion This case report demonstrates that dysphagia can be the initial symptom of an acute ischemic stroke. Diagnosis and recognition of an atypical presentation of lateral medullary syndrome can pose a particular challenge especially in this era of “time is brain” but is of the utmost importance to facilitate good outcomes. Patients presenting with dysphagia who have risk factors for stroke and no other obvious etiology for their symptoms should be worked up for possible cerebrovascular etiology.

Non-inferiority of intermittent theta burst stimulation over the left V1 vs. classical target for depression: A randomized, double-blind trial

BackgroundRepetitive transcranial magnetic stimulation (rTMS) targeting the visual cortex (VC) has shown antidepressant effects for major depressive disorder (MDD) in sham-controlled trials, but comparisons with rTMS targeting the left dorsolateral prefrontal cortex (DLPFC) are lacking. We aimed to determine the non-inferiority of intermittent theta-burst stimulation (iTBS) over VC vs DLPFC for MDD. MethodsParticipants randomly received navigated iTBS over the left V1 or the left DLPFC twice daily for 14 days with a 3-month follow-up. The primary outcome was change in Hamilton Depression Rating Scale (HAMD-17) score from baseline to treatment end, with 2.5 points as the non-inferiority margin. Secondary outcomes included: improvement in Montgomery-Asberg Depression Rating Scale (MADRS), Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA); response and remission rates; suicidal ideation and adverse events. ResultsOf 75 randomized patients, 67 completed full treatment, including 52 first-episode patients and 15 relapsers. The primary outcome indicated the non-inferiority of VC (adjusted difference 1.14, lower 97.5 % CI −1.24; p = .002), confirmed by improvements in objective cognitive task and protein levels, as did most secondary outcomes. Reduced suicidal ideation after treatment, incidence of eye discomfort and pain score were lower in the VC group. ConclusionsLeft VC iTBS has the potential to be non-inferior to DLPFC iTBS in most first-episode MDD in improving depressive symptoms and cognitive function, with less suicidal ideation and adverse events. LimitationsGiven the limited sample size, the lack of a sham control and the use of antidepressants, the findings should be interpreted with caution.

Abstract PO-099: Short-term outcomes of an extended endoscopic endonasal resection of a clival giant cell tumor with adjuvant RANK-L inhibitor therapy: Case report

Abstract Background Clival giant cell tumors (GiCT) are rare neoplasms that commonly target the epiphysis. Recently, skull base GiCTs have been reported, predominantly in the sphenoid and temporal bones. Although typically benign, GiCTs of the skull-base can cause neurologic deficits due to compression of cranial nerves or intracranial contents. The efficacy of adjuvant chemotherapy in treating GiCTs is not known. One potential treatment option neoplastic mononuclear stromal cells in GiCTs express NF-κB ligands (RANK-L), which can be therapeutically targeted with Denosumab, a monoclonal antibody against RANK-L. Here, we describe the case of a GiCT invasive to the clivus, an extended endoscopic endonasal resection of the tumor, and management of the lesion with Denosumab. Methods A retrospective chart review was performed on the patient of interest. Magnetic resonance imaging (MRI) and computed tomography (CT) scans were used to assess disease growth and response to surgical and therapeutic intervention. Case presentation A previously healthy seventeen-year-old female presented with headaches and numbness of the left V2 and V3. A diagnosis of a clival giant cell tumor was confirmed with strict pathologic, radiographic, and clinical correlation. She was found to have a clival mass extending into the sphenoid sinus. Surgical excision was performed by both the otolaryngology and neurosurgery departments at a single institution. She underwent an extended endoscopic endonasal resection of the clival mass. Following surgery, the numbness on the left V2 and V3 distribution improved. She occasionally reported bilateral V3 distribution symptoms without definite anatomic correlates for right sided complaints. Due to the presence of residual tumor, we recommended adjunctive medical therapy. We performed adjunctive medical therapy with Denosumab, a RANKL inhibitor. Discussion When complete surgical excision with negative margins is not feasible in lesions of the skull base, adjuvant treatment is commonly required to achieve local disease control. Our case demonstrates the efficacy of a combined approach where surgery is used to achieve a histologic diagnosis, decompression and evaluate for respectability. Adjuvant medical therapy using RANKL inhibitors is a promising approach that may be effective to achieve lifelong disease control but requires continued maintenance on therapy. Citation Format: Myra A. Zaheer, Abhisri Ramesh, Aadit P. Mehta, Adriana S. Fonseca, Daniel A. Donoho. Short-term outcomes of an extended endoscopic endonasal resection of a clival giant cell tumor with adjuvant RANK-L inhibitor therapy: Case report [abstract]. In: Proceedings of the AACR-AHNS Head and Neck Cancer Conference: Innovating through Basic, Clinical, and Translational Research; 2023 Jul 7-8; Montreal, QC, Canada. Philadelphia (PA): AACR; Clin Cancer Res 2023;29(18_Suppl):Abstract nr PO-099.

Multiple Cranial Neuropathies with Orbital Myositis as an Initial Presentation of Lyme Disease (P9-10.002)

<h3>Objective:</h3> To report a case of Lyme disease presenting with subacute multiple cranial neuropathies and orbital myositis. <h3>Background:</h3> Lyme disease can present with multiple cranial neuropathies. Orbital myositis is not well described as one of the rare complications of Lyme disease. Here, we describe a patient with multiple cranial neuropathies and orbital myositis as an initial manifestation of Lyme disease. <h3>Design/Methods:</h3> A 69-year-old male with a history of hyperthyroidism status post thyroidectomy, presented with a new onset headache, double vision, numbness of the face, and dysphagia. On examination, he had left lower motor neuron facial weakness, left eye proptosis, and findings suggestive of III and VI nerve palsies. Brain MRI with contrast revealed abnormal enhancement along the left V2 and V3 nerves and enhancement of the bilateral III cranial nerve. Abnormal enhancement was also seen at the left orbital apex in addition to enhancement along the left retro-orbital optic nerve. MRI of the orbit showed asymmetric enlargement and subtle enhancement of the left extra orbital muscles with mild orbital fat infiltration, compatible with orbital myositis. Lyme IgG/IgM antibody screen was positive which was confirmed by Lyme immunoblot assay which was also positive for Lyme IgG (5 bands) and IgM (3 bands) antibodies. B2 Glycoprotein IgM was elevated. Cerebrospinal fluid (CSF) analysis revealed lymphocytic pleocytosis and elevated protein. CSF cytology and flow cytometry were negative for malignant cells. TSH, thyroxin, and anti-thyroid peroxidase antibodies were unremarkable. Sarcoidosis, IgG4-related disease, autoimmune, and infectious workups were unrevealing. The patient received IV ceftriaxone with significant improvement and with near resolution of the symptoms and clinical findings after 1 month. <h3>Results:</h3> NA <h3>Conclusions:</h3> Orbital myositis is a rare complication of Lyme disease. <b>Disclosure:</b> Dr. Biso has nothing to disclose. Dr. Philip has nothing to disclose. Dr. Chevula has nothing to disclose. Dr. El-Dokla has nothing to disclose.

An Atypical Manifestation of Lateral Medullary Syndrome (P12-5.011)

<h3>Objective:</h3> To describe a case of lateral medullary syndrome (LMS) presenting with ipsilateral hemiparesis and upper motor neuron (UMN)-type facial palsy. <h3>Background:</h3> LMS is a classical vascular syndrome involving the posterior inferior cerebellar artery, which presents typically with ipsilateral Horner syndrome, ipsilateral ataxia, and contralateral hemianesthesia. Motor weakness and facial palsy are not traditionally presented in LMS. <h3>Design/Methods:</h3> Case report. <h3>Results:</h3> A 62-year-old male with poorly controlled hypertension presented with sudden onset left hemiparesis. On presentation, initial blood pressure was 178/95 mmHg. The neurological exam showed dysarthria, left facial palsy sparing the forehead, left facial hypoesthesia, and left hemiparesis (NIHSS 8). Diffusion-weighted MR Brain showed acute infarct in the left lateral medulla. FLAIR sequence showed chronic infarct in the right thalamus. CT arteriogram revealed non-opacification of the left vertebral artery at the level of C2–C3 with opacification of the distal left V4 via retrograde flow, severe stenosis of the right M1 segment, and multifocal atherosclerosis of the bilateral internal carotid arteries. Initial labs showed elevated LDL (213 mg/dl) and normal hemoglobin A1c. Right hemianesthesia was reported during his hospitalization; dysphagia, frequent hiccups, and left dysmetria out of proportion to weakness were noted during the recovery. After acute interventions, he was started on dual antiplatelet treatments for 90 days and a single antiplatelet afterward given concerns of large vessel disease as stroke etiology. <h3>Conclusions:</h3> Atypical clinical presentation in this LMS case included the combination of ipsilateral hemiparesis and ipsilateral UMN-type facial palsy. LMS with ipsilateral hemiparesis is known as Opalski’s syndrome, which is explained by involving the post-decussating pyramidal tract at the lower medulla and upper cervical spine. The explanation of ipsilateral UMN-type facial palsy in our case remains unclear. One possible explanation is the aberrant caudal looping of facial corticobulbar fibers into medulla oblongata prior to synapsing with the pontine facial nucleus. <b>Disclosure:</b> Dr. Yu has nothing to disclose. Mr. Bluntson has nothing to disclose. Dr. Sharma has nothing to disclose.

The endoscopic anterior transmaxillary temporal pole approach for mesial temporal lobe epilepsies: a feasibility study.

In mesial temporal lobe epilepsy (MTLE), the ideal surgical approach to achieve seizure freedom and minimize morbidity is an unsolved question. Selective approaches to mesial temporal structures often result in suboptimal seizure outcomes. The authors report the results of a pilot study intended to evaluate the clinical feasibility of using an endoscopic anterior transmaxillary (eATM) approach for minimally invasive management of MTLEs. The study is a prospectively collected case series of four consecutive patients who underwent the eATM approach for the treatment of MTLE and were followed for a minimum of 12 months. All participants underwent an epilepsy workup and surgical care at a tertiary referral comprehensive epilepsy center and had medically refractory epilepsy. The noninvasive evaluations and intracranial recordings of these patients confirmed the presence of anatomically restricted epileptogenic zones located in the mesial temporal structures. Data on seizure freedom at 1 year, neuropsychological outcomes, diffusion tractography, and adverse events were collected and analyzed. By applying the eATM technique and approaching the far anterior temporal lobe regions, mesial-basal resections of the temporal polar areas and mesial temporal structures were successfully achieved in all patients (2 with left-sided approaches, 2 with right-sided approaches). No neurological complications or neuropsychological declines were observed. All 4 patients achieved Engel class Ia outcome up to the end of the follow-up period (19, 15, 14, and 12 months). One patient developed hypoesthesia in the left V2 distribution but there were no other adverse events. The low degree of white matter injury from the eATM approach was analyzed using high-definition fiber tractography in 1 patient as a putative mechanism for preserving neuropsychological function. The described series demonstrates the feasibility and potential safety profile of a novel approach for medically refractory MTLE. The study affirms the feasibility of performing efficacious mesial temporal lobe resections through an eATM approach.

Abstract Number ‐ 86: Intracranial Angioplasty via Type II Proatlantal Intersegmental Artery

Introduction A proatlantal intersegmental artery (PIA) is an exceedingly rare primitive anastomosis between the carotid and vertebrobasilar circulations. PIA’s may be accompanied by ipsilateral or bilateral vertebral artery (VA) agenesis and can originate from the cervical internal carotid artery (ICA, type I) or external carotid artery (ECA, type II) before eventually joining the vertebrobasilar system. Several authors have described this anomaly in different clinical scenarios, but to our knowledge, there are no studies documenting intracranial vertebral artery angioplasty through a type II PIA in the setting of a vertebrobasilar stroke. Methods Single case study Results A 62‐year‐old male presented to the ED with slurred speech that began one hour prior to arrival. Computer tomography (CT) of the head revealed a small right posterior acute parietal subdural hematoma, and CT perfusion scan revealed ischemia of the cerebellar hemispheres bilaterally with small areas of core infarction and a moderate‐to‐large surrounding penumbra. Magnetic resonance imaging (MRI) of the brain was positive for bilateral acute ischemic strokes of the cerebellar and pontine arteries. CT angiogram of the head and neck revealed high grade stenosis of the right intracranial VA and narrowing of the left V1, V2, and V3 segments. The proximal left V4 segment was occluded with distal reconstitution. Catheter angiogram of the ICAs and ECAs showed that the patient’s right VA did not originate from the right subclavian artery but instead from the right ECA. The patient was subsequently determined to have a type II PIA with critical stenosis. We proceeded with right VA submaximal angioplasty via the type II PIA. The procedure went without complications and resulted in restoration of vertebrobasilar blood flow, with only moderate stenosis following the submaximal angioplasty. On day 5 postoperatively, the patient reported resolution of his symptoms and was subsequently discharged. Conclusions We presented a case of vertebrobasilar stroke in which the right VA did not originate from the right subclavian artery but instead from the ECA, with a subsequent diagnosis of a type II PIA. The only option for management was to perform the right VA angioplasty via the PIA, which we believe to be the first documented case of intracranial vertebral angioplasty through a type II PIA. This case serves as a reminder of the very rare cases of persistent fetal circulation and the importance of performing a catheter angiogram of both the ICA and ECA. Evaluation of the ECA and subsequent observation of a PIA can completely change both the management and outcomes of the patient. This case underscores the complexity of the intracranial atherosclerotic disease, the beneficial role of endovascular intervention, and the necessity of future studies to identify the optimal treatment methods for vertebrobasilar stroke.

Functional maturation in visual pathways predicts attention to the eyes in infant rhesus macaques: Effects of social status

Differences in looking at the eyes of others are one of the earliest behavioral markers for social difficulties in neurodevelopmental disabilities, including autism. However, it is unknown how early visuo-social experiences relate to the maturation of infant brain networks that process visual social stimuli. We investigated functional connectivity (FC) within the ventral visual object pathway as a contributing neural system. Densely sampled, longitudinal eye-tracking and resting state fMRI (rs-fMRI) data were collected from infant rhesus macaques, an important model of human social development, from birth through 6 months of age. Mean trajectories were fit for both datasets and individual trajectories from subjects with both eye-tracking and rs-fMRI data were used to test for brain-behavior relationships. Exploratory findings showed infants with greater increases in FC between left V1 to V3 visual areas have an earlier increase in eye-looking before 2 months. This relationship was moderated by social status such that infants with low social status had a stronger association between left V1 to V3 connectivity and eye-looking than high status infants. Results indicated that maturation of the visual object pathway may provide an important neural substrate supporting adaptive transitions in social visual attention during infancy.