Multifocal Cerebral Infarctions Research Articles

Abstract TP134: White Matter Disease and Patterns of Infarction: A Single Center Study

Background: Patterns of acute cerebral infarction can often reveal the underlying mechanism of ischemic injury. Despite the strong overlap between vascular risk factors and embolic infarct mechanisms (with multifocal infarct patterns), acute multifocal subcortical infarcts may be related to microangiopathic changes. Methods: A prospective stroke registry was queried for patients with acute infarction in >1 vascular territory on diffusion-weighted imaging (unrelated to any endovascular procedure). The odds of a multi-infarct subcortical pattern (vs. cortical pattern) were estimated for patients with higher Fazekas grade (2-3) versus low grade (0-1) patients using forward stepwise logistic regression with greatest minimization of corrected Akaike information criterion including all demographic covariates. Results: Out of 746 patients with acute infarcts and complete covariate data, 226 patients (30.3%) had a multi-infarct pattern, of whom 113 (50.0%) had high grade (Fazekas 2-3) white matter disease. Compared to patients with grade 0-1 Fazekas score, those with grade 2-3 more frequently had multifocal subcortical infarcts (4.4% vs. 10%, p=0.01). Following multivariable adjustment, the odds of multifocal subcortical infarcts were greater for patients with higher Fazekas grades (adjusted odds ratio [OR] 2.9, 95% confidence interval [CI] 1.3-6.7). The higher odds of multifocal subcortical infarcts were observed in a stepwise fashion for each Fazekas grade when compared to grade 0 (adjusted OR for grade 3 10.1, 95% CI 1.2-84; grade 2 OR 9.4, 95% 1.2-75.6; grade 1 OR 4.9, 95% 0.6-40.4). Conclusions: In this single center analysis we found that white matter burden is correlated with subcortical patterns of multifocal cerebral infarction. This suggests such infarcts may be caused by uncontrolled vascular risk factors rather than a proximal embolic source when chronic white matter disease is present.

A Case of Retiform Purpura associated with Coronavirus Disease 2019 Infection

Since the emergence of coronavirus disease 2019 (COVID-19), several reports have described various skin manifestations associated with COVID-19. Retiform purpura is a cutaneous manifestation that is likely associated with coagulopathy in patients with severe COVID-19. Here, we present the case of a 62-year-old man with hypertension and multiple myeloma who presented with retiform purpuric patches on both legs two days after a chemotherapy session with carfilzomib and dexamethasone. He had no other respiratory symptoms or fever; however, he was hospitalized for supportive care and underwent COVID-19 screening with reverse transcriptase polymerase chain reaction, which was positive. Histopathologic evaluation of the two punch biopsy samples obtained from the affected skin revealed perivascular lymphocytic lesions with fibrinoid degeneration, extravasated red blood cells, and fibrin deposition in the deep dermis. Based on these findings, the patient was diagnosed with COVID-19 and retiform purpura. He received intensive care after developing fever, cough, sputum production, and dyspnea. However, the patient developed multifocal cerebral infarctions and eventually died. Dermatologists should recognize retiform purpura, which may appear before other COVID-19 symptoms, as an alarm sign which can aid in the prompt implementation of appropriate treatment.

Unusual case of multifocal cerebral infarction in a patient with gastric mucosa-associated lymphoid tissue lymphoma

Unusual case of multifocal cerebral infarction in a patient with gastric mucosa-associated lymphoid tissue lymphoma

Intravascular CNS Lymphoma: An elusive diagnosis (P2-5.016)

<h3>Objective:</h3> To report a rare case of intravascular CNS lymphoma presenting with subacute neuropsychiatric symptoms and multifocal cerebral infarcts and hemorrhages. <h3>Background:</h3> Intravascular lymphoma is a rare and aggressive subtype of extra-nodal non-Hodgkin lymphoma. It is characterized by proliferation of neoplastic B-lymphocytes within the lumen of small blood vessels, especially capillaries and post-capillary venules. Presentation is variable and depends on the organ dysfunction due to small vessel occlusion. Most common organs involved are CNS, skin and lungs. Given the rarity of the disease, variable presentation and absence of an extravascular tumor mass or peripheral blood abnormalities, the diagnosis can be extremely challenging and is often delayed. <h3>Design/Methods:</h3> NA <h3>Results:</h3> A 62-year old healthy woman presented with transient left hemiplegia and left facial numbness and was diagnosed with transient ischemic attack. In one month, she developed dysarthria and left hemibody clonic seizures without any systemic complaints. Over the next four months, she had a step-wise decline and developed severe apathy, decreased verbal fluency, diffuse hypertonia and worsening encephalopathy. Serial brain MRIs over four months showed acute-subacute infarcts and intracerebral hemorrhages involving both anterior and posterior circulation bilaterally with scattered micro-hemorrhages. Extensive work up, including CT-angiogram and PET-CT were unrevealing. CSF was notable for high protein level without pleocytosis and negative infectious and autoimmune workup. DSA was unrevealing. She did not respond to high dose steroids, intravenous immunoglobulin and cyclophosphamide. Brain biopsy revealed CNS intravascular large B-cell lymphoma. Patient was started on chemotherapy with HyperCVAD-R protocol with no improvement. <h3>Conclusions:</h3> Intravascular CNS lymphoma is a challenging diagnosis. It presents as subacute-chronic CNS vasculopathy with multifocal infarcts and hemorrhages and can mimic other CNS vasculopathies, including primary CNS angiitis and amyloid-related angiopathy. Tissue biopsy is the diagnostic gold standard and should be considered early if poor response to immunotherapy is noted. Despite high-dose chemotherapy, prognosis is poor. <b>Disclosure:</b> Dr. Ticku has nothing to disclose. Dr. Serra has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for Biogen Idec. Dr. Serra has received personal compensation in the range of $5,000-$9,999 for serving on a Speakers Bureau for Bristol Myers Squibb.

Transcranial Doppler ultrasonography in tuberculous meningitis: A systematic review.

Tuberculous (TB) meningitis is a common type of central nervous system infection, and may cause multifocal cerebral infarctions due to the involvement of cerebral vasculature. This systematic review aims to review and synthesize the utility of transcranial Doppler (TCD) in TB meningitis. This is a systematic review of observational studies on the use of TCD in patients diagnosed to have TB meningitis. Study outcomes included changes in TCD parameters during stages of TB meningitis, frequency of neurologic complications (such as hydrocephalus, vasculopathy, and cerebral infarction), correlation of TCD findings with neuroimaging, and functional outcomes. Five studies were included with a total of 141 participants, with ages from 4 months to 75 years. The most common neurologic complication was hydrocephalus (87.1%), cerebral infarction (29.2%), and arterial stenosis (26.3%). There was increased mean flow velocity (MFV) most commonly in the middle cerebral artery in the early stage of TB meningitis, and decreased MFV in the advanced disease stage. TCD findings of stenosis were well correlated with CT or MR angiogram. Among patients with hydrocephalus, pulsatility indices were significantly decreased after ventriculoperitoneal shunting. A considerable proportion of patients with TB meningitis develop cerebral hemodynamic disturbances which lead to cerebral ischemia and affect clinical outcomes. TCD is a reliable tool for the diagnosis of vasculopathy and increased intracranial pressure and can thus help monitor disease progression and treatment response. Future studies with larger populations and longer follow-ups are recommended to determine the association of TCD findings with functional outcomes.

Paradoxical and Retrograde Air Embolism from Pressurized Peripheral Bolus

Introduction Cerebral air embolism is a rare, yet serious neurological occurrence with unclear incidence and prevalence. Here, we present a case of fatal cerebral arterial and venous cerebral gas embolism in a patient with infective endocarditis and known large right-to-left shunt and severe tricuspid regurgitation following pressurized fluid bolus administration. Case Presentation. A 32-year-old female was admitted to the medical intensive care unit from a long-term acute care facility with acute on chronic respiratory failure. Her medical history was significant for intravenous heroin and cocaine abuse, methicillin-sensitive Staphylococcus aureus tricuspid valve infective endocarditis on vancomycin, patent foramen ovale, septic pulmonary embolism with cavitation, tracheostomy with chronic ventilator dependence, multifocal cerebral infarction, hepatitis C, nephrolithiasis, anxiety, and depression. After intravenous fluid administration, she became unresponsive with roving gaze, sluggish pupils, and hypotensive requiring vasopressors. CT of the brain showed diffuse arterial and venous cerebral air embolism secondary to accidental air administration from fluid bolus. Magnetic resonance imaging of the brain showed diffuse global anoxic injury and flattening of the globe at the optic nerve insertion. Given poor prognosis, her family chose comfort measures and she died. Conclusions Fatal cerebral air embolism can occur through peripheral intravenous routes when the lines are inadequately primed and fluids administered with pressure. Caution must be exercised in patients with right-to-left shunting as air may gain access to systemic circulation.

Sudden Onset Hemiplegia and Neglect: A Case Report of Type A Aortic Dissection Presenting as a Code Stroke

Stanford type A acute aortic dissection with ischemic stroke is a rare yet highly morbid presentation of sudden onset neurological symptoms. We present a case of a 57-year-old African American male brought to the emergency department with a witnessed syncopal episode, abdominal pain, right sided gaze preference, and left side weakness. Upon initiation of the hospital’s “Code Stroke” response protocol, a computed tomography angiogram of the neck incidentally identified Stanford type A aortic dissection with extension into and occlusion of the brachiocephalic artery, occlusion of the right common carotid artery and right internal carotid artery, and dissection flap propagation into the origin of the left common carotid artery. Postoperative magnetic resonance imaging of the brain and the entire spine demonstrated multifocal cerebral infarcts, as well as T10 - L1 spinal infarct. Despite provision of multidisciplinary intensive care unit level of care, the patient failed to demonstrate clinically significant neurological recovery and was transitioned to comfort care after 3 weeks of hospitalization. This case highlights the importance of considering acute aortic dissection as a potential etiology of acute ischemic stroke through the use of computed tomography angiography, as this diagnosis carries profoundly different implications for the consideration of thrombolytic agents and other emergent treatment modalities. J Neurol Res. 2020;10(6):248-252 doi: https://doi.org/10.14740/jnr638

Catecholamine-induced cerebral vasospasm and multifocal infarctions in pheochromocytoma.

SummaryWe report the case of a 76-year-old male with a remote history of papillary thyroid cancer who developed severe paroxysmal headaches in the setting of episodic hypertension. Brain imaging revealed multiple lesions, initially of inconclusive etiology, but suspicious for metastatic foci. A search for the primary malignancy revealed an adrenal tumor, and biochemical testing confirmed the diagnosis of a norepinephrine-secreting pheochromocytoma. Serial imaging demonstrated multiple cerebral infarctions of varying ages, evidence of vessel narrowing and irregularities in the anterior and posterior circulations, and hypoperfusion in watershed areas. An exhaustive work-up for other etiologies of stroke including thromboembolic causes or vasculitis was unremarkable. There was resolution of symptoms, absence of new infarctions, and improvement in vessel caliber after adequate alpha-adrenergic receptor blockade for the management of pheochromocytoma. This clinicoradiologic constellation of findings suggested that the etiology of the multiple infarctions was reversible cerebral vasoconstriction syndrome (RCVS). Pheochromocytoma remains a poorly recognized cause of RCVS. Unexplained multifocal cerebral infarctions in the setting of severe hypertension should prompt the consideration of a vasoactive tumor as the driver of cerebrovascular dysfunction. A missed or delayed diagnosis has the potential for serious neurologic morbidity for an otherwise treatable condition.Learning points:The constellation of multifocal watershed cerebral infarctions of uncertain etiology in a patient with malignant hypertension should trigger the consideration of undiagnosed catecholamine secreting tumors, such as pheochromocytomas and paragangliomas.Reversible cerebral vasoconstriction syndrome is a serious but reversible cerebrovascular manifestation of pheochromocytomas that may lead to strokes (ischemic and hemorrhagic), seizures, and cerebral edema.Alpha-adrenergic receptor blockade can reverse cerebral vasoconstriction and prevent further cerebral ischemia and infarctions.Early diagnosis of catecholamine secreting tumors has the potential for reducing neurologic morbidity and mortality in patients presenting with cerebrovascular complications.

Sudden Onset Hemiplegia and Neglect: A Case Report of Type A Aortic Dissection Presenting as a Code Stroke

Stanford type A acute aortic dissection with ischemic stroke is a rare yet highly morbid presentation of sudden onset neurological symptoms. We present a case of a 57-year-old African American male brought to the emergency department with a witnessed syncopal episode, abdominal pain, right sided gaze preference, and left side weakness. Upon initiation of the hospital’s “Code Stroke” response protocol, a computed tomography angiogram of the neck incidentally identified Stanford type A aortic dissection with extension into and occlusion of the brachiocephalic artery, occlusion of the right common carotid artery and right internal carotid artery, and dissection flap propagation into the origin of the left common carotid artery. Postoperative magnetic resonance imaging of the brain and the entire spine demonstrated multifocal cerebral infarcts, as well as T10 - L1 spinal infarct. Despite provision of multidisciplinary intensive care unit level of care, the patient failed to demonstrate clinically significant neurological recovery and was transitioned to comfort care after 3 weeks of hospitalization. This case highlights the importance of considering acute aortic dissection as a potential etiology of acute ischemic stroke through the use of computed tomography angiography, as this diagnosis carries profoundly different implications for the consideration of thrombolytic agents and other emergent treatment modalities. J Neurol Res. 2020;10(6):248-252 doi: https://doi.org/10.14740/jnr638

Kingella kingae endocarditis causing multifocal cerebral infarcts in a previously healthy 17-month-old male

Kingella kingae endocarditis causing multifocal cerebral infarcts in a previously healthy 17-month-old male

Kingella kingae endocarditis causing multifocal cerebral infarcts in a previously healthy 17-month-old male

Background: Kingella kingae colonizes up to 10-12% of children aged 6 months-4 years (1) and is part of the HACEK group of organisms that is associated with culture-negative endocarditis. We report a case of a 17-month-old male who developed multifocal cerebral infarcts secondary to septic emboli from K. kingae endocarditis. Case: A 17-month-old previously healthy Caucasian male was admitted with 2 weeks of intermittent fevers and 1 day of extreme lethargy and decreased movement of the left arm and leg. On presentation …

Multifocal Cerebral Infarction and Status Epilepticus as a Result of 3-bromopyruvate Toxicity for Treatment of Ocular Melanoma (P2.6-011)

Multifocal Cerebral Infarction and Status Epilepticus as a Result of 3-bromopyruvate Toxicity for Treatment of Ocular Melanoma (P2.6-011)

A Case Of Cavernous Sinus Syndrome and Mutifocal Cerebral Infarction Related To Mucormycosis Of Sphenoid Sinus

A 54-year-old man, suffering from severe headache and ophthalmoplegia after undergoing endoscopic sinus surgery was referred to a tertiary hospital. Computed tomography (CT) revealed soft tissue density lesions in the left sphenoid sinus. The internal carotid artery was shown to be occluded in brain magnetic resonance imaging (MRI) scans without any other cerebral lesion. Endoscopic view of left nasal cavity shows whitish hyphae in the ethmoid and the sphenoid sinuses. We diagnosed him with cavernous sinus syndrome caused by mucormycosis and conducted endoscopic sinus surgery to remove remaining lesions and decompress orbit and optic nerves. After the revision surgery the patient's headache and ophthalmoplegia were improved. However, multifocal cerebral infarctions were newly discovered in a postoperative CT scan. We experienced a case of mucormycosis of sphenoid sinus resulting in occlusion of internal carotid artery and multifocal cerebral infarction, and report it with a brief review of these disease entities.

Brain Magnetic Resonance Imaging and Angiography Findings in Ugandan Children with Sickle Cell Anemia; A Cross Sectional Study

Sickle Cell Anemia (SCA) is a leading cause of childhood stroke in sub-Saharan Africa and sickle cell brain vasculopathy manifests either as overt stroke or clinically “silent infarcts”. This study aimed to describe brain abnormalities seen on magnetic resonance imaging in Ugandan SCA children. Our hypothesis was that multi-model abnormalities would be associated with cerebrovasculopathy found on MRI/MRA.MethodsAs part of a larger study to determine the burden and spectrum of neurological and cognitive impairments in SCA children in Uganda, we selected 81 children ages 1-12 years with HbSS, a sample enriched for possible brain pathology from Mulago hospital SCA clinic out of a random sample of 265 stable children. None was receiving hydroxyurea. All had detailed clinical history, and physical, neurological and cognitive testing, trans-cranial Doppler (TCD) cerebral blood flow velocity determination and non-contrasted brain MRI/MRA using a 1.5 Tesla scanner. Cognitive testing was performed using age-specific tools validated for Ugandan children.ResultsOf the 81 participants imaged, 61 had one or more of history of stroke, an abnormal neurological exam, cognitive impairment or abnormal TCD, while 20 had normal test results. MR abnormalities were seen in 35/61 (63.9%) participants with probable brain pathology and in 4/20 (20.0%) without any probable brain pathology. They included different structural abnormalities seen in all brain regions ranging from only T2 weighted hyper-intensities, white matter lacuna infarction to bilateral ischemic and multi-focal cerebral infarcts with associated compensatory hydrocephalus. MRA abnormalities ranged from cerebral microangiopathy to multiple stenosis and occlusions of major arteries, including moya-moya in 4 subjects. Severe vessel obstructions were also seen in multiple young children <36 months.ConclusionsBrain injury in Uganda children with SCA begins early in childhood and becomes a common finding during later childhood. Early screening for stroke and intervention therapy is warranted to prevent sickle brain vasculopathy initiated early after diagnosis. The risk factors for such early brain injury should be investigated. DisclosuresNo relevant conflicts of interest to declare.

A Risk Factor Analysis of Cognitive Impairment in Elderly Patients with Chronic Diseases in a Chinese Population.

BackgroundThis study analyzed the risk factors of cognitive impairment (CI) in elderly patients with chronic diseases.Material/MethodsIn total of 385 elderly patients with chronic diseases were selected and assigned into CI and normal groups. The activities of daily living (ADL), global deterioration scale (GDS), Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment Scale (MoCA), patient-generated subjective global assessment (PG-SGA), and mini nutritional assessment (MNA) were performed to analyze the differences between the 2 groups. Logistic regression analysis was conducted for risk factors of CI in elderly patients with chronic diseases.ResultsThere were differences in age, education level, type 2 diabetes mellitus, multifocal cerebral infarction, hearing, and eyesight between CI and normal groups. Patients in the CI group showed more CD4+ cells, more admission times, and higher GDS scores than the normal group. Also, MMSE and MoCA scores revealed differences in total score, directive force, attention and calculating ability, language, delayed memory, reading comprehension, writing, and visual-spatial ability between the 2 groups. The number of B and CD8+ cells, ADL, and MNA scores were protective factors, while cerebral infarction history, number of CD4+ cells, admission times, GDS score, and age were risk factors of CI in elderly patients with chronic diseases.ConclusionsOur study provides evidence that cerebral infarction history, number of CD4+ cells, admission times, GDS score, and age are risk factors of CI in elderly patients with chronic diseases.

Neurologic Complications of Transplantation.

Neurologic disturbances including encephalopathy, seizures, and focal deficits complicate the course 10-30% of patients undergoing organ or stem cell transplantation. While much or this morbidity is multifactorial and often associated with extra-cerebral dysfunction (e.g., graft dysfunction, metabolic derangements), immunosuppressive drugs also contribute significantly. This can either be through direct toxicity (e.g., posterior reversible encephalopathy syndrome from calcineurin inhibitors such as tacrolimus in the acute postoperative period) or by facilitating opportunistic infections in the months after transplantation. Other neurologic syndromes such as akinetic mutism and osmotic demyelination may also occur. While much of this neurologic dysfunction may be reversible if related to metabolic factors or drug toxicity (and the etiology is recognized and reversed), cases of multifocal cerebral infarction, hemorrhage, or infection may have poor outcomes. As transplant patients survive longer, delayed infections (such as progressive multifocal leukoencephalopathy) and post-transplant malignancies are increasingly reported.

Multifocal Cerebral and Bilateral Middle Cerebellar Peduncle Infarctions in CADASIL

Multifocal Cerebral and Bilateral Middle Cerebellar Peduncle Infarctions in CADASIL

Unexpected Pathologic Diagnosis of the Mitral Valvular Mass

A 59-year-old man with multifocal cerebral infarction was found to have the large obstructive mitral valvular mass. Although benign tumor was under suspicion before surgery, he was finally diagnosed as chronic infective endocarditis by microscopic evaluation. The precise diagnosis and the proper management of a cardiac mass are very important since even the benign tumor may cause fatal complications. However, primary cardiac mass has the broad spectrum from pseudo-tumor to malignancy and the differential diagnosis using non-invasive methods is not easy even with the currently available imaging techniques.

Correlation analysis of serum estrogen and lipid levels in elderly female patients with cerebral infarction

Objective To investigate the elderly female patients with cerebral infarction （ CI） serum estrogen levels and changes in lipid levels ,and the correlation between infarct size .Methods 150 elderly female patients with cerebral infarction were chosen as the observation group;150 cases of healthy elderly women as the control group .The sex hormone levels and lipid levels were measured .The number of new lesions and the maximum area of the lesion were detected by 64-slice spiral CT.Results The serum estradiol（E2）was（84.32 ±34.16）pmol/L,triglyceride （TG）was（2.11 ±0.85）mmol/L,low density lipoprotein（LDL）was（4.12 ±1.17）mmol/L,all were higher in the ob-servation group.while the high-density lipoprotein（HDL）levels was（0.87 ±0.43）mmol/L,lower than that of the control group,the differences were statistically significant （t=2.43,3.88,6.91,9.98,all P〈0.05）.While multifocal CI,serum E2 ,TG and LDL levels than a single lesion type CI increased ,the difference was statistically significant （ t=2.06,3.08,2.47,all P〈0.05）;The serum Chol,HDL levels than a single lesion type CI decreased infarct size com-pared with single stove type CI decreases ,the difference was statistically significant （ t=2.37,3.01,13.43,all P〈0.05 ） .Conclusion Elderly patients with CI female sex hormone E 2 elevated not only a stress response ,but also may influence the mechanism of lipid metabolism ,reduce infarct size . Key words: Estrogens; Brain Infarction; Femininity; Aged

Progressive multifocal cerebral infarction in a young kidney transplant recipient due to thrombotic microangiopathy

BackgroundRenal transplant recipients frequently experience neurological complications. Whereas ischemic stroke, cerebral haemorrhage or hypertensive encephalopathy often result from vascular alterations prior to transplantation, other cerebral diseases like CNS infections, primary brain tumors and drug induced neurotoxicity may develop as consequences of the required post-transplant immunosuppressive treatment.Case presentationHere we report on an unusual clinical course of a young kidney transplant recipient with a cluster of fulminant necrotic brain lesions within a period of two months due to thrombotic microangiopathy.ConclusionCerebral ischemia in organ transplant recipients should prompt one to consider thrombotic microangiopathy.