Posterior Circulation Infarction Research Articles

Erratum. Predictors of unexplained early neurological deterioration after thrombectomy for posterior circulation infarction: a reanalysis of the BASILAR study.

Erratum. Predictors of unexplained early neurological deterioration after thrombectomy for posterior circulation infarction: a reanalysis of the BASILAR study.

Vascular Consequences: A Case Report on Posterior Circulation Infarction as a Sequela of COVID-19

Vascular Consequences: A Case Report on Posterior Circulation Infarction as a Sequela of COVID-19

Recurrent Posterior Circulation Infarction Caused by Vertebral Artery Dissection Secondary to Atlas Hypoplasia.

Recurrent Posterior Circulation Infarction Caused by Vertebral Artery Dissection Secondary to Atlas Hypoplasia.

Posterior Circulation Ischemic Stroke Is Associated with More Severe Forward Head Posture in Patients with Cervicalgia

Chronic risk factors of posterior circulation ischemic strokes remain unknown. There is, however, evidence that anatomical variations within the vertebrobasilar system could potentially lead to the development of posterior circulation strokes. We investigated the association of forward head posturing (FHP), a chronic anatomic change seen in patients with cervicalgia, with posterior circulation strokes. In this case control study, we identified adult patients diagnosed with cervicalgia and ischemic posterior circulation infarcts from 2007 to 2023. Patients were paired to cervicalgia controls without posterior circulation stroke and matched for known risk factors. Patients' C0-C2 angle, C2-C7 angle, and sagittal vertical axis (SVA) shift were measured as metrics for FHP severity on lateral cervical spine x-rays. Paired T-tests were applied to compare patient stroke risk factors and FHP between groups. 206 patients (103 cases and 103 controls) were included with an average age of 64.4 years with 51.5% female. There were no statistically significant differences between the patients' risk factors for stroke, including hypertension, hyperlipidemia, diabetes, smoking, hypercoagulable state, and atrial fibrillation. There were statistically significant differences in C0-C2 angle (30.7 degrees vs 23.2 degrees, P-value=0.002) and SVA shift (35.4 mm vs 25.3 mm, P-value<0.001). This case control matched pair study found that within adults with cervicalgia, posterior circulation ischemic stroke was associated with more severe FHP as noted in C0-C2 angle and SVA shift measurements. This study further speculates that this association may be because of chronic changes in circulation flow dynamics within the vertebrobasilar system with the postural change.

Rare case of massive middle cerebral artery infarct after bronchial artery embolisation

Bronchial artery embolization (BAE) is a procedure that aims to control bleeding from bronchial arteries in massive and chronic haemoptysis. It is considered to be a life-saving measure in severe life-threating haemoptysis. Although it is minimally invasive and has a high success rate, it still carries a list of complications. These include post-embolisation syndrome, chest pain, back pain, dysphagia, vascular injury at the site of the embolisation leading to dissection, perforation, pseudoaneurysm and, very rarely, embolic infarction to non-target vessels. Stroke is one of the rare complications post BAE, and it can be severe and fatal. Few cases of stroke post BAE have been reported in the literature, and they were mainly due to posterior cerebral circulation infarction. Here, we report a case of a stroke post BAE due to massive middle cerebral artery (MCA) infarction and to our knowledge it seems to be the first reported case of MCA infarction post BAE. The discussion will cover the possible mechanisms of embolic passage, the outcome of the case including rehabilitation perspectives and the learning points. These will also highlight the importance of early recognition, which can save patients from a disabling stroke in the future.

Investigation of the Relationship Between Cervical Vertebral Column Degeneration and Posterior Circulation Perfusion Area Ischemia

Aim: The primary objective of this study was to establish whether degeneration of the cervical vertebrae and paravertebral structures serves as a predisposing factor for ischemic processes by disrupting hemodynamics in the posterior system through mechanical effects on the vertebral arteries. Material and Method: We conducted a retrospective analysis of 180 patients who underwent various imaging tests between January 2017 and October 2023. These tests included cervical magnetic resonance imaging (MRI), cervical computed tomography (CT), carotid-vertebral neck CT angiography (CTA), cranial CT, and cranial MRI. Of the 180 patients, 90 had mild degeneration or no significant degeneration, with a mean age of 58 years, and 90 had significant cervical spondylosis (CS) with a mean age of 64 years. The radiological findings were statistically analyzed, and a p-value of less than 0.05 was considered statistically significant. Results: There was no significant difference between age and parenchymal density in the control group (p=0.09). There was no statistically significant difference between the age and parenchymal density in the CS group (p=0.07). As CS became more severe, there was a statistically significant increase in the incidence of atrophic enlargement of the cerebellar folia and loss of density in the posterior fossa (p=0.03) and posterior circulation infarcts (POCI) (p=0.04). Conclusion: When severe, CS can adversely affect vascular hemodynamics in the posterior system, predisposing perfused neural parenchyma to ischemia.

Chronic Lymphocytic Inflammation with Pontine Perivascular Enhancement Responsive to Steroids (CLIPPERS) Mimicking Posterior Circulation Infarction

CLIPPERS is a rare inflammatory condition of the central nervous system. It is pathologically characterised by white matter perivascular lymphohistiocytic infiltrate with or without parenchymal extension. A male patient in mid sixties presented with dysarthria and facial numbness underwent an MRI brain which supported a diagnosis of a subacute posterior circulation infarct. The patient re-presented with worsening of symptoms and a repeat MRI revealed changes atypical for ischaemia and consistent with CLIPPERS. Our case represents a common presentation of a very rare condition.

Application of 3D-PCASL combined with t-ASL and MRA in the diagnosis of patients with isolated vertigo induced by posterior circulation ischemia

ObjectivesIsolated vertigo induced by posterior circulation ischemia (PCIV) can further progress into posterior circulation infarction. This study aimed to explore the diagnostic values of three-dimensional pseudo-continuous arterial spin labeling (3D-PCASL) combined with territorial arterial spin labeling (t-ASL) and magnetic resonance angiography (MRA) in visualizing and evaluating PCIV, seeking improved diagnostic tools for clinical guidance. Methods28 PCIVs (11 males, 17 females, aged from 55 to 83 years, mean age: 69.68 ± 9.01 years) and 28 healthy controls (HCs, 12 male, 16 female, aged from 56 to 87 years, mean age: 66.75 ± 9.86 years) underwent conventional magnetic resonance imaging (MRI), diffusion-weighted imaging (DWI), MRA, 3D-PCASL, and t-ASL. We compared the incidence of anatomic variants of the posterior circle of Willis in MRA, cerebral blood flow (CBF) and anterior collateral blood flow on postprocessing maps obtained from 3D-PCASL and t-ASL sequence between PCIVs and HCs. Chi-square test and paired t-test were analyzed statistically with SPSS 24.0 software. Results7 PCIVs (7/28, 25%) and 6 HCs (6/28, 21%) showed fetal posterior cerebral artery (FPCA) on MRA, including 1 HC, and 6 PCIVs with FPCA appeared hypoperfusion. 18 PCIVs (64%) and 2 HCs (7%) showed hypoperfusion in the posterior circulation (PC), including 1 HC and 7 PCIVs displayed anterior circulation collateral flow. Chi-square analyses demonstrated a difference in PC hypoperfusion between PCIVs and HCs, whether in the whole or FPCA-positive group assessment (P < 0.05). Paired t-test showed that the CBF values were significant difference for the bilateral PC asymmetrical perfusion in the PCIVs (P < 0.01). When compared to the bilateral PC symmetrical non-hypoperfusion area in the PCIVs and HCs, the CBF values were not significant (P > 0.05). The CBF values of the PC in PCIVs were lower than in HCs (P < 0.05). The reduction rate in the hypoperfusion side of the bilateral PC asymmetrical perfusion of the PCIVs ranged from 4% to 37%, while the HCs reduction rate was 7.7%. The average PC symmetrical perfusion average reduction rate of the PCIVs was 52.25%, while the HCs reduction rate was 42.75%. Conclusion3D-PCASL is a non-invasive and susceptible method for detecting hypoperfusion in PC, serving as a potential biomarker of PCIV. The suspected hypoperfusion in PC may be attributed to the emergence of FPCA and the manifestation of anterior collateral flow when combining t-ASL and MRA sequences. These findings demonstrated that 3D-PCASL combined with t-ASL and MRA sequences are the potential method to identify PCIV, leading to early diagnosis of PCIV and reducing the risk of progressing into infarction.

Inflammatory Type Focal Cerebral Arteriopathy of the Posterior Circulation in Children: A Comparative Cohort Study.

Inflammatory type focal cerebral arteriopathy (FCA-i) in the anterior circulation (AC) is well characterized, and the focal cerebral arteriopathy severity score (FCASS) reflects the severity of the disease. We identified cases of FCA-i in the posterior circulation (PC) and adapted the FCASS to describe these cases. In this comparative cohort study, patients from the Swiss NeuroPaediatric Stroke Registry with ischemic stroke due to FCA-i between January 2000 and December 2018 were analyzed. A comparison between PC and AC cases regarding pediatric National Institutes of Health Stroke Scale score and pediatric stroke outcome measure and FCASS was performed. We estimated infarct size by the modified pediatric Alberta Stroke Program Early Computed Tomography Score in children with AC stroke and the adapted Bernese posterior diffusion-weighted imaging score in the PC. Thirty-five children with a median age of 6.3 (interquartile range, 2.7-8.2 [95% CI, 0.9-15.6]; 20 male; 57.1%) years with FCA-i were identified. The total incidence rate was 0.15/100 000/year (95% CI, 0.11-0.21). Six had PC-FCA-i. Time to final FCASS was longer in the PC compared with AC; the evolution of FCASS did not differ. Initial pediatric National Institutes of Health Stroke Scale score was higher in children with FCA-i in the PC with a median of 10.0 (interquartile range, 5.75-21.0) compared with 4.5 (interquartile range, 2.0-8.0) in those with AC-FCA-i. Different from the anterior cases, PC infarct volume did not correlate with higher discharge, maximum, or final FCASS scores (Pearson correlation coefficient [r], 0.25, 0.35, and 0.54). FCA-i also affects the PC. These cases should be included in future investigations into FCA-i. Although it did not correlate with clinical outcomes in our cohort, the modified FCASS may well serve as a marker for the evolution of the arteriopathy in posterior FCA-i.

Predictors of atrial fibrillation detection in embolic stroke of undetermined source patients with implantable loop recorder.

Covert atrial fibrillation (AF) is a predominant aetiology of embolic stroke of undetermined source (ESUS). Evidence suggested that AF is more frequently detected by implantable loop recorder (ILR) than by conventional monitoring. However, the predictive factors associated with occult AF detected using ILRs are not well established yet. In this study we aim to investigate the predictors of AF detection in patients with ESUS undergoing an ILR. This observational multi-centre study included consecutive ESUS patients who underwent ILR implantation. The infarcts were divided in deep, cortical infarcts or both. The infarction sites were categorized as anterior and middle cerebral artery, posterior cerebral artery with and without brainstem/cerebellum involvement. Multivariable logistic regression analysis was performed to investigate variables associated with AF detection. Overall, 3,000 patients were initially identified. However, in total, 127 patients who consecutively underwent ILR implantation were included in our analysis. AF was detected in 33 (26%) out of 127 patients. The median follow-up was 411 days. There were no significant differences in clinical characteristics and comorbidities between patients with and without AF detected. AF was detected more often after posterior cerebral artery infarct with brainstem/cerebellum involvement (p < 0.001) whereas less often after infarction in the anterior and middle cerebral artery (p = 0.021). Multivariable regression analysis demonstrated that posterior cerebral artery infarct with brainstem/cerebellum involvement was an independent predictor of AF detection. Our study showed that posterior circulation infarcts with brainstem/cerebellum involvement are associated with AF detection in ESUS patients undergoing ILR. Larger prospective studies are needed to validate our findings.

Acute concurrent bilateral internal carotid artery occlusion: a teaching clinical image

Acute bilateral internal carotid artery (ICA) occlusion is a rare stroke syndrome presenting with acute coma, and patients usually have preserved brainstem function on initial examination. In this clinical image, we report a case of acute concurrent bilateral ICA occlusion. Acute bilateral ICA occlusion is an unusual entity with a poor outcome. It can mimic metabolic encephalopathies and posterior circulation infarcts and can be differentiated by careful evaluation of brainstem functions.

Long term for patients with futile endovascular reperfusion after stroke.

With the progress of thrombectomy technology, the vascular recanalization rate of patients with stroke has been continuously improved, but the proportion of futile recanalization (FR) is still quite a few. The long-term prognosis and survival of patients with FR and its influencing factors remain unclear. Consecutive patients who received endovascular treatment (EVT) for ischemic stroke were enrolled between 2013 and 2021 from a single-center prospectively registry study. We evaluated the long-term outcome of these patients by Kaplan-Meier survival analysis, and the multivariable logistic regression curve was performed to analyze influencing factors. Among 458 patients with FR, 56.4% of patients survived at 1 year, and 50.4% at 2 years. In the multivariate regression analysis, age, premorbid modified Rankin Scale (mRS), National Institutes of Health Stroke Scale (NIHSS), posterior circulation infarct, general anesthesia, symptomatic intracerebral hemorrhage (sICH), and decompressive craniectomy were found to be related to unfavorable outcomes in long-term. Age, premorbid mRS, NIHSS, general anesthesia, and sICH were predictors of long-term mortality. Futile recanalization accounts for a large proportion of stroke patients after thrombectomy. This study on the long-term prognosis of such patients is beneficial to the formulation of treatment plans and the prediction of therapeutic effects.

Development and validation of a novel scoring system for acute ischemic stroke

BackgroundThis study aimed to assess the clinical application of the Artery Occlusion Image Score (AOIS), a new metric based on computed tomographic angiography (CTA) that reflects the severity of occlusive changes in the main intracranial arteries.Materials and MethodsPatients diagnosed with acute ischemic stroke (AIS) were divided into three groups: anterior circulation infarcts (ACI group), posterior circulation infarcts (PCI group), and both anterior and posterior circulation infarcts (ACI + PCI group). The sensitivity and specificity of AOIS were evaluated using the Basilar Artery on Computed Tomography Angiography (BATMAN) score, the Clot Burden Score (CBS), and the National Institutes of Health Stroke Scale (NIHSS) as comparators through receiver-operating characteristic (ROC) curve analysis.ResultsThe final analysis included 439 consecutive patients. In the ACI group, AOIS demonstrated high sensitivity (86.3%) and specificity (85.0%) and outperformed CBS in predicting patient prognosis. In the PCI group, AOIS also showed high sensitivity (88.9%) and specificity (90.0%) and outperformed BATMAN in predicting patient prognosis. In the ACI + PCI group, AOIS positively correlated with the NIHSS score (Spearman’s ρ = 0.602, P < .001). Additionally, the scoring time of AOIS did not significantly differ from CBS and BATMAN.ConclusionAOIS is a convenient and reliable method for guiding treatment and predicting outcomes in patients with ACI or/and PCI. Furthermore, AOIS is the first CTA-based scoring system that covers both the anterior and posterior circulation, providing a convenient and reliable evaluation for patients with concurrent acute ischemic stroke in both circulations.

Abstract TP252: Forward Head Posturing as a Significant Risk Factor for Posterior Circulation Infarcts

Objective: Forward head posturing (FHP) has been associated with chronic anatomic vertebral artery disturbances possibly leading to posterior circulation ischemia. The data supporting FHP as a true risk factor of posterior circulation stroke has not been well established. We aim to study if patients with severe cervical myalgias and FHP have an increased risk of posterior circulation stroke. Methods: We identified all adult patients with posterior circulation stroke and diagnosis of cervical myalgia at Loyola University Medical Center from January 2018 to January 2023. Information on demographics and comorbidities were also collected. We then identified matched pair case-controls (based on age and gender) with non-stroke cervical myalgia patients in the same 5-year period. We compared the relevant comorbidities, C2 tilt angle, and C2-C7 tilt angle of patients to their matched controls to for statistical difference. Results: 76 patients (38 cases and 38 controls) with an average age of 64 years, including 38 (50%) females met our inclusion criteria. The average C2 tilt of cases was 22.9 degrees compared to 17.7 degrees in controls, and the average C2-C7 tilt of cases was 18.9 degrees in cases compared 10.5 degrees in controls. There were no significant differences between relevant comorbidities (including hypertension, hyperlipidemia, diabetes, atrial fibrillation, hyper-coagulopathy, or body mass index) of cases and controls. There was a significant difference of 5.2 degrees higher C2 tilt and 8.1 degrees higher C2-C7 tilt in cases compared to controls respectively (p-value = 0.03). Conclusion: In this single-center retrospective analysis, we found that after controlling for age, gender, and comorbidities, patients with posterior circulation stroke were more likely to have significantly higher C2 and C2-C7 cervical tilt (worse FHP based on radiographic standards) compared to their matched control counterparts.

Disability-free outcomes after mechanical thrombectomy: A systematic review and meta-analysis of the randomized controlled trials.

The modified Rankin Scale (mRS) score of ≤2 (functional independence) has been the most common primary endpoint of modern mechanical thrombectomy (MT) trials. However, unlike mRS 0-1, mRS score of 2 indicates disability. An important proportion of the mRS 2 patients are home dependent and report a significant decrease in their quality of life. To investigate excellent outcome (mRS 0-1) rates after MT. We systematically searched Ovid MEDLINE, Ovid EMBASE, Cochrane Central Register of Controlled Trials, Scopus, and Web of Science databases. Randomized controlled trials (RCTs) investigating the role of modern MT in acute ischemic stroke were screened. Posterior circulation and large-core infarct trials were excluded from the study. The data regarding excellent outcomes (mRS: 0-1), functional independence (mRS: 0-2), and reperfusion were collected. Twenty-two RCTs comprising 5692 patients were included in the meta-analysis. The overall mRS 0-1 rate was 31.24% (95% CI = 26.95-36.2). The rate of successful reperfusion was 81.8% (95% CI = 77.93-85.86). MT achieved significantly higher rates of mRS 0-1 compared to standard care alone (OR = 2.04; 95% CI = 1.64-2.55; P-value < 0.001), with no heterogeneity detected among studies (I2= 0%; P-value = 0.52). The direct MT and MT plus intravenous thrombolytic treatment groups' excellent outcome rates were comparable (OR = 0.98; 95% CI = 0.82-1.18; P-value = 0.863). Also, aspiration and stent retriever thrombectomy techniques provided similar excellent outcome rates (OR = 0.76; 95% CI = 0.55-1.05; P-value = 0.141). Our results prove the additional benefit of MT over standard care, using a stricter definition for favorable functional outcome. Nearly one-third of patients presenting with large artery occlusion and treated with MT had no disability at 90 days. While this is remarkable, our results also indicate that reperfusion alone is often not enough to prevent disability and underline the need for better neuroprotection strategies.

Bilateral Medial Medullary Infarct with Unique Radiological Presentation

Bilateral medial medullary infarction (MMI) is a rare subtype of stroke. The typical heart-shaped appearance on magnetic resonance imaging is pathognomonic for the bilateral medial medullary syndrome. Vertebrobasilar dolichoectasia (VBD) is a condition characterized by tortuous dilatation and marked enlargement of the basilar and vertebral arteries, and it may cause posterior circulation infarction. We present a case of a 55-year-old female patient with complaints of speech disorder, regression in consciousness, and difficulty breathing. Diffusion-weighted imaging examination was normal on arrival. In the cranial imaging after 24 h, acute infarction was observed in the bilateral medial medullary area. Time-of-flight magnetic resonance angiography revealed VBD. In this report, a case of bilateral MMI with a unique radiological appearance accompanied by VBD, which is rarely reported in the literature, is presented.

Acquired Cerebral Achromatopsia Secondary to Occipital Stroke

Background: Acquired cerebral achromatopsia, a form of color vision impairment, is infrequently reported and often results from injuries to the occipital cortex. Case Presentation: We detail a case of a middle-aged women with vascular risk factors who visited the emergency department with blurred vision and disturbances in color perception, characterized as an inability to differentiate colors. A notable finding in her neurological examination was homonymous hemianopia. Hyperacute magnetic resonance imaging revealed a subacute infarction in the right occipital lobe. As she was outside the treatment window for alteplase and invasive interventions, she received aspirin and clopidogrel as treatment. Discussion: Patients with posterior circulation strokes often present with non-specific symptoms, which can lead to delayed diagnoses and treatment. Acquired cerebral achromatopsia, the inability to perceive color after acute brain injury, is a rare phenomenon associated with PCA stroke that has not been well studied yet. It usually involves the ventral occipitotemporal cortex in V4 complex, which anatomically is theorized to be the brain&amp;apos;s color center. A comparison was made between two instances of acquired cerebral achromatopsia. In the first case, a 60-year-old woman displayed hemi-achromatopsia in the right visual field. In the second case, a 74-year-old woman suffered two strokes. The first stroke on the left hemisphere resulted only in a right homonymous hemianopia with normal color perception; however, upon the occurrence of the second stroke on the right hemisphere, she developed full field achromatopsia. The contrasting presentations of these cases after lesions in the ventral posterior regions of their left hemisphere suggests a hypothesis that individual differences might exist in the hemispheric laterality of color centers in the brain. Our patient experienced a right subacute occipital stroke; however, she exhibited bilateral achromatopsia. The exact cause of this full field achromatopsia from this specific lesion remains uncertain, but her presentation might support the hypothesis. Conclusion: Posterior circulation stroke infarctions often present with nonspecific symptoms making timely diagnosis and management challenging. Achromatopsia is an infrequent and subtle manifestation of posterior circulation infarctions that warrant further investigations and management.

Association between vertebral artery dominance and basilar artery curvature in migraineurs: an anatomical magnetic resonance imaging study.

Numerous studies demonstrate a link between cerebrovascular alterations and migraine pathogenesis. We investigated the association between migraine and vertebral artery dominance (VAD), basilar artery (BA) curvature, and elongation. This cross-sectional MRI study included 74 migraine patients and 74 control subjects aged between 18 and 55 years. Diameters of the intracranial part of the vertebral artery (VA) and BA, height of the BA bifurcation, and total lateral displacement of the BA were measured. In addition, we investigated the directional relationship between VAD and BA curvature. There were no statistically significant differences between the groups regarding VA and BA diameters and total lateral displacement of the BA. The height of the BA bifurcation was found to be significantly higher in migraine patients compared to controls (p = 0.002). The left-side VAD was more frequent in migraine patients compared to control subjects (60.8% (45/74) vs 41.9% (31/74), p = 0.001). In migraine patients, particularly those with aura (MwA) patients, with left-side VAD, the rate of BA displacement to the right side is significantly higher than those with right-side VAD or non-VAD (p = 0.022). Also, we found that total lateral displacement of the BA is correlated with VA asymmetry in patients with MwA (r = 0.538, p = 0.007). VAD and its opposite-directional relationship with the lateral displacement of the BA may be associated with migraine pathophysiology. Together with aging, this association may contribute to changes in the vertebrobasilar system (VBS) geometry which may result in increased risk for posterior circulation infarction (PCI) in migraineurs.

Circulus Willis Anomalies Diagnosed with CT Angiography and Evaluation of Their Relations with Ischemic Stroke

Our aim in this study is examining the frequency of posterior communicating artery (PCoM), Anterior Cerebral Artery A1 segment (ACA AI) and Fetal type posterior cerebral artery (FPCA) anomalies and their effects on ischemic stroke by retrospectively analyzing examinations of Computerized Tomography Angiography (CTA) taken in our hospital within 2017. 22 cases (26.5%) diagnosed with bilateral hypoplastic / aplastic PCoA anomaly, were diagnosed with anterior circulation infarct, 24 cases (28.9%) were diagnosed with posterior circulation infarct, but 37 cases (44.6%) were not diagnosed with ischemic stroke. 17 (37.8%) of the cases who have unilateral hypoplastic / aplastic PCoA anomaly, were diagnosed with anterior circulation infarct, 14 cases (31.1%) were diagnosed with posterior circulation infarct. 13 (26%) of 50 cases diagnosed with unilateral hypoplastic / aplastic ACA A1 segment, were diagnosed with anterior circulation infarct, 10 cases (20%) were diagnosed with posterior circulation infarct. 27 cases (54%) were not diagnosed with ischemic stroke. Both of 2 cases diagnosed with bilateral hypoplastic / aplastic ACA A1 segment, had anterior circulation infarct. 4 (30.8%) of 13 cases diagnosed with unilateral FPCA anomaly, were diagnosed with anterior circulation infarct, 3 cases (23.1%) were diagnosed with posterior circulation infarct, 6 cases (46.2%) did not have ischemic stroke symptoms. In conclusion, even though these variations’ role in optimum stroke prophylaxis in individuals having one or more stroke risk factors, has not determined yet, there is no doubt that clinical researcher will eliminate these uncertainties in future studies.

48 A Case of an Extremely Rare CNS C. Bantiana Infection with Cognitive Sequela in an Immunocompetent Patient

Objective:Central nervous system (CNS) infections with the dematiaceous fungus Cladophialophora bantiana (C. bantiana) are extremely rare, with approximately 120 confirmed cases reported as of 2016. C. bantiana is a highly neurotropic and thermotolerant fungus found in soil worldwide. The mode of entry into the CNS remains unknown, but inhalation of fungal spores or subcutaneous trauma have been suggested. Entry of fungal spores can cause cerebral phaeohyphomycosis with the main clinical manifestation of a brain abscess. Symptoms are non-specific and can include headache, fever, hemiparesis, aphasia, visual disturbances, and confusion. C. bantiana cerebral phaeohyphomycosis occurs in both immunocompetent and immunocompromised individuals, with a slightly higher prevalence in immunocompetent males for unknown reasons. Diagnosis is often delayed due to its nonspecific presentation and prevalence in individuals without pre-existing immunological disease. Prognosis is poor, with mortality rates of approximately 70% despite aggressive treatment. Treatment is not standardized but may include several anti-fungal agents and surgical intervention. Case reports documenting the variability seen with cerebral phaeohyphomycosis by C. bantiana can provide valuable insight into this emerging disease. C. bantiana’s neurotropic propensity also warrants cognitive investigation of the disease; however, there are currently limited descriptions of cognitive findings in published case reports of C. bantiana CNS infections.Participants and Methods:Here, we describe a case of a 35-year-old immunocompetent, college educated male with a CNS C. bantiana infection, presumably following a fall while biking in Costa Rica. First symptoms included left sided facial palsy, headache, and hand weakness, prompting extensive diagnostic workup, with diagnosis of C. bantiana infection confirmed 8 months after symptom onset. Initial treatment included anti-fungal agents and steroids, but his course of infection was complicated by infectious vasculitis with posterior circulation infarcts and obstructive hydrocephalus requiring ventriculoperitoneal shunt placement two years following the fungal infection diagnosis. The most recent brain MRI revealed encephalomalacia in global periventricular areas, two small masses, likely representing small fungal phlegmons, and enhancing lesions in the upper cervical spinal canal.Results:The patient reported cognitive changes following the infarcts and shunt placement including difficulties with spatial navigation, following directions, and articulating thoughts. Memory concerns and lapses in judgment were also reported. Results from a neuropsychological evaluation revealed high average baseline intellectual abilities with decrements in visuospatial processing, processing speed, executive functioning, and aspects of memory stemming from his executive dysfunction. At the time, his cognitive profile suggested parietal and frontosubcortical systems disruption meeting criteria for mild cognitive impairment. Two years later, the patient reported continuing cognitive difficulties prompting a follow-up neuropsychological evaluation. Results were similar to his first evaluation, revealing deficits in aspects of visuospatial processing, decreased verbal and visual learning, bradyphrenia and processing speed deficits, and difficulties with visual planning and organization. Minimal anxiety and depression, but increased apathy and executive dysfunction were endorsed on self-report measures.Conclusions:This case report highlights neurological sequela resulting from CNS infection with C. bantiana, -with a course complicated by subsequent strokes, hydrocephalus, and cognitive impairment-, and contributes additional insight into the relatively limited existing reports of an extremely rare but emerging disease.