Right-sided Hemiparesis Research Articles

Subacute Subdural Hematoma Presenting as Non-Fluent Aphasia

We present the case of a 69-year-old male, alcohol consumer, who was brought in by the ambulance for language impairment with onset two days prior to presentation in our hospital. Medical history revealed therapeutically neglected gout and colchicine allergy. On neurological exam, the patient presented predominantly motor aphasia with poor verbal fluency and anomic elements, mild right-sided hemiparesis 4/5 MRC and right-sided Babinski sign. Still, he was conscious and cooperative, and denied any recent head trauma or headache. Based on clinical picture, an acute cerebrovascular event was suspected, and the patient was hospitalized. However, brain CT revealed a late subacute subdural hematoma in the left hemisphere, with maximum thickness of 20 mm and displacement of median structures by 12 mm to the right (subfalcine herniation). The patient was then rapidly transferred to a Neurosurgical department for appropriate treatment and care.

Motor Recovery and the Fracture Risk in Patients during Post-Stroke Rehabilitation

Indices of motor recovery and the fracture risk were estimated in patients examined after stroke and suffering from osteoporosis or osteopenia. Our study included 57 patients (29 with osteoporosis and 28 with osteopenia) who received treatment at a rehabilitation clinic. The average age of patients was 69.62 ± 9.86 years. The data were based on anamneses, questionnaires, and bone mineral density (BMD) measured by the DXA method. The fracture risk was assessed by applying the FRAX index. The functional status was evaluated by the Barthel index (BI), and motor recovery was evaluated by the Signe Brunnstrom scale (SB). The prevalent impairment was left-sided hemiparesis (n = 30; 52.63%). Most patients with stroke and a reduced BMD (42, 73.68%) had low and intermediate risk estimates, while 15 (26.31%) patients had a high risk of major osteoporotic fractures. Patients with stroke and osteopenia had a significantly higher risk for major osteoporotic fractures, compared to patients with osteoporosis (P < 0.001). Concerning the hip fracture, more patients with a reduced BMD (34, 59.65%) had a lower fracture risk than those with an intermediate (15, 26.31%) or high risk (8, 14.03%). The majority of patients had significantly higher scores on the SB scale in lower segments of the extremities. No statistically significant difference in motor recovery between left- and right-sided patients with stroke and reduced BMD was found (P ˃ 0.01). Thus, an association between the high risk level for major osteoporotic fractures and osteopenia was found. Patients with right-sided hemiparesis and osteopenia had more significant reduction in the BMD on the femur, when compared to patients with left-sided hemiparesis. Patients with stroke and an increased fracture risk require preventive individual therapeutic programs in order to avoid fractures.

Acute alcohol intoxication may cause delay in stroke treatment \u2013 case reports

BackgroundThe signs and symptoms of acute alcohol intoxication resemble those of vertebrobasilar stroke. Due to their shared symptoms including double vision, nystagmus, dysarthria, and ataxia, the differential diagnosis of alcohol intoxication and vertebrobasilar stroke may pose a challenge. Moreover, if alcohol intoxication and stroke occur simultaneously, the signs and symptoms of stroke may be attributed to the effects of alcohol, leading to delayed stroke diagnosis and failure to perform reperfusion therapy.Case presentationsThree cases of alcohol intoxication and stroke are presented. The first patient (female, 50 years old) had dysarthria, nystagmus and trunk ataxia on admission. Her blood alcohol level was 2.3‰. The symptoms improved after forced diuresis, but 5.5 h later progression was observed, and the patient developed diplopia and dysphagia in addition to her initial symptoms. Angiography showed occlusion of the basilar artery. Intraarterial thrombolysis was performed. The second patient (male, 62 years old) developed diplopia, dysarthria and trunk ataxia after consuming 4-units of alcohol, and his symptoms were attributed to alcohol intoxication. Two hours later, neurological examination revealed dysphagia and mild right-sided hemiparesis, which questioned the causal relationship between the symptoms and alcohol consumption. Cerebral CT was negative, and intravenous thrombolysis was administered. The third patient (male, 55 years old) consumed 10 units of alcohol before falling asleep. Three hours later, his relatives tried to wake him up. He was unresponsive, which was attributed to alcohol intoxication. When he woke up 8 h later, right-sided hemiparesis and aphasia were observed, and cerebral CT already revealed irreversible ischemic changes.ConclusionsOur cases show that alcohol consumption may interfere with stroke diagnosis by mimicking the signs and symptoms of vertebrobasilar stroke. Moreover, attributing the symptoms of stroke to alcohol intoxication may delay stroke diagnosis resulting in failure of reperfusion therapy. Based on our observations we conclude that stroke should be considered in the case of worsening symptoms, dysphagia, hemiparesis and disproportionately severe signs that cannot be attributed to the amount of alcohol consumed. In the case of ambiguity, ambulance should be called, and if stroke cannot be excluded, specific therapy should be administered.

Cardiac myxoma with glandular elements: An unusual histologic variant with a brief review of the literature

Cardiac myxoma with glandular elements is an unusual histologic variant of cardiac myxoma and constitutes 2%–5% of all cardiac myxomas. Here, we report a case of cardiac myxoma with glandular elements in a 34-year-old male, who presented with right-sided hemiparesis following a cardiovascular attack 2 months back. Echocardiography revealed a large right atrial mass measuring 3.5 cm × 3.5 cm × 2 cm. Under cardiopulmonary bypass, left atrial mass was excised. Histopathological and immunohistochemical examination of the mass confirmed the diagnosis of cardiac myxoma with glandular elements. It is important to recognize this variant to avoid misdiagnosis of metastatic adenocarcinoma due to its rarity as well as due to its unusual morphological features.

A rare case of gliosarcoma after acute hemorrhage

Gliosarcoma (GSM) is a rare primary neoplasm of the brain, characterized by a biphasic tissue pattern with alternating areas displaying glial and mesenchymal differentiation. GSM is usually treated as glioblastoma multiforme (GBM) and the prognosis is poor. Here, we discuss a 50-year-old male presenting with sudden decreased consciousness and a history of recent headache. A noncontrasted computed tomography of the brain revealed a well-circumscribed, hyperdense lesion in the left frontal lobe with significant perilesional edema, suggestive of an intracranial hemorrhage. The patient underwent emergency craniotomy to evacuate the hematoma. Intraoperatively, a mass was present, and fluid around the mass was collected and analyzed. Cytology revealed the presence of malignant cells. A 1-week postmagnetic resonance imaging (MRI) revealed a heterogenously enhancing mass in the left frontal lobe, suggestive of a high-grade glioma. The patient was then treated with radiation followed by adjuvant treatment with temozolomide plus bevacizumab. One year after the surgery, the patient was readmitted with headache, right-sided hemiparesis, and seizure. A follow-up MRI found a residual mass in the same region. A second surgery was performed. Histopathology examination showed GSM, and this was confirmed with an immunohistochemistry panel including glial fibrillary acid protein and vimentin. GSM is a rare variant of GBM. Intracranial hemorrhage is an uncommon clinical presentation of GSM. Diagnosis is established by histopathology. Treatment is surgery, followed by radiotherapy and chemotherapy. The study was approved by the Health Research Review Committee of Mohammad Hoesin Central General Hospital and Faculty of Medicine Sriwijaya University (No. 089/kepkrsmhunsri/2019) on March 1, 2019.

Cardioembolic ischemic stroke as the initial presenting complaint of a patient with acute infective endocarditis and acquired immunodeficiency syndrome

Human immunodeficiency virus (HIV) infection is an independent predictor of ischemic stroke, especially in the younger age group. Approximately 1%–5% of HIV/acquired immunodeficiency syndrome patients develop stroke. A 16-year-old male presented with a decreased level of consciousness and a history of right-sided hemiparesis, fever, cough, and dyspnea. The patient was an intravenous drug user (IVDU). Examination revealed the following: blood pressure: 130/70 mmHg, heart rate: 124×/min, temperature 38.5°C, and respiratory rate: 26×/min. Electrocardiographic findings revealed the following: sinus tachycardia: 124×/min, right-axis deviation, incomplete right bundle branch block, and right ventricular hypertrophy. Laboratory findings were as follows: microcytic hypochromic anemia (7.33 g/dL), leukocytosis (32.2 × 10^3/μL) with shift to the left, hyponatremia (122 mmol/L), HIV was positive, and chest X-ray showed pneumonia. Echocardiography showed vegetation in the posterior mitral leaflet, mitral regurgitation, and tricuspid regurgitation with an intact interatrial septum. Computed tomography scan revealed ischemic stroke of the left parieto-occipital lobe. HIV-infected individuals are at 1.5 times increased risk of stroke compared to those without. This case involves an IVDU and a HIV-positive young male presenting with large ischemic stroke in large-vessel territory, suggestive of embolic origin. A part of vegetation on the left side of the heart of this patient dislodged and caused a cerebrovascular accident. There was also unconfirmed suspicion of pulmonary embolism from the right side of the heart. Empiric antibiotics should be started before tailoring to the result of blood culture. Endocarditis conveys a significant risk of cerebral embolism resulting in ischemic stroke and a potentially dismal prognosis.

Recurrent Stroke in a Ghanaian Patient With Polycythemia

BackgroundPolycythemia is a rare but important preventable cause of stroke with potential for recurrence when not identified and appropriately managed. Case PresentationThis is a case of a 55-year-old Ghanaian who presented to our tertiary facility after a 2-month delay with a history of sudden onset of right-sided hemiparesis and expressive aphasia. He had suffered a previous stroke with left hemiparesis 2 years previously where hypertension and polycythemia were identified and treatment initiated. However, patient defaulted treatment for 18 months prior to the onset of recurrent stroke. A cranial CT scan revealed chronic right and subacute left middle cerebral artery territorial infarcts. Presenting hematocrit was 71%. Treatments initiated included high dose hydroxyurea, venesections, and dual antiplatelet therapy of Aspirin and Clopidogrel. He has since been discharged and remains stable under follow-up with moderate functional deficits– Modified Rankin score of 3/6 and the hematocrit of 54% at 3 months postdischarge. ConclusionsDefault of therapy for polycythemia is associated with a profound risk of recurrent strokes requiring patient education and support to prevent the devastating consequence of this modifiable but rare cause of stroke. This case report highlights the challenges of instituting secondary prevention for stroke in resource-limited settings.

Temporal Profile of CT and T2*-Weighted Gradient-Echo MRI in a Patient with Unilateral Thalamostriate Vein Thrombosis

Deep cerebral venous system thrombosis (DCVST) is an uncommon variety of thrombosis that accounts for 11% of cases of cerebral venous thrombosis. Thalamostriate vein (TSV) thrombosis is further rare among patients with DCVST. Although patients with cerebral venous thrombosis commonly have characteristic neurological deficits including headache, deterioration of consciousness, and seizures, patients with DCVST do not necessarily show such symptoms. Therefore, diagnose of DCVST is sometimes difficult. Here we report a case of TSV thrombosis with a unilateral basal ganglion lesion presenting with right-sided hemiparesis. A 61-year-old Japanese female was referred to our hospital. On neurological examination, she had no headache but presented with right facial paresis with dysarthria. Her right hemiparesis was present in the upper and lower extremities. We repeatedly performed brain computed tomography (CT) and T2*-weighted conventional gradient-echo (GRE) magnetic resonance imaging, and conclusively diagnosed as left TSV thrombosis. We firstly report a case of unilateral DCVST associated with TSV thrombosis in which a temporal profile of CT and T2*-weighted GRE images was obtained. Although DCVST is a rare clinical entity, physicians should be aware that repeated radiological observations can be useful for the diagnosis and early medical treatment for DCVST.

Effect of kinesthetic illusion induced by visual stimulation on ankle dorsiflexion dysfunction in a stroke patient: ABAB single-case design

ABSTRACTThe purpose of this study was to investigate the effect of simultaneous intervention with the kinesthetic illusion induced by visual stimulation (KiNvis) and voluntary exercise on ankle dorsiflexion dysfunction in a patient with right-sided stroke hemiparesis. Within an ABAB single-case design, we conducted two phases each lasting five days. Phase A represented the baseline during which only voluntary ankle dorsiflexion (VAD) was performed. Phase B involved simultaneous performance of VAD and KiNvis. We measured the angle of ankle joint dorsiflexion (AJD), and the 10 m maximum walking speed (10MWS). AJD and 10MWS were significantly improved in phase B.

Levamisol-induced leukoencephalopathy: clinical case

This is a description of a clinical case of levamisole-induced leukoencephalopathy. A few hours after the single intake of the immunomodulator levamisole (150 mg), the patient developed following cerebral symptoms: febrile fever, dizziness, frequent urination, impaired color vision, divergent strabismus, unsteady gait, severe weakness, increased drowsiness, retardation, delusions. The symptoms progressed towards a full clinical picture for about 2 months. The course of the disease was of a wavy nature: left-sided hemiparesis and the left facial nerve palsy were present at the beginning, with later inversion of symptoms represented by the right-sided hemiparesis and the right facial nerve palsy combined with dysarthria. Magnetic resonance imaging (MRI) revealed multiple foci of demyelination in both hemispheres of the brain that regressed after corticosteroid therapy administration. No abnormalities of the cerebrospinal fluid were detected. No pathology of the fundus was evident. The evoked potentials of the brainstem (auditory and visual) and somatosensory evoked potentials from the hands and feet were within normal limits. Plasmapheresis (3 procedures, each 2 liter, with intravenous administration of 1 g of solu-medrol after each session) was performed in the acute phase, which benefited the decrease in severity of the neurological symptoms. Vascular and metabolic therapy was performed afterwards, with the regression of the neurologic symptoms. No specific therapy was administered after the woman was discharged from the hospital. For a 10-year survey after the acute demyelinating process outbreak there’s a complete regression of neurologic symptoms and positive dynamics of the patient’s MRI. The woman is fully adapted physically, emotionally and socially.

WED 170 The utility of brain FDG-PET in a patient with natalizumab associated PML-IRIS

Natalizumab, a highly effective disease modifying drug used in relapsing remitting multiple sclerosis (RRMS), is associated with progressive multifocal leukoencephalopathy (PML), a fatal intracerebral demyelinating disease caused by the JC virus that can be worsened with concurrent use of steorids. Stopping natalizumab in the context of PML can cause immune reconstitution inflammatory syndrome (IRIS) that can be treated with steroids. IRIS can be indistinguishable from PML on MRI - thus causing a clinical conundrum.We describe a woman with RRMS on Natalizumab who developed dysarthria and right-sided hemiparesis. MRI demonstrated non-enhancing peridentate white matter signal abnormality in the right middle cerebellar peduncle (RMCP). Cerebrospinal fluid JC virus DNA was &gt;1 million copies/ml. PML was diagnosed and Natalizumab withdrawn. Four weeks later she developed bulbar weakness and left-sided hemiparesis despite falling JC virus DNA. Repeat MRI demonstrated new extensive pontine changes consistent with PML-IRIS.FDG-PET imaging confirmed focal areas of hypometabolism at the original site of PML and multiple areas of hypermetabolism in the left pons and middle cerebellar peduncle, suggestive of IRIS. Her clinical deterioration was attributed to IRIS and Prednisolone was commenced.In this case FDG-PET scanning helped distinguish between PML and IRIS, guiding patient management.

Acute Subclavian Artery Thrombosis Secondary to Oral Contraceptive Agent Consumption: A Case Report

Subclavian artery thrombosis is an uncommon cause of limb ischemia in females without a history of vasculopathy. This condition usually occurs secondary to atherosclerotic changes and hypercoagulable states, which are generally asymptomatic. However, it can manifest with such symptoms as coldness, pain, and pulselessness in the upper extremity. Herein, we presented a 40-year-old female admitted to our hospital with three days history of right-side hemiparesis and complaints of imbalance and vertigo. The patient had a history of 2-month consumption of high-dose oral contraceptive (OCP) agents for birth control purposes. Cervical magnetic resonance angiography showed a significant occlusion in the proximal part of the left subclavian artery, leading to the diagnosis of subclavian artery thrombosis secondary to the use of long-term high-dose OCP. Our diagnosis was confirmed with the Doppler color sonography. This case demonstrated the importance of a full assessment regardless of the patient’s chief complaints. This kind of assessment allows for a faster and more effective management, thereby reducing the associated costs. Therefore, any suggestive signs or symptoms of arterial thrombosis should be followed up even in low-risk patients. Accordingly, in case the achievement of confirmatory findings regarding the diagnosis of arterial thrombosis, the patient should be immediately subjected to proper medical and surgical interventions.

An unusual case of inflammatory meningitis in a young man with systemic lupus erythematosus

We describe a man presenting with unusual neurological manifestations of systemic lupus erythematosus (SLE) including pachymeningitis, aseptic meningitis and encephalitis with grossly elevated cerebrospinal fluid protein, responding to immunosuppression. Initially he had intermittent dysarthria, dysphasia and unilateral upper limb weakness. One month later he experienced dysphasia, right-sided hemiparesis and confusion. Cerebrospinal fluid (CSF) analysis showed a white cell count of 70 x 106/litre and an unusually elevated protein level of 5.39 g/litre. An MRI brain showed dural and leptomeningeal enhancement compatible with a meningitic process. He improved with cefotaxime and aciclovir. On day seven of antimicrobials he developed left-sided weakness, sensory inattention and a left homonymous hemianopia. He responded well to intravenous methylprednisolone. On switching to oral prednisolone he developed expressive dysphasia, a right inferior quadrantanopia and seizures. His bloods were suggestive of macrophage activation syndrome. The patient improved with methylprednisolone and intravenous immunoglobulins, and the improvement was sustained on switching back to oral prednisolone. The prevalence of neuropsychiatric manifestations of SLE varies between 14 and 80% and according to the American College of Rheumatology includes 19 conditions. This case is unique because although some features were in keeping with aseptic meningitis the MRI appearances were also suggestive of pachymeningitis.

Unilateral moyamoya disease mimicking intracranial hemorrhage in a pediatric patient: Surgical treatment with encephalo-duro-myo-synangiosis in a progressive disease

Abstract Background Moyamoya disease (MMD) is characterized by progressive bilateral internal carotid artery stenosis and its distal branches. When angiographic findings are unilateral, the diagnosis is considered to be probable MMD. Surgery is recommended treatment of patients with deterioration caused by progressive cerebral ischemic events. Different techniques have been described, and the encephalo-duro-myo-synangiosis (EDMS) procedure is highly recommended for patients with rapid deterioration. A case of unilateral MMD mimicking intracranial hemorrhage in a pediatric patient is reported. Case description A 14-year-old girl was referred to our center due to a decreased level of consciousness. Physical examination revealed right-sided hemiparesis; however, a brain CT scan showed multiple hyperdense masses mimicking a hemorrhagic lesion. A brain MRI showed a large hypointensity in the temporoparietal, suggesting a vascular lesion. In all children that exhibit encephalitis, vascular events such as MMD should be considered. An emergency surgical EDMS procedure was performed, and the patient regained consciousness and exhibited no TIAs during the follow-up period. A postoperative brain MRI showed an improvement in brain vascularity. Conclusion After EDMS, a considerable degree of neurological recovery was observed in our patient with rare unilateral MMD mimicking intracranial hemorrhage. We found that the progression of clinical improvement after indirect revascularization in our case was due to EDMS. Surgical treatment with EDMS is reasonable for MMD because it allows for flexible revascularization that adequately addresses the requirement for new blood supply in the ischemic lesion. The EDMS procedure is followed by an observation period to preclude the possibility of the patient developing definite MMD.

Anti-NMDAR Encephalitis in a 13-Year-Old Female: A 24-Month Clinical Follow-Up

Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is a rare autoimmune disorder manifesting as seizures, movement disorders, and psychiatric changes. However, there have been few case reports concerning this disorder in South Korean children. The current case report describes a pediatric patient with anti-NMDAR encephalitis. A 13-year-old female patient developed clonic movements of the right arm followed by aphasia, paresthesia, and right-sided hemiparesis. The electroencephalogram (EEG) results indicated electroclinical seizures arising from the left temporal area. Brain magnetic resonance imaging (MRI) revealed high signal intensity and cortical swelling in left temporal lobe. Anti-NMDAR antibodies were detected in the cerebrospinal fluid (CSF). The patient was treated with intravenous immunoglobulin and high-dose methylprednisolone and showed partial improvement in language skills, paresthesia, and motor power. The brain MRI and EEG results also indicated improvement. However, anti-NMDAR antibodies persisted in the CSF. After four doses of rituximab, the patient exhibited complete recovery of language and motor skills, and was seizure free under treatment with antiepileptic medication. There were no residual anti-NMDAR antibodies in the CSF at her 24-month follow-up visit. This case report elucidates the benefits of early intervention using rituximab to improve neurological deficits and achieve baseline recovery in patients with anti-NMDAR encephalitis.

Feasibility of robot-based perturbed-balance training during treadmill walking in a high-functioning chronic stroke subject: a case-control study

BackgroundFor stroke survivors, balance deficits that persist after the completion of the rehabilitation process lead to a significant risk of falls. We have recently developed a balance-assessment robot (BAR-TM) that enables assessment of balancing abilities during walking. The purpose of this study was to test feasibility of using the BAR-TM in an experimental perturbed-balance training program with a selected high-functioning stroke survivor.MethodsA control and an individual with right-side chronic hemiparesis post-stroke were studied. The individual post-stroke underwent thirty sessions of balance-perturbed training that involved walking on an instrumented treadmill while the BAR-TM delivered random pushes to the participant’s pelvis; these pushes were in various directions, at various speeds, and had various perturbation amplitudes. We assessed kinematics, kinetics, electromyography, and spatio-temporal responses to outward-directed perturbations of amplitude 60 N (before training) and 60 N and 90 N (after training) commencing on contact of either the nonparetic-left foot (LL-NP/L perturbation) or the paretic-right foot (RR-P/R perturbation) while the treadmill was running at a speed of 0.4 m/s.ResultsBefore training, the individual post-stroke primarily responded to LL-NP/L perturbations with an in-stance response on the non-paretic leg in a similar way to the control participant. After training, the individual post-stroke added adequate stepping by making a cross-step with the paretic leg that enabled successful rejection of the perturbation at lower and higher amplitudes. Before training, the individual post-stroke primarily responded to RR-P/R perturbations with fast cross-stepping using the left, non-paretic leg while in-stance response was entirely missing. After training, the stepping with the non-paretic leg was supplemented by partially recovered ability to exercise in-stance responses on the paretic leg and this enabled successful rejection of the perturbation at lower and higher amplitudes. The assessed kinematics, kinetics, electromyography, and spatio-temporal responses provided insight into the relative share of each balancing strategy that the selected individual post-stroke used to counteract LL-NP/L and RR-P/R perturbations before and after the training.ConclusionsThe main finding of this case-control study is that robot-based perturbed-balance training may be a feasible approach. It resulted in an improvement the selected post-stroke participant’s ability to counteract outward-directed perturbations.Trial registrationClinicalTrials.gov Identifier: NCT03285919 – retrospectively registered.

Campylobacter fetus prosthetic valve endocarditis presenting as a stroke

IntroductionCampylobacter is a common pathogen of the gastrointestinal tract, but invasive disease is rare. Campylobacter fetus can play a role in osteomyelitis, meningitis and joint infection and has a prediliction for the vascular endothelium, causing mycotic aneurysms, thrombophlebitis and endocarditis. Here we present a case of prosthetic valve endocarditis caused by C. fetus and a review of the literature.Case presentationAn 85-year-old woman with a tissue aortic valve replacement and atrial fibrillation was admitted to hospital with tonic-clonic seizures, right-sided hemiparesis, facial droop and hemianopia. Multiple cerebral emboli were seen on magnetic resonance imaging of the brain. Blood cultures grew C. fetus and an echocardiogram showed thickening and restricted movement of the aortic valve, a significant difference from an echocardiogram done 2 months before when the same organism was again isolated in blood cultures. She improved after treatment with 6 weeks of amoxicillin and 2 weeks of synergistic gentamicin for prosthetic valve endocarditis.ConclusionThere have only been five previously reported cases of C. fetus prosthetic valve endocarditis and this is the only patient who presented as a stroke. The majority of surviving patients required replacement of the affected valve with only one other patient surviving in the absence of surgery. No guidelines exist on the optimum treatment of C. fetus endocarditis and this case reports adds to the growing literature on the appropriate management for this rare and potentially devastating disease.

Stereotactic neuronavigation-assisted evacuation of intracranial abscess localized in the thalamus. A case report

Introduction: A brain abscess is a localized focal area of intracerebral infection that develops into a collection of pus surrounded by a well vascularized capsule. It has a rare incidence of 2% of all space occupying lesions and the deep-seated thalamus as a location is reported in 1.3 to 6% of all brain abscesses. The use of stereotactic neuronavigation-guided surgical evacuation is a minimally invasive option for achieving good treatment results. Materials and Methods: A 67-year-old female with constant headache, vertigo, staggering and muscle weakness for the right leg developed memory problems and confusion few days prior to admission in the Department of Neurosurgery. Upon examination, raised intracranial pressure, right-sided spastic hemiparesis, and memory and cognitive disturbance were present. The laboratory results showed leukocytosis, elevated glucose, cholesterol and C-reactive protein levels. A computed tomography (CT) scan showed a circular ring-like lesion localized in the region of the left thalamus that enhanced its peripheral hyperdensity after contrast application. Neuronavigation-assisted surgical evacuation was executed. A biopsy needle was inserted in the left thalamic region and the evacuated sample was sent for pathological and microbiological examinations. Results: The lesion was verified as an abscess and antibiotic therapy was prescribed for 20 days based upon the isolated bacterium and its sensitivity. Conclusion: An abscess localized in the deep-seated region of the brain is a diagnostic and therapeutic challenge. Frameless neuronavigation-guided surgical procedure is an elegant option for minimally invasive approach that allows evacuation and additional examination for correct diagnosis and effective treatment.

Chronic subdural hematoma associated with fahr syndrome: A clinical association or just a simple coincidence?

The Fahr syndrome (FS) is a rare degenerative neurological disorder (its prevalence is <0.5%). FS is distinguished by the presence of abnormal bilateral intracranial calcifications with a predilection for the basal ganglia, also presented by movement disorders such as parkinsonism, paresis, and speech disorders. Chronic subdural hematoma (CSH), which is typically the result of mild head trauma, is a regularly encountered condition in elderly. A 63-year-old man has referred to our clinic from another hospital with a history of mild head trauma approximately a month ago. At the time of admission, the patient's Glasgow Coma Scale point was 15 points. In the history, there was only mild ataxia and right-sided hemiparesis. The laboratory examination revealed no electrolytes level abnormalities and normal endocrinal test examinations. Computed tomography revealed bilateral calcifications of basal ganglia, dentate nuclei which were misinterpreted as intracerebral contusion; with CSH of left temporal and parietal region. The hematoma was evacuated by burr-hole drainage. The patient was discharged 5 days after the surgery. The pathophysiology of FS is still unrevealed. There are some suggestions such as secondary to local disturbance of blood-brain barrier or a calcium neuronal metabolism disorder. However, on the other hand, local blood-brain barrier disturbance would also take part in CSH pathology. We hypostasized that patients with the history of FS, who had mild head traumas, might prone to subdural collections. On the other hand, FS and CSH coexistence is very unusual. Neurosurgeons might keep in mind FS when bilateral calcifications are seen in a patient.

Successful microsurgical treatment of intracranial aneurysms in infants: a retrospective study and literature review.

Intracranial aneurysms are extremely rare in infants, especially less than 1year old. This study aimed to analyze the frequency of infantile intracranial aneurysm in our department and investigate the clinical characteristics, treatment strategies, and outcomes of this disease. Six infants under 1year old in 4350 patients with intracranial aneurysms were retrospectively analyzed from January 2010 to December 2016. The patients (5 females and 1 male) ranged in age from 2 to 11 (mean age, 4.67) months. Four patients presented with generalized seizure and vomiting, 3 showed lethargy, 1 presented eye deviation, and 1 had right-sided hemiparesis. Radiographically, two aneurysms were localized in the middle cerebral artery (MCA) of the M2 segment, two were located in the M3 segment of MCA, one was located at left MCA bifurcation, and one was located at the nonbranching site of the left supraclinoid internal carotid artery. All these lesions were successfully managed with aneurysm clipping or resection, and the improvement of neurological deficits was achieved in all patients. Intracranial aneurysms should be considered in the differential diagnosis of infants who present with acute raised intracranial pressure. An improvement of neurological deficits is noted in infants who are managed promptly with microsurgical techniques of clipping during the long-term follow-up.