Thalamic Infarction Research Articles

Successfully intravenous thrombolytic therapy in systemic lupus erythematosus-related ischemic stroke: A case report.

Stroke is a relatively frequent complication occurring in patients with systemic lupus erythematosus (SLE). The increasing number of patients with Ischemic Stroke secondary to SLE aroused the clinician's concern. SLE thrombosis markers, diagnostic high-resolution magnetic resonance image (HR-MRI), and therapeutic interventions for acute ischemic stroke were recently coming into focus perspectives from the field. A 42-year-old female with slurred speech and numbness in her left limb was admitted to our hospital. Magnetic resonance imaging (MRI) revealed right thalamic infarction with diffusion-weighted lesions. Prior to admission, the patient had a National Institute of Health Stroke Scale (NIHSS) score of 3. In light of the clinical manifestation, the American Heart Association/American Stroke Association (AHA/ASA) Guidelines for Intravenous Thrombolysis in Acute Ischemic Stroke (2019) should be referred to. The patient was treated with thrombolytic alteplase (rt-PA). The patient was hospitalized for 2 weeks and discharged after his symptoms improved. After thrombolysis, the NIHSS score of the patient decreased to zero. The computed tomography scan was reexamined 24 hours later, and no acute changes or hemorrhage were identified in the infarcted area. Subsequent imaging and serological analyses indicated that HR-MRI of the responsible vessel was negative, but the infarction in this patient was still regarded as being caused by vasculitis of the right posterior cerebral artery in the region supplying the thalamus. This is the first case of successful intravenous thrombolytic therapy with rt-PA in a patient with SLE secondary to stroke with an NIHSS score of 3. This provides further evidence for expanding the reference of indications with rt-PA intravenous thrombolysis.

Methylfenidaat als behandeling voor hypersomnolentie als gevolg van een thalamusinfarct

Methylphenidate as a treatment for hypersomnolence due to a thalamic infarction Fatigue after a stroke can persist for a long time and has consequences for the patient’s rehabilitation. Fatigue is also associated with a higher mortality and a reduced quality of life. Hypersomnia (or hypersomnolence) is much less common after a stroke, but can seriously hinder a person’s recovery and treatment. In this article, 2 cases of severely disabling hypersomnolence after an ischemic stroke in the thalamus are presented and the typical features and treatment options are discussed. The clinical course of thalamic lesions, as well as the contribution of the electroencephalogram and medical imaging are reported. The stimulating effect of methylphenidate on the central nervous system explains the beneficial influence on the hypersomnolence in the 2 cases described here. Treatment of hypersomnia improves a patient’s recovery and quality of life after a stroke.

Coma Due to Artery of Percheron Infarction: An Unusual Case Report

Ischemic stroke attributable to obstruction of the artery of Percheron (AOP), an infrequent anatomical arterial variant perfusing both medial thalami, can pose difficult diagnostic challenges. Obstruction or occlusion of the AOP results in bilateral paramedian thalamic infarction which is an unusual and rare vascular cause of coma. We present a 65-year-old male patient who came to the emergency department with altered sensorium for 10 days. The initial computed tomography (CT) brain was normal, followed by subsequent CT revealing an ill-defined hypodensity in the ventromedial aspect of the left thalamus and ventral aspect of the midbrain. T2/fluid-attenuated inversion recovery magnetic resonance imaging illustrated hyperintensity in the mesencephalon and bilateral paramedian thalami with restricted diffusion, suggesting an AOP infarct.

Cerebrale ischemie als oorzaak van verminderd bewustzijn: het Percheron-infarct

Artery of Percheron infarction as an unusual cause of a reduced level of consciousness An acute onset of hemiparesis, aphasia or hemianopsia will promptly lead to the diagnosis of a stroke. However, a thalamic infarction does not always manifest with these classical symptoms due to its crucial role as a relay station between cortical brain structures, subcortical areas and the brainstem. The case of an 87-year-old woman with an altered state of consciousness due to bilateral thalamic ischemia as a result of an artery of Percheron infarction is reported. This case illustrates the clinical and diagnostic challenges in patients with an altered consciousness. The differential diagnosis is broad. One has to exclude a bilateral thalamic infarction since an early diagnosis of an ischemic stroke is crucial to initiate a proper treatment and thereby prevent morbidity and mortality.

Diagnostic challenges in bilateral thalamic infarction: national series of cases

Diagnostic challenges in bilateral thalamic infarction: national series of cases

An atypical stroke manifestation: Sleep disturbance in unilateral thalamic lesion

Thalamic strokes may present with a wide variety of symptoms depending on their location, volume and lateralization. Hypersomnia is a less frequent manifestation, that has been associated with unilateral paramedian thalamic ischemic lesions. We report a case of a patient who presented to the emergency department (ED) with sudden onset of hypersomnolence. Initial head computed tomography (CT) showed no signs of acute ischemia. Follow-up head CT 24 h after thrombolysis exposed a hypodense lesion on the left ventromedial thalamic and mesencephalic regions, with corresponding T2/FLAIR hyperintensity and diffusion restriction on brain magnetic resonance imaging, confirming a recent ischemic stroke. Clinicians should be aware of the association between acute hypersomnia and strategic unilateral thalamic infarcts, particularly when the initial CT scan has no signs of acute ischemia.

Successful Thrombolysis in Artery of Percheron Infarction: Grabbed an Extremely Rare Opportunity

Artery of Percheron (AOP) is an uncommon anatomical variation in the posterior circulation neurovasculature. It is a single artery arising from P1 segment of posterior cerebral artery (PCA) which supplies bilateral paramedian thalami and the rostral midbrain and as a result, occlusion of it leads to bilateral thalamic and mesencephalic infarction. Due to very low incidence (ranges from 0.1% to 2% of all ischemic strokes) and varied presentation, the diagnosis of AOP infarction requires strong clinical and radiological suspicion and hence, AOP infarction is often missed and patients are rarely thrombolysed. Here we discuss a patient with acute altered sensorium who recovered completely in short time following treatment with intra-venous thrombolysis for bilateral medial thalamic ischemic stroke due to AOP occlusion.

Neuro-Behcet’s Disease Manifesting as Bilateral Fornix and Left Thalamus Infarction

Neuro-Behcet’s disease (NBD) is defined as neurological involvement in Behcet’s disease. A 32-year-old man was admitted due to sudden memory impairment and had a history of recurrent oral/genital ulcers. Brain magnetic resonance imaging (MRI) revealed ischemic lesions in the bilateral fornix and left thalamus, and high-resolution vessel wall MRI demonstrated vasculitis in the anterior communicating artery. We report a rare case of NBD that presented as vasculitis and ischemic stroke in the bilateral fornix and thalamus.

Isolated Hypersomnia Due to Bilateral Thalamic Infarcts: A Case Report

Thalamic pathology should be considered in patients with vague nonlateralizing neurological symptoms. Diagnosis of Percheron artery infarction is challenging and ofen made later in presentation due to lack of clinical awareness and the nonclassic stroke signs/symptoms on presentation. In this article, we report a case of bilateral thalamic stroke whose clinical presentation was dominated by a sudden onset of hypersomnia.

Isolated Downgaze Palsy in a Patient with Acute Pretectum Paramedian Midbrain and Left Thalamic Ischemic Infarctions: A Case Report (P6-10.006)

Isolated Downgaze Palsy in a Patient with Acute Pretectum Paramedian Midbrain and Left Thalamic Ischemic Infarctions: A Case Report (P6-10.006)

Artery Of Percheron Infarction: A Great Mimicker

The thalamus is a deep structure located in the diencephalon, whose arterial blood supply is mainly from four branches of posterior cerebral artery. The artery of percheron (AOP) is an infrequent variation of thalamic perfusion, occlusion of which presents with a heterogenous, atypical list of symptoms without focal signs. This is in contrast to the typical, easily recognizable focal neurology of other ischemic infarcts. Therefore, AOP infarctions may be misdiagnosed, delayed in diagnosis or missed altogether. It is a rare, but vital area of neurology that needs to be studied by clinicians to facilitate an overall care for patients.We report the case of a 59-year-old lady who presented to us with bilateral complete ptosis with bilateral vertical gaze palsy and nystagmus, whose initial NCCT brain was normal. Subsequent MRI showed bilateral thalamic and midbrain ischemic infarctions in the artery of Percheron distribution. Our case highlights the importance of high degree of suspicion, early diagnosis and role of MRI in the diagnosis when initial CT is normal.

Artery of Percheron Infarction: Clinical Presentation and Outcomes.

Occlusion of the artery of Percheron (AOP) produces bilateral thalamic infarction classically leading to deficits of arousal. This nonspecific presentation complicates the diagnosis of acute ischemic stroke. We sought to describe the spectrum of clinical presentation, diagnostic neuroimaging findings, and outcomes in AOP infarction (AOPi). We conducted a keyword search of our health system's neuroimaging database from 2014 to 2022 to identify patients with AOPi. We abstracted patient demographics, clinical presentation, neuroimaging findings, acute treatment, and modified Rankin Scale (mRS) scores (at baseline, 3 months, and 12 months). We used descriptive statistics to report our findings. Our initial keyword search identified 192 potential AOPi cases. Fifteen cases of AOPi were confirmed and included in our study (8 female [53%], median age 65 years [interquartile range (IQR): 59.5-79.5], median presenting NIHSS 6 [IQR: 2-22]). Common clinical findings on presentation were systolic blood pressure (SBP) > 140: 12 patients (80%); decreased level of consciousness (LOC): 11 patients (73%); diplopia: 8 patients (57%); disorientation: 6 patients (42%); dysarthria: 4 patients (28%); and acute memory/cognitive disturbance: 3 patients (21%). Twelve cases (80%) presented to the emergency department (ED). Median time from symptom onset to ED arrival was 774.5 minutes (IQR: 202.25-3789.0), 4 cases (27%) arrived within 4.5 hours, and one patient (7%) received intravenous thrombolysis. The median time from ED arrival to stroke diagnosis was 519.0 minutes (IQR: 227.5-1307). Head CT was only diagnostic when obtained >570 minutes from time last known well; MRI was diagnostic at all time points. Rates of functional independence (mRS ≤2) at baseline, 3 months, and 12 months were 64%, 21%, and 18%, respectively. The diagnosis of stroke was considerably delayed in patients with AOPi, and only one patient received IV thrombolysis. SBP >140, impaired consciousness, and diplopia were the most common findings at presentation. CT was often nondiagnostic, but MRI demonstrated bilateral thalamic infarct in all cases. AOPi caused considerable long-term morbidity. Clinicians should maintain a high degree of suspicion for AOP stroke and consider thrombolysis in appropriately selected patients.

Teaching Video NeuroImage: Torsional Saccadic Palsy in Bilateral Thalamic Infarctions.

Teaching Video NeuroImage: Torsional Saccadic Palsy in Bilateral Thalamic Infarctions.

Acute Ischaemic Stroke in the Context of Neurosyphilis: How Does Antibiotic Therapy Help, and When Should It Be Given?

Neurosyphilis (NS) refers to a central nervous system infection caused by Treponema pallidum. In recent years, there has been an increasing incidence of syphilis; however, NS is uncommon compared to the era before the discovery of penicillin. Manifestations are usually non-specific, ranging from asymptomatic cases to syphilitic meningitis, meningovascular syphilis, general paresis and tabes dorsalis. Meningovascular syphilis can cause an inflammatory arteritis of cerebral arteries, leading to vascular occlusion and cerebral infarction. We report a case of an ischaemic stroke in a patient with several vascular risk factors, presenting with right hemiparesis, hemihypesthesia and dysarthria. Initial computed tomography with angiography of the head and neck was normal; however, magnetic resonance imaging of the brain revealed a thalamic and internal capsule infarct. Serum T. pallidum antibodies were positive, as well as a rapid plasma reagin test. Cerebrospinal fluid analysis confirmed the diagnosis of neurosyphilis, and the patient was treated with ceftriaxone for 14 days due to a penicillin allergy. Although there is a high prevalence of stroke in patients with NS, this condition is typically underdiagnosed. Untreated NS carries a higher risk of stroke recurrence compared to other risk factors. Therefore, early diagnosis and treatment are essential. This case highlights the importance of considering NS in stroke victims, even in older patients with several additional vascular risk factors, to prevent recurrence and other complications. Neurosyphilis (NS) can occur at any stage of syphilis infection, and it can be asymptomatic or symptomatic, presenting as syphilitic meningitis, meningovascular syphilis, general paresis or tabes dorsalis.Ischaemic strokes are a frequent complication of NS, occurring in 14% of the cases. However, only 19% of the cases are correctly diagnosed.NS should be considered as a potential cause of stroke, even in older patients with several other vascular risk factors. This is essential to prevent future strokes, as well as dementia and other complications.

Diagnostic and prognostic implications of non-high-density lipoprotein cholesterol and homocysteine levels for cognitive impairment in thalamic infarction.

Patients with thalamic infarction experience abnormal blockages of multinucleated vessels, affecting the body and thereby the thalamus. Most patients with thalamic infarction have an adverse prognosis, which seriously affects their safety. Therefore, it is essential to analyze the independent risk factors that influence the prognosis of patients with thalamic infarction and develop corresponding preventive measures. To explore the effect of non-high-density lipoprotein cholesterol (non-HDL-C) and Homocysteine (Hcy) levels in cognitive impairment in thalamic infarction. From March 2019 to March 2022, 80 patients with thalamic infarction were divided into a group with cognitive impairment [Montreal Cognitive Assessment (MoCA) score < 26; 35 patients] and a group with normal cognitive function (MoCA score of 26-30; 45 patients) according to the MoCA score. In addition, 50 healthy people in the same period were selected as the control group. A correlation between the non-HDL-C and Hcy levels and the MoCA score and receiver operating characteristic curve was observed, and the serum non-HDL-C and Hcy levels were analyzed for the diagnosis of cognitive impairment in patients with thalamic infarction. According to the Modified Rankin Scale (MRS) score, 80 patients with thalamic infarction were divided into a good prognosis group (MRS score ≤ 2) and a poor prognosis group (MRS score >2). The non-HDL-C and Hcy levels were significantly higher in the group with cognitive impairment than in the group with normal cognitive function (P < 0.05). There was no significant difference in the non-HDL-C level between the control group and the group with normal cognitive function (P > 0.05). The MoCA scores of the group with cognitive impairment were significantly lower than those of the group with normal cognitive function and the control group (P < 0.05). There was a significant difference between the control group and the group with normal cognitive function (P < 0.05). The non-HDL-C and Hcy levels were correlated with the MoCA score (P < 0.05), cognitive impairment [areas under the curve (AUC) = 0.709, 95% confidence interval (95%CI): 0.599-0.816], the non-HDL-C level, and could predict cognitive impairment in patients with thalamic infarction (AUC = 0.738, 95%CI: 0.618-0.859). Hcy combined with non-HDL-C levels can predict cognitive impairment in patients with thalamic infarction (AUC = 0.769, 95%CI: 0.721-0.895).There were 50 patients in the good prognosis group and 30 patients in the poor prognosis group. Compared with the good prognosis group, in the poor prognosis group, the National Institutes of Health Stroke Scale (NIHSS) score, non-HDL-C level, Hcy level, large-area cerebral infarction, atrial fibrillation, and activated partial prothrombin time were statistically significant (P < 0.05). The non-HDL-C level, the Hcy level, the NIHSS score, extensive cerebral serum, and atrial fibrillation may all be independent risk factors for poor prognosis in patients with thalamic infarction (P < 0.05). Non-HDL-C and Hcy levels are positively correlated with cognitive impairment in patients with thalamic infarction. Non-HDL-C and Hcy levels can be used in the diagnosis of cognitive impairment in patients with thalamic infarction, and the combined detection effect is better. The main factors affecting the prognosis of patients with thalamic infarction are the non-HDL-C level, the Hcy level, the NIHSS score, large-area cerebral infarction, and atrial fibrillation. Clinically, corresponding preventive measures can be formulated based on the above factors to prevent poor prognosis and reduce mortality.

NODDI Identifies Cognitive Associations with In Vivo Microstructural Changes in Remote Cortical Regions and Thalamocortical Pathways in Thalamic Stroke.

The roles of cerebral structures distal to isolated thalamic infarcts in cognitive deficits remain unclear. We aimed to identify the in vivo microstructural characteristics of remote gray matter (GM) and thalamic pathways and elucidate their roles across cognitive domains. Patients with isolated ischemic thalamic stroke and healthy controls underwent neuropsychological assessment and magnetic resonance imaging. Neurite orientation dispersion and density imaging (NODDI) was modeled to derive the intracellular volume fraction (VFic) and orientation dispersion index. Fiber density (FD) was determined by constrained spherical deconvolution, and tensor-derived fractional anisotropy (FA) was calculated. Voxel-wise GM analysis and thalamic pathway tractography were performed. Twenty-six patients and 26 healthy controls were included. Patients exhibited reduced VFic in remote GM regions, including ipsilesional insular and temporal subregions. The microstructural metrics VFic, FD, and FA within ipsilesional thalamic pathways decreased (false discovery rate [FDR]-p < 0.05). Noteworthy associations emerged as VFic within insular cortices (ρ = -0.791 to -0.630; FDR-p < 0.05) and FD in tracts connecting the thalamus and insula (ρ = 0.830 to 0.971; FDR-p < 0.001) were closely associated with executive function. The VFic in Brodmann area 52 (ρ = -0.839; FDR-p = 0.005) and FA within its thalamic pathway (ρ = -0.799; FDR-p = 0.003) correlated with total auditory memory scores. In conclusion, NODDI revealed neurite loss in remote normal-appearing GM regions and ipsilesional thalamic pathways in thalamic stroke. Reduced cortical dendritic density and axonal density of thalamocortical tracts in specific subregions were associated with improved cognitive functions. Subacute microstructural alterations beyond focal thalamic infarcts might reflect beneficial remodeling indicating post-stroke plasticity.

Distinct alterations of retinal structure between thalamic and extra-thalamic subcortical infarction patients: A cross-sectional and longitudinal study.

Cerebrovascular lesions in the primary visual cortex, the lateral geniculate nucleus, and the optic tract have been associated with retinal neurodegeneration via the retrograde degeneration (RD) mechanism. We aimed to use optical coherence tomography (OCT) to assess the effects of the strategic single subcortical infarction (SSI) location on retinal neurodegeneration and its longitudinal impacts. Patients with SSI were enrolled and stratified by lesion location on cerebral MRI into the thalamic infarction group and extra-thalamic infarction group. Healthy controls from the native communities were also recruited. Retinal nerve fiber layer (RNFL) and ganglion cell-inner plexiform layer (GCIPL) were quantified using OCT. Generalized estimating equation (GEE) models were used for cross-sectional analyses and linear mixed models for longitudinal analyses. P < 0.05 was considered statistically significant. We included a total of 283 eyes from 149 SSI patients. Of these, 115 eyes of 60 patients with follow-up were included in the longitudinal analyses. Cross-sectionally, thalamic-infarction patients had reduced retinal thickness compared with extra-thalamic infarction patients after adjustment for age, gender, disease duration, and vascular risk factors (p = 0.026 for RNFL, and p = 0.026 for GCIPL). Longitudinally, SSI patients showed greater retinal thinning compared with healthy controls over time (p = 0.040 for RNFL, and p < 0.001 for GCIPL), and thalamic infarction patients exhibited faster rates of GCIPL thinning in comparison with extra-thalamic infarction patients (p < 0.001). Our study demonstrates a distinct effect of subcortical infarction lesion site on the retina both at the early stage of disease and at the 1-year follow-up time. These results present evidence of significant associations between strategic infarction locations and retinal neurodegeneration. It may provide novel insights for further research on RD in stroke patients and ultimately facilitate individualized recovery therapeutic strategy.

Abstract 108: Artery Of Percheron Infarctions (AOP): A Tale of Two Outcomes

Introduction The AOP is a rare anatomic variant in which a solitary arterial trunk arises from the proximal segment of the posterior cerebral artery (PCA) and supplies the bilateral paramedian thalami and rostral midbrain. Occlusion may result in variable bilateral thalamic and midbrain infarcts. The clinical presentation is most commonly lethargy and somnolence thought to lack other localizing features. Often the diagnosis and treatment of stroke is delayed. Methods Here we present two cases of likely AOP infarcts which highlight the importance of considering this diagnosis on the differential of acute lethargy as timely treatment can lead to a significant difference in morbidity and mortality. Results Case 1: A 68‐year‐old male was initially admitted to an outside hospital with acute lethargy. He was transferred to our institution where he was found to be somnolent and required repeated stimulation to participate with interview. On further exam he was noted to have left ptosis, anisocoria, restricted left supra‐ and add‐ duction, and dysarthria. CT angiogram (CTA) showed no large vessel occlusion (LVO) or significant stenosis. Magnetic resonance imaging (MRI) demonstrated acute infarcts in the medial thalami and subthalamic nuclei bilaterally and uppermost portion of the midbrain. He was out of the window for IV thrombolytic. He was ultimately discharged to inpatient rehab with a persistent CN III palsy. Case 2: A 71‐year‐old female was evaluated emergently via telestroke for acute lethargy and was found to additionally have vertical diplopia, right facial palsy, and subsequent bilateral numbness of the face, arms, and legs. NIHSS 10 for LOC questions (1), facial palsy (2), motor drift (1 pt for each limb), sensory loss (1), aphasia (1), and dysarthria (1). She was treated with IV tenecteplase 179 minutes after the last known well and ultimately had complete symptom resolution. CTA was negative for LVO or significant stenosis. MRI brain demonstrated acute infarcts in the medial thalami bilaterally. Conclusion Here we present two cases of acute onset lethargy. MRI Brain revealed relatively symmetric restricted diffusion in the bilateral thalami of both patients suggesting the presence of an AOP variant. In contrast to the first case, signs of a posterior circulation infarct were quickly recognized in the second patient and IV thrombolytic administration resulted in return to baseline. In both cases there were subtle neurologic findings that suggested midbrain involvement – ptosis, restricted ductions, anisocoria. A high level of suspicion for bilateral thalamic infarct and potential AOP variant should be maintained in cases of acute lethargy. Careful neurologic exam often reveals other signs suggestive of posterior circulation infarct and timely therapeutics can significantly improve morbidity and mortality.

A Case Report on Right Hemiparesis after Left Thalamus Infarction Treated with &lt;italic&gt;Boyanghwanoh-tang-gagam&lt;/italic&gt; and Complex Korean Medicine Treatment

Objectives: This study reports the case of a patient with right hemiparesis after a left thalamic infarction, in which the patient experienced improved clinical symptoms (hemiparesis, constipation) after treatment with a complex Korean medicine treatment.Methods: A 81-year-old male patient diagnosed with acute left thalamic infarction was treated with daily acupuncture and herbal medicine (&lt;i&gt;Boyanghwanoh-tang-gagam&lt;/i&gt;) three times a day. &lt;i&gt;Jowiseunggi-tang&lt;/i&gt; extract granules were administered to treat constipation by adjusting the dosage according to the reported symptoms. The patient’s clinical course was assessed using changes in Modified Barthel Index (MBI) score, Manual Muscle Testing (MMT) grade, and defecation frequency .Results: The patient’s MBI score improved from 35 to 69 and was discharged with the ability to walk under supervision. The MMT grade also improved from 3/4 to 5/5 in the upper/lower extremities. Other clinical symptoms, including constipation, also improved, leading to the discontinuation of magnesium medication.Conclusion: These findings suggest that complex Korean medicine treatments, including herbal medicine and acupuncture, may be an effective treatment for post-stroke hemiplegic patients.

Progressive lacunar strokes behave differently from stable ones even at one year—An observational study

Background and aimsSmall fraction of lacunar stroke patients have an early fluctuating course, described as progressive lacunar syndrome [PLS].We studied the predictors and short term outcome of progressive lacunar strokes in comparison with those with an early stable course. Materials and methodsSingle centre retrospective study where patients with lacunar strokes from 2016 to 2020 were included in the study. Progression was defined as increase in stroke severity [NIHSS] by ≥2 points from baseline without imaging evidence of new infarcts or haemorrhagic transformation. We compared the clinical variables, risk factors, imaging, treatment received and 1 year outcome of subjects with PLS with those with a stable course, with modified Rankin score 0–2 taken as good outcome. ResultsOf the 216 patients with a mean age 63.17 years, progressive course was noted in 56 subjects [26 %].Majority of the fluctuations occurred within 24 h of onset of symptoms. Though stroke severity at admission was comparable between the 2 groups, discharge and 1 year outcome was poorer in those with an early progressive course. We found that presentation as pure motor syndrome, hypertriglyceridemia and thrombolytic therapy were predictors of poor outcome in progressive lacunar strokes, while age, risk factors, infarct location or leukoaraiosis failed to show an association. Thalamic infarcts and atypical lacunar syndromes were associated with a stable course. ConclusionProgressive course is seen in a quarter of lacunar strokes and they have poorer outcome at 1 year. Our finding of thrombolysis being associated with worse outcome in PLS patients, should alert physicians regarding need for more definitive therapies for this condition.