Neurobrucellosis as an exceptional cause of transient ischemic attacks.

We report a series of four cases presented with transient ischemic attacks (TIA) or ischemic stroke as the predominant manifestation of neurobrucellosis (NB). Three of the patients were 20-28 years of age, and one patient was 53 years old. They all used to consume unpasteurized milk or its products. Two patients had systemic brucellosis in the past and received antibiotic treatment. Other causes of TIA including cardiac embolism, hypercoagulability, vascular malformations, systemic vasculitis, and infective endocarditis were excluded. NB was diagnosed with serological tests or cultures for Brucella in the cerebrospinal fluid. None of the patients had any further TIA after the initiation of specific treatment. NB should always be sought in young patients with TIA or ischemic stroke, especially if they have no risk factors for stroke and live in an endemic area for brucellosis, even if they do not have other systemic signs of brucellosis.

Carotid artery tortuosity, kinking, coiling: stroke risk factor, marker, or curiosity?

Although abnormalities in course and geometry (tortuosity, kinking, and coiling) of the internal carotid arteries (ICA) are commonly identified, their etiology and relationship with stroke and stroke risk factors remain unclear This study assessed the clinical and ultrasonographic features of the patients with abnormalities in course and geometry of the ICA. Carotid color duplex ultrasound studies of 345 consecutive patients referred to the Neuroultrasound Lab were prospectively evaluated. Abnormalities in direction and course of the ICA were classified according to the criteria of Weibel-Fields and Metz modified by the authors. Kinking was categorized as mild (> 60 degrees), moderate (30 degrees-60 degrees), and severe (< 30 degrees). Carotid abnormalities (CA) were found in 85/345 (24.6%), 60/85 (70.6%) were female. More CA were seen in females older than 60 y/o (p < 0.001), but there was no gender difference in patients 60 y/o or younger CA were bilateral in 41 patients (48%), but in those with unilateral CA, most were on the left. The most common CA was kinking (71 arteries, 56%), followed by tortuosity (48 arteries, 38%), and coiling (7 arteries, 6%). None of the atherosclerotic vascular diseases or risk factors was associated with CA. Mild atheromatous plaques predominated in patients with CA, but moderate and large plaques were more common in the others (p = 0.001). Maximal systolic velocity at the level of CA was higher in patients with kinking or coiling compared with tortuosity (p = 0.001). Lumen diameter at the level of CA was inversely correlated to the severity of CA (p < 0.001). However, carotid stenosis was equally present in all groups. This study suggests that CA have no clear importance as a stroke risk factor or marker of atherosclerotic vascular disease. Our results suggest that CA do not develop as a consequence of vascular risk factors or atherosclerotic lesions, and they are not related to ischemic stroke, TIA or the presence of carotid stenosis. In women, CA was related with advanced age. It appears that CA frequently identified by color duplex sonography are more of curiosity than a clinically significant finding.

Wernicke's encephalopathy due to hyperemesis gravidarum: an under-recognised condition.

We present a case of a 25-year-old woman with drowsiness, nystagmus, severe ataxia and areflexia, which developed six weeks after admission to an obstetric clinic for hyperemesis gravidarum. She had been treated with intravenous dextrose and electrolyte solutions and antiemetics. Magnetic resonance imaging (MRI) performed on the fifth day of her neurologic symptoms showed increased intensity in both thalami, periaqueductal grey matter, the floor of the fourth ventricle and superior cerebellar vermis in T2 weighted and FLAIR images. Clinical signs and MRI findings were consistent with the diagnosis of Wernicke's encephalopathy. On the third day of thiamine replacement, neurologic signs improved dramatically In addition to our case, we review 29 previously reported cases of Wernicke's encephalopathy associated with hyperemesis gravidarum, and emphasize the importance of thiamine supplementation to women with prolonged vomiting in pregnancy especially if they are given intravenous or parenteral nutrition.