Diffusion-weighted MRI diagnosis of pure motor stroke limited to primarily distal leg weakness.

Pure motor stroke (PMS) manifesting as distal weakness of a single extremity has rarely been described. The authors report a 59-year-old man with PMS who had primarily distal weakness of a single lower extremity, which to the authors' knowledge has not been previously described. Four days after onset, positive diffusion-weighted imaging confirmed that the small subcortical T2-weighted hyper-enhancing and nonenhancing T1-weighted hypo-intensity noted on magnetic resonance imaging (MRI) represented an acute PMS that was the cause of the patient's weakness. Increased awareness of this rare clinical presentation of PMS coupled with the promise of imaging the PMS with diffusion-weighted MRI should lead to earlier stroke intervention in these patients.

Diffuse meningeal enhancement in patients with overdraining, long-standing ventricular shunts.

The authors report two elderly men with diffuse meningeal enhancement 13 and 21 years following insertion of ventriculojugular shunts. Lumber puncture documenting low CSF pressures suggests that diffuse meningeal enhancement in patients with long-standing ventricular shunts may be secondary to dural venous dilatation rather than meningeal fibrosis. The authors theorize that these elderly patients, neither of whom had postural headache, may be less subject to brain "sag" because of decreased brain weight.

Early diagnosis by diffusion-weighted MRI of pure motor stroke limited to finger weakness.

Pure motor neurologic deficits occur among 3%-14% of all patients with ischemic stroke. Pure motor monoparesis occurs among 2%-22% of patients with pure motor stroke. The authors report the case of a 73-year-old woman with isolated finger weakness as the sole manifestation of a small cortical-subcortical pure motor stroke diagnosed within 4 hours of onset by means of diffusion-weighted echoplanar magnetic resonance imaging. To the authors' knowledge, the case of a patient with pure motor stroke with finger weakness as the only manifestation has not been previously reported. Increased awareness of this rare clinical presentation of pure motor stroke coupled with the promise of prompt diagnosis by means of diffusion-weighted MRI should lead to earlier stroke intervention.

Hyperekplexia: report of a nonfamilial adult onset case associated with obstructive sleep apnea and abnormal brain nuclear tomography.

We report the unique occurrence of hyperekplexia and obstructive sleep apnea (OSA) in a 48-year-old male. Polysomnography and multiple sleep latency testing excluded cataplexy, which can be confused with startle attacks. A new imaging finding was a nuclear tomography abnormality in the left frontal lobe. We postulate that this finding may represent a functional cortical lesion of a descending pathway that normally inhibits the startle reflex. Serious complications of pharmacotherapy with clonazepam, the drug of choice for hyperekplexia, can be avoided by first evaluating for OSA.

Spontaneous intracranial hypotension with pachymeningeal enhancement on MRI.

Spontaneous intracranial hypotension (SIH) is a rarely reported syndrome of spontaneously occurring postural cephalalgia associated with low CSF pressure. We report a case of SIH in which MRI of the brain revealed diffuse symmetric pachymeningeal enhancement that resolved without specific therapy.

Reversal of fixed pupils after spontaneous intraventricular hemorrhage with secondary acute hydrocephalus: report of two cases treated with early ventriculostomy.

Rapid reversal of fixed pupils, complete external 3rd nerve ophthalmoplegia, and coma occurred after early ventriculostomy in two hypertensive male patients with spontaneous intraventricular hemorrhage and secondary acute hydrocephalus. Putative pathophysiology of fixed pupils secondary to transtentorial herniation from obstructive hydrocephalus is discussed. Cases such as the present ones are unsettling because they are exceptions to the usually reliable negative prognosis indicated by fixed pupils. Nonetheless, it is important to report these cases to delineate which patients with this important clinical sign may benefit from aggressive management.

Syndrome of the mesencephalic artery: report of a case with CT and necropsy findings.

The syndrome of the mesencephalic artery refers to the clinical constellation of akinetic mutism and third nerve palsy which results from occlusion of one or more of the posterior thalamo-perforating arteries that arise from the proximal posterior cerebral artery. A patient with this syndrome is described in whom a bilateral paramedian midbrain infarct was shown by computed tomography and confirmed pathologically. To our knowledge, this is only the second reported case of mesencephalic infarct shown by computed tomography and the first in which the CT findings have been corroborated by pathological examination.

Isolated lateral rectus muscle palsy associated with leukopenia in two adults.

Benign lateral rectus palsy developed in two adults, a 62-year-old man and a 56-year-old woman. Both were hospitalized because of headache and diplopia. Extensive laboratory and neurologic testing showed no abnormalities except leukopenia (the white blood cell count was 2,600 cells/mm3 in one patient and 3,100 cells/mm3 in the other). Both recovered without treatment. The benign course and spontaneous improvement in both patients suggested that extensive neurodiagnostic procedures can be deferred for several weeks in such patients.

Chronic paroxysmal hemicrania. A new type of treatable headache.

A new variant of cluster headache termed chronic paroxysmal hemicrania is described. The importance of recognizing this chronic, intractable headache syndrome is emphasized in view of the dramatic response to the drug, indomethacin.