Importance of multiplanar reformation angiographic images for the detection of carotid web: A case series.

Carotid web (CW) is considered a variant of intimal fibromuscular dysplasia. CW represents between 9.4% and 37% of ischemic strokes that were initially misclassified as "cryptogenic." However, in Latin America, there is a lack of detection. We present 5 cases of ischemic stroke due to CW and discuss the usefulness of multiplanar reformatting (MPR) imaging in computed tomography angiography. The identification of CW with the use of tridimensional (3D) reconstructions and maximum intensity projection was 20%, the rest was misdiagnosed as atherosclerotic plaque. With the MPR, the identification of typical CW findings was improved, such as a thin septum, a shelf-like image, and a mountain shadow-like image. However, one must be alert to changes in the 3D disposition of the carotid bifurcation, as they may mask the typical CW findings. A good practice is to align the internal carotid artery exactly posterior to the external carotid artery in the sagittal plane.

Burden of Stroke and Population-Attributable Fractions of Risk Factors in Latin America and the Caribbean.

Background Stroke burden characterization studies in low- and middle-income countries are scarce. We estimated the burden of stroke and its risk factors in Latin America and the Caribbean (LAC). Methods and Results We extracted GBD (Global Burden of Disease) study 2019 data on overall stroke and 3 subtypes (ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage) for 20 LAC countries. We estimated absolute and age-standardized rates of disability-adjusted life years, years of life lost, years lived with disability, and deaths. The population-attributable fractions of 17 risk factors were estimated. All analyses were performed at regional and national levels by stroke subtype, sex, and age subgroups. In 2019, the LAC region had the fourth largest stroke burden worldwide (6.8 million disability-adjusted life years), predominantly attributable to premature deaths (89.5% of disability-adjusted life years). Intracerebral hemorrhage was the primary cause of the overall stroke burden (42% of disability-adjusted life years), but ischemic stroke was the leading cause of disability (69% of total years lived with disability). Haiti and Honduras had the highest age-standardized rates. Older adults and men had the largest burdens, although women had the highest rate of disability. Socioeconomic development level did not influence the burden. The major risk factor clusters were metabolic (high systolic blood pressure [population-attributable fraction=53%] and high body mass index [population-attributable fraction=37%]), which were more influential in hemorrhagic events, women, and older adults. Household air pollution was an important risk factor in low-income countries in LAC. Conclusions The stroke burden and stroke-related mortality in LAC are higher than the worldwide averages. However, stroke is a highly preventable disease in this region. Up to 90% of the burden could be reduced by targeting 2 modifiable factors: blood pressure and body mass index. Further research and implementation of primary and secondary prevention interventions are needed, as well as integrated national stroke care programs for acute, subacute, and rehabilitation management in LAC.

Bilateral Ischemic Strokes Secondary to Moyamoya Syndrome Associated With Graves Thyrotoxicosis in a Patient of Amerindian Descent From Peru: A Case Report.

Moyamoya disease (MMD) is characterized by progressive stenosis of the distal portion of the internal carotid artery and its two main branches, the middle cerebral artery, and the anterior cerebral artery. Clinically, MMD can present with ischemic or hemorrhagic cerebrovascular events. The term Moyamoya syndrome (MMS) is used when the characteristic Moyamoya vasculopathy presents in association with other conditions such as Graves' disease (GD). We report a case of a 34-year-old, right-handed male patient of Amerindian descent. He presented to the emergency room with a two-month history of palpitation, fatigue, and weight loss associated with sudden-onset left hemiparesis, facial asymmetry, and dysarthria. His workup was remarkable for elevated levels of thyroid hormones with the presence of autoantibodies and radiological findings typical of MMS. Moyamoya syndrome in association with Graves' disease has increasingly been noted in Latin American patients and should be considered in the differential diagnosis in the appropriate clinical context.

Spinal Dural Arteriovenous Fistula: A Mimic of Demyelinating Disease and Radiculopathy.

Spinal dural arteriovenous fistula (SDAVF) is characterized by an abnormal connection between a radicular artery and the venous plexus producing spinal cord venous congestion. It manifests with nonspecific sensory and motor symptoms. We present three cases of SDAVF with different forms of presentation; in two cases, an autoimmune etiology was considered, and in the third case, the initial diagnosis was chronic radiculopathy. In all three cases, a serpentine enhancement was observed after the gadolinium in the dorsal region of the spinal cord corresponded to flow voids in T2-weighted images, which guided the diagnosis. SDAVF should be considered in atypical clinical presentations of radiculopathies or spinal cord syndromes, especially spinal conus or epicone syndrome. Likewise, it should be part of the differential diagnosis of spinal cord presentations of demyelinating diseases such as multiple sclerosis or neuromyelitis optica spectrum disorders.

Acute disseminated encephalomyelitis and COVID-19: A systematic synthesis of worldwide cases.

Acute disseminated encephalomyelitis (ADEM) has been reported after coronavirus disease 2019 (COVID-19). In this review, we systematically included worldwide reported cases on this association. We included 30 case reports (pediatric and adults) and explored epidemiological and clinical evidence. We described time to diagnosis, clinical, imaging, and laboratory features, response to treatment regimens, and differences regarding severity. Also, an original case report was presented. Neurologists must be alert to the occurrence of multifocal neurological symptoms with or without encephalopathy in patients recovered from COVID-19. Timely MRI studies should be performed to establish the diagnosis and to consider early corticosteroid-based treatment.

Carotid Web Diagnosed by Ultrasound Carotid Duplex in a Patient With Ischemic Stroke.

Carotid web (CW) is an atypical form of intimal fibromuscular dysplasia that occurs at the level of the carotid bulb. It is associated with ischemic strokes. The first report of this association was in 1967 and it is currently known to represent a significant percentage of cryptogenic stroke. We report the case of a young female patient with a history of transient ischemic attack who presented a cerebral infarction of the territory of the left middle cerebral artery. The diagnosis of CW was suggested by the findings of the ultrasound carotid duplex and was confirmed by digital subtraction angiography. Likewise, brain magnetic resonance angiography showed an incipient alteration in the morphology of the wall of the left internal carotid artery in its intracranial segment. Aspirin treatment was started and there was no recurrence up to two years of follow-up. CW represents a diagnostic challenge; it should be suspected in young adults with ischemic stroke. In them, studies of the supra-aortic vessels should be performed. Ultrasound carotid duplex can be a useful diagnostic tool.

Diagnostic Value of Thunderclap Headache and Convexal Subarachnoid Hemorrhage for Reversible Cerebral Vasoconstriction Syndrome: A Case Report.

Reversible cerebral vasoconstriction syndrome (RCVS) is an underdiagnosed cause of convexal subarachnoid hemorrhage, characterized by thunderclap headache associated with focal and segmental intracranial vasoconstriction. It can appear complications such as intracerebral hemorrhage, seizures, posterior reversible leukoencephalopathy, or ischemic stroke. Our objective is to present the case of a 51-year-old woman with an RCVS diagnosis, who had a normal digital subtraction angiography at the illness onset. We highlight the high diagnostic value of thunderclap headache and convexal subarachnoid hemorrhage. We also highlight the importance of repeating the angiographic studies in the second week when there is strong diagnostic suspicion.

Case Report: Anti-LGI1 Limbic Encephalitis Associated With Anti-thyroid Autoantibodies.

Anti-LGI1 encephalitis is an autoimmune encephalitis with antibodies against leucine-rich glioma-inactivated 1 (LGI1), first described in 2010. It is a non-frequent and poorly understood entity that represents the second most frequent cause of autoimmune encephalitis. This entity is characterized by the presence of limbic encephalitis, hyponatremia, and faciobrachial dystonic seizures. Herein, we present the case of a male patient with an onset of epileptic seizures (generalized tonic-clonic seizure), and involuntary dystonic movements that affect the right side of his face and right upper limb associated with mental disorder, and affectation of higher functions. The electroencephalogram showed continuous generalized slowing of the background activity. The brain magnetic resonance imaging showed signal hyperintensity at the level of both mesial temporal lobes and hippocampi and in the head of the right caudate nucleus. Anti-thyroglobulin antibodies were positive, and he was initially diagnosed as Hashimoto's encephalopathy (HE). However, the response to corticosteroids was not completed as it is usually observed in HE. For that, antibodies for autoimmune encephalitis were tested, and the anti-LGI1 antibodies were positive in serum and cerebrospinal fluid. HE is an important differential diagnosis to consider. Furthermore, the presence of Anti-thyroglobulin antibodies should not be taken as the definitive diagnostic criteria, since these antibodies could be associated with other autoimmune encephalopathies, which include in addition to anti-LGI1, anti-NMDA and anti-Caspr2.

Brainstem venous congestion due to a direct carotid-cavernous fistula: Case report. / Congestión venosa en tronco encefálico debido a una fístula carótido-cavernosa directa: a propósito de un caso.

A 50-year-old male patient who, after 3 months of cranial brain trauma, presented proptosis, chemosis and exophthalmos in the left eye. Subsequently, dysmetria develops in the left extremities and right hemiparesis. The diagnosis of carotid-cavernous fistula (FCC) associated with hyperintensity of signal in FLAIR and diffuse contrast uptake at the level of the pseudo tumoral protuberance and cerebellar peduncle was established. This finding was compatible with venous congestion. His symptoms were fluctuating, he started with orbital symptoms and then from the posterior fossa with improvement of the orbital symptoms. FCC microcoil embolization produced resolution of ocular symptoms followed by improvement of brainstem symptoms. Magnetic resonance findings significantly reversed one year of follow-up. We describe a case of direct FCC with venous congestion in the brainstem and fluctuating symptoms with a considerable clinical and imaging improvement after treatment.