Cushing's ulcer: Further reflections.

BACKGROUND: Brain tumors, traumatic head injury, and other intracranial processes including infections, can cause increased intracranial pressure and lead to overstimulation of the vagus nerve. As a result, increased secretion of gastric acid may occur which leads to gastro-duodenal ulcer formation known as Cushing's ulcer. METHODS: A review of original records of Dr. Harvey Cushing's patients suffering from gastro-duodenal ulcers was performed followed by a discussion of the available literature. We also reviewed the clinical records of the patients never reported by Cushing to gain his perspective in describing this phenomenon. Dr. Cushing was intrigued to investigate gastro-duodenal ulcers as he lost patients to acute gastrointestinal perforations following successful brain tumor operations. It is indeed ironic that Harvey Cushing developed a gastro-duodenal ulcer in his later years with failing health. RESULTS: Clinically shown by Cushing's Yale Registry, a tumor or lesion can disrupt this circuitry, leading to gastroduodenal ulceration. Cushing said that it was "reasonable to believe that the perforations following posterior fossa cerebellar operations were produced in like fashion by an irritative disturbance either of fiber tracts or vagal centers in the brain stem." CONCLUSION: Harvey Cushing's pioneering work depicted in his Yale registry serves as a milestone for continuing research that can further discern this pathway.

Stroke Mimic Secondary to IV Fentanyl Administration.

Fentanyl is a potent opioid used commonly in acute care because of its rapid onset and short duration of action. It has fewer side effects when compared with commonly available opioids, such as morphine and hydromorphine. We report an unusual side effect of transient aphasia following fentanyl administration. A 61-year-old female presented for an elective embolization of a periophthalmic artery aneurysm. She developed immediate episodes of aphasia on two separate occasions following administration of intravenous (IV) fentanyl. The high lipid solubility explains the rapid onset of action of fentanyl as it rapidly passes through the blood-brain barrier and through cell membranes. Immediately following the administration of fentanyl, the patient developed aphasia. There were no other clinical or neurological imaging findings that could account for these symptoms. We believe that aphasia may be an unusual side effect of fentanyl, and it is something clinicians should be aware of.

Endovascular treatment of tandem internal carotid and middle cerebral artery occlusions.

OBJECTIVE: Extracranial internal carotid artery (ICA) angioplasty and intracranial thrombectomy may be a safe and efficacious therapeutic option for recanalization of a subset of arterial occlusions termed tandem occlusions of Internal carotid artery and Middle cerebral artery (TIM). BACKGROUND: Approximately 25% of patients with middle cerebral artery (MCA) occlusion will have a concomitant ICA occlusion and 50% of patients with an ICA occlusion will have a proximal MCA occlusion. Cervical ICA occlusion with MCA embolic occlusion is associated with a low rate of recanalization and poor outcome after intravenous thrombolysis. We report our experience on acute ischemic stroke patients with TIM occlusion treated with extracranial ICA angioplasty/stenting and intracranial thrombectomy and/or standard intravenous thrombolysis. DESIGN/METHODS: A retrospective analysis of 7 patients from our stroke database was done. 6 patients of the 7 patients were treated with extracranial ICA angioplasty and intracranial thrombectomy and/or intravenous thrombolysis. We examined early neurological improvement (defined by a reduction of National Institutes of Health Stroke Scale (NIHSS) > 8 points). We also evaluated the rate of successful recanalization based on thrombolysis in cerebral infarction (TICI) score of 2b or 3. RESULTS: All but one of the 6 treated patients achieved a TICI score of 2b or 3 signifying successful recanalization. In addition, treated patients had an early reduction of their NIHSS by greater than 8 points. The 1 patient who did not to achieve TICI 2b or 3 also failed to show early neurological improvement. Four of the treated patients had a follow up NIHSS at 90 days of 1 or less and mRS at 90 days of 0. CONCLUSIONS: In cases of tandem occlusions of ICA and MCA, multimodal therapy consistent of intravenous thrombolysis and/or extracranial ICA stenting and intracranial thrombectomy to achieve recanalization may be a safe and efficacious therapeutic option for recanalization. Further prospective studies are warranted.

Intravenous thrombolysis in a patient using factor Xa inhibitor.

UNLABELLED: Until recently, only warfarin was approved for the prevention of stroke in patients with AF. Patients on warfarin with ischemic stroke were considered candidates for IV tPA as long as their PT/INR was not prolonged. Now, there are several new agents approved for stroke prevention in patients with non-valvular AF. The newer agents include direct thrombin inhibitors, like dabigatran, and factor Xa inhibitors, like rivaroxaban and apixaban. The coagulation profile of patients on direct thrombin inhibitors is more predictable than that of patients on factor Xa inhibitors, and the usage of IV tPA in patients on dabigatran has been previously reported. To our knowledge, there are no prior reports of IV tPA in a patient on a factor Xa inhibitor. We report a case of a 71-year-old man on rivaroxaban who improved with IV tPA after presenting with acute onset of aphasia and right-sided weakness. ABBREVIATIONS: AFAtrial fibrillationIV tPAIntravenous tissue plasminogen activatorINRInternational normalized ratioPTTPartial thromboplastin timeNIHNational Institute of HealthPTProthrombin timeCTComputed tomographyMCAMiddle cerebral arteryMRIMagnetic resonance imaging.

Possible role of Eptifibatide drip in-patient with aneurysmal subarachnoid hemorrhage in vasospasm prevention.

OBJECTIVE: Approximately 18,000 patients suffer from a subarachnoid hemorrhage (SAH) in the United States annually. SAH is a form of stroke and comprises 1%-5% of all strokes. Nearly 50% of all SAH cases end in fatality within 30 days of presentation; one of eight patients die before reaching a hospital. Those who survive often have neurological or cognitive impairment. METHODS: This case report describes the course of two patients who presented to the emergency department with aneurismal subarachnoid hemorrhage and received external ventricular drainage and endovascular treatment of their aneurysm. RESULTS: Both patients required treatment with Eptifibatide drip after endovascular approach and their SAH in the basal cisterns resolved by day 5. Neither patient developed signs of clinical or subclinical vasospasm. COMMENTS: Eptifibatide drip facilitated resolution of the thick clot in the subarachnoid space early enough to eliminate the direct toxicity of oxyhemoglobin on the cerebral arteries and arachnoid granulations, thus preventing vasospasm and eliminating the necessity for a long-term shunt.

Impact of the number of metastatic brain lesions on survival after Gamma Knife radiosurgery.

Effectiveness of Gamma Knife radiosurgery (GKRS: Elekta AB, Stockholm, Sweden) for patients with metastatic brain disease and the prognostic factors influencing their survival were analyzed in a 5 year retrospective data analysis (July 2001 to June 2006). Kaplan-Meier survival curves were constructed using univariate and multivariate analyses with the respective salient prognostic factors. This study analyzed data on 330 patients with brain metastases who underwent GKRS. Lung carcinoma (55%) was the most common primary cancer followed by breast (17.8%), melanoma (9.4%), colorectal (4.8%) and renal (3.9%). The median survival for all patients was 8 months. Survival ranged from 13 months for breast metastases, 10 months for renal, and 8 months for lung to 5 months for colorectal and melanoma. Mean age of patients was 58.5 years (range 18-81). Melanoma patients were younger with a mean age of 49 and also had the highest number of lesions (3.8) when compared to patients with renal (2.5), lung (2.8), colorectal (3) and breast (3.6). When stratified according to the number of lesions patient survival was 8 months (one to three lesions), 7.5 months (four or five lesions) and 7 months (six lesions or more). Mean Karnofsky Performance Status score (KPS) was 77 and survival dropped significantly from 8 months to 4.5 months if KPS was less than 70. Survival improved with a KPS of 70 or more, regardless of the number of lesions treated. Selection of patients based on the number of lesions may not be justified. A prospective trial is required to further define the prognostic factors affecting survival.

Salivoma after carotid endarterectomy.

Although the diagnosis and management of postoperative or traumatic fluid collections have been documented extensively in the literature, to our knowledge the occurrence of a salivoma after carotid endarterectomy has not been reported. We report an extra salivary glandular collection of saliva - a "salivoma" - in a 79-year-old patient who underwent a carotid endarterectomy with a high carotid bifurcation. He presented with serous watery drainage from the incision site that had started spontaneously 4 days after surgery. The patient was taken to the operating room for exploration and washout of the wound with presumption of an infectious source. As self-retaining retractors were placed under the platysma, a large release of serous fluid occurred. Copious irrigation allowed complete washout of the wound. On postoperative day 2, the patient re-exhibited neck wound fullness and a Penrose drain was placed in the incision with clear serous fluid flowing through the drain. The patient was given a scopolamine patch to decrease salivary secretions. Within 5 days, the drainage significantly decreased and the drain was removed. This diagnosis should be included in the differential diagnosis of an expanding neck mass following carotid endarterectomy to properly treat this complication.

Mean transit time on Aquilion ONE and its utilization in patients undergoing acute stroke intervention.

BACKGROUND: Neuroimaging techniques have been beneficial in identifying patients with salvageable penumbra. We sought to validate the mean transit time (MTT) map on computed tomography perfusion (CTP) imaging utilizing an Aquilion ONE computed tomography (CT) scanner running a singular value decomposition plus algorithm in patients with acute large vessel ischemic stroke who underwent endovascular therapy. METHODS: We conducted a retrospective analysis of consecutive patients presenting to the emergency room who met the following criteria: 1) had a large vessel acute ischemic stroke; 2) had a high-quality whole-brain CTP; 3) treated with endovascular therapy; and 4) received a follow-up MRI with diffusion-weighted imaging (DWI) within 48 h. A blinded neurologist, neuroradiologist, and neurosurgeon utilized the Vitrea software to process the images independently using an infarct perimeter method. RESULTS: Twelve patients met the inclusion criteria. A comparison was made between the volumes of infarct core (IC) utilizing MTT and DWI after accounting for other co-founding factors (i.e., recanalization rate, time between CT and MRI, time to achieve recanalization, and IV t-PA administration). MTT was redefined as capillary MTT (cMTT) which represented evolving capillary flow influenced by hypoxia induced vasodilation/vasoconstriction. We divided the patients into two groups based on the degree of reperfusion: A) patients with a TICI score of IIb or III and B) patients with a TICI score of I or IIa. We compared the two groups and found that the rate of reperfusion significantly affected the volume of the infarct on MTT when compared with a follow-up MRI (p value < 0.04). Furthermore, we found a strong positive correlation R(2) = 0.6 between the average MTT infarct volume and the final DWI MR volumes. In addition, the averaged MTT IC volumes were 84% of the final averaged DWI IC volumes. CONCLUSION: Although further studies are required to validate this retrospective study, preliminary data suggest that cMTT maps can be a valuable and accurate tool in the assessment of patients with acute stroke who may benefit from aggressive endovascular therapy.

Teaching NeuroImages: Comatose patient with bilateral thalamic infarct due to internal carotid artery occlusion.

An 88-year-old woman with a medical history of diabetes, hypertension, and atrial fibrillation presented to the emergency room after being found unresponsive with a NIH Stroke Scale score of 23 and Glasgow Coma Scale score of 3. She was unresponsive to painful stimuli. Noncontrast CT demonstrated bilateral thalamic infarcts (figure 1A).

Vessel wall enhancement in herpes simplex virus central nervous system vasculitis.

Infection is a well-known cause of cerebral vasculopathy and vasculitis. We report a 36-year-old woman with cerebral vasculitis and ischemic stroke secondary to herpes simplex virus (HSV). MRI studies revealed a pontine stroke with basilar artery stenosis and vessel wall gadolinium enhancement. This case demonstrates the ability of HSV to cause a focal brainstem vasculitis and the utility of enhanced MRI in the diagnosis of stroke related to HSV central nervous system vasculitis.

Hemiparesis, encephalopathy, and extrapontine osmotic myelinolysis in the setting of hyperosmolar hyperglycemia.

Osmotic demyelination syndrome (ODS) is a recognized complication of rapid correction of hyponatremia. However, other medical conditions have been associated recently with the development of ODS in the absence of changes in serum sodium. We present a 23-year-old man who developed left hemiparesis and encephalopathy after treatment of hyperglycemia. MRI demonstrated changes in the splenium of the corpus callosum and the posterior limb of the right internal capsule. This report, together with others, suggests that the full spectrum of lesions of ODS, pontine and extrapontine, can occur in the setting of any rapid change in osmolar state.

Stress-induced cardiomyopathy complicating a stroke caused by an air embolism.

Systemic air embolism is a very rare (<0.1%) complication of computed tomography-guided transthoracic needle aspiration and can result in serious neurological and/or cardiac sequelae. Stroke and stress cardiomyopathy can have a variety of etiologies; however, an association of Takotsubo cardiomyopathy with cerebrovascular events precipitated by an air embolus has not been reported. We report a patient with stress-induced cardiomyopathy after an air embolus-induced stroke. The patient was managed with hyperbaric oxygenation and her cardiomyopathy was initially treated as per the acute coronary syndrome protocol until coronary angiography confirmed patent arteries. We review the pathophysiology and management recommendations for both events. Prompt recognition of air embolism-induced cerebrovascular events and stress cardiomyopathy by clinicians is imperative to the timely initiation of appropriate management and a successful treatment outcome.