Novel Algorithm to Help Identify Stroke Mimics.

BACKGROUND: Stroke is a major cause of disability in the United States. A portion of patients presenting with stroke-like symptoms in the emergency room who receive tissue plasminogen activator (tPA) do not end up having a true stroke, leading to unnecessary health-care costs. The aim of our study is to identify those patients who have a high likelihood of experiencing a stroke mimic using a novel stroke mimic score and to identify a cutoff point with a high specificity of ruling in stroke mimics. METHODS: We reviewed literature on stroke mimics and the various associated risk factors. We devised a 9-point scoring system and applied it retrospectively to patients who received tPA from 2010 to 2014 to calculate a score for each patient. RESULTS: The final sample size was 105 patients, out of which 25% turned out to be patients with stroke mimics. Patients with stroke mimic were significantly younger and more likely to have history of seizure, migraine, or prior psychiatric illness. History of atrial fibrillation had the highest correlation with true stroke. We found approximately 100% specificity in ruling in a stroke mimic if a patient scored more than 5 points. CONCLUSIONS: Our stroke mimic scoring system along with a basic neurologic examination could be a useful tool in the identification of stroke mimics with a high specificity in the emergency room setting. These patients may require further studies such as rapid magnetic resonance imaging, which would decrease unnecessary tPA administration and hospital admissions.

An unusual recurrence of dysembroplastic neuroepithelial tumours after a seizure-free period of 8 years.

Dysembryoplastic neuroepithelial tumours (DNETs) are grade 1 central nervous tumours, which can be diagnosed judiciously based on clinical features and radiological investigations, having a good prognosis after surgical resection. However, the recurrence of tumours due to variable epileptic zones leading to persistence of seizures can make the management of such cases challenging. We present a case of DNET where the patient had recurrence of the tumour with worsening of seizure activity 8 years after initial surgical resection.

Acquired hepatocerebral degeneration.

Acquired (non-Wilsonian) hepatocerebral degeneration is a rare irreversible neurological syndrome that occurs in patients with chronic liver disease associated with multiple metabolic insults. Van Woerkom was the first to describe acquired hepatocerebral degeneration in 1914 followed by the landmark article by Victor et al in 1965. Multiple bouts of hepatic coma are the only known risk factors that trigger this devastating neurodegenerative disease with features suggesting toxic exposure to the brain. Clinically and pathologically the disorder is similar to Wilson's disease although subtle differences in immunostaining of glial fibrillar acidic protein have been documented. Acquired hepatocerebral degeneration occurs in 0.8-2% of patients with cirrhosis. As acquired hepatocerebral degeneration is relatively rare, we are reporting one such case from our hospital in a 50-year-old male patient who had long-standing portal systemic shunt and presented with progressive cognitive decline, bradykinesia, tremors and bilateral extrapyramidal signs.

Intravascular large B-cell lymphoma confirmed by brain biopsy: a case report.

Intravascular lymphoma (IVL) is a rare variant of non-Hodgkin's lymphoma characterised by neoplastic lymphoid cells growing inside the lumina of medium and small vessels. The diversity of clinical presentation owing to the possibility of its occurrence in any organ often makes it a challenging diagnosis. We present an intriguing case of intravascular large B-cell central nervous system (CNS) lymphoma in which the patient presented with a non-specific neurological symptom and had no systemic symptoms or dermatological manifestations. The patient deteriorated rapidly after presentation and succumbed to multi-organ failure within 2 weeks of admission.

Tryst and treatment of an unusual case of MDR CNS tuberculosis.

A case of multidrug resistance central nervous system tuberculosis is described. During the initial 6 months of therapy, intracranial embolic spread of tuberculomas from exudates around the proximal left middle cerebral artery was seen. This phenomenon was reported earlier. Further management, therapeutic considerations, particularly with secondary and tertiary line of antitubercular medication and neuroimaging are discussed.