Necrotic Ulcers Secondary to Apomorphine Infusion.

Background: Apomorphine is a potent dopamine agonist used in the treatment of advanced and fluctuating Parkinson's Disease. However the need for its subcutaneous infusion can lead to skin reactions. Phenomenology Shown: We illustrate necrotic ulcers at infusion sites as a rare event during continuous subcutaneous apomorphine infusion. Educational value: This case demonstrates the rare adverse event of necrotic ulcers in a patient with long term apomorphine infusion.

Jaw Clonus: A Rhythmic Oscillatory Movement, but Not Tremor.

Background: Jaw clonus is rhythmic, oscillatory contraction of jaw muscles induced by stretch and is caused by lesions of the descending motor neurons in the corticopontine tracts. Phenomenology shown: We illustrate jaw clonus elicited with jaw activation and upon testing of the jaw jerk in a patient with amyotrophic lateral sclerosis. Educational value: This video clearly demonstrates the uncommon sign of jaw clonus, a finding which needs to be distinguished from tremor and should direct the examiner to consider lesions of the corticopontine fibres, including amyotrophic lateral sclerosis.

Type A aortic dissection secondary to a left common carotid artery dissection.

Common carotid artery dissection is an unusual clinical event that most commonly occurs secondary to type A aortic dissection. We present a rare case of spontaneous common carotid artery dissection temporally preceding aortic dissection. Our case highlights the careful attention that cases of common carotid dissection should be given; our knowledge base regarding their natural history and evidence-based management is distinctly lacking compared to dissection of other cervical vessels. It also demonstrates the importance of imaging the entire aorta at the time of, a seemingly isolated, common carotid dissection to exclude other potential synchronous dissections.

Effect of anticoagulation on cardioembolic stroke severity, outcomes and response to intravenous thrombolysis.

Our objective was to evaluate the effect of anticoagulation on cardioembolic stroke (CS) severity, outcomes, and response to intravenous thrombolysis (IVT). Observational study of CS patients admitted to a Stroke Center (2010-2013). The sample was classified into three groups based on pre-stroke oral anticoagulants (OAC) treatment (all acenocumarol) and the international normalized ratio (INR) on admission: (1) non-anticoagulated or anticoagulated patients with INR <1.5, (2) anticoagulated with INR 1.5-1.9 and (3) anticoagulated with INR ≥2. We compared demographic data, vascular risk factors, symptomatic intracranial hemorrhage, severity on admission (NIHSS) and 3 month outcomes (mRS). Overall 475 patients were included, 47.2 % male, mean age 75.5 (SD 10.7) years old, 31.8 % were on OAC. 76 % belonged to the INR <1.5 group, 13.3 % to the INR 1.5-1.9 and 10.5 % to the INR >2. 35 %of patients received IVT. Multivariate analyses showed that an INR ≥2 on admission was a factor associated with a higher probability of mild stroke (NIHSS <10) (OR 2.026, 95 % CI 1.006-4.082). Previous OAC in general (OR 2.109, 95 % CI 1.173-3.789) as well as INR 1.5-1.9 (OR 3.676, 95 % CI 1.510-8.946) were associated with favorable outcomes (mRS ≤2). OAC was not related to stroke outcomes in the subgroup of IVT patients. Therapeutic OAC levels are associated with lesser CS severity, and prior OAC treatment with favorable outcomes. In this study, OAC are not related with response to IVT.