Joan Miró and Cyclic Depression.

Psychopathology has been closely related with artists. A link between creativity and a tendency to affective disorders has become widely accepted. Several studies have shown that artists suffer disproportionately high rates of mood disorders, particularly manic depression and major depression. The famous twentieth century Spanish artist Joan Miró suffered from depression during the entirety of his life, as was recognized by some authors in private letters. The artist worked using several styles, as well as in ceramics and sculpture. Some of his work reflects the feelings he experienced during the Spanish Civil War and the Second World War. He contributed considerably to the world of art with works such as The Farm as the culminant work of detailism, The Harlequin's Carnival as one of the main expressions of surrealism, the Birth of the World as the precursor of abstract expressionism, or The Dutch Interiors with "mironians" shapes, among others. Whether depression was the inspiration for his work, or his work was the treatment for his depression, will never be clarified. However, he left a great legacy for humanity and his work is admired all over the world.

De Clérambault Syndrome, Othello Syndrome, Folie à Deux and Variants.

Non-bizarre delusion, defined as a false belief possible although highly unlikely, is the main manifestation of delusional disorders, previously known as paranoia. Based on the predominant delusional themes, 5 main subtypes may be described - erotomanic, grandiose, jealous, persecutory, and somatic. We present here 2 main delusional disorders, the De Clérambault syndrome and the Othello syndrome, and another closely related to the previous ones - Folie à deux. In the De Clérambault syndrome, the main delusional theme is erotomanic type, related to passional delirium where the patient has strong sexual feelings towards another person and has the belief that this other person is deeply in love with him or her. Patients with the Othello syndrome present a delusional disorder of jealous type, a pathological delusion that the partner is unfaithful. In Folie à deux, 2 individuals shared the same psychiatric symptom. However it may be variable, describing variants such as folie imposée or folie simultenée. The risk of aggressive behavior exists in these patients. Knowledge of these syndromes is essential to allow an accurate diagnosis and prompt treatment.

Misoplegia.

In 1974, Critchley described misoplegia as the phenomenon in which a hemiplegic patient develops a morbid dislike towards the offending immobile limbs. Patients with misoplegia may employ, but more commonly strike their paretic limbs not recognized as self. The pathophysiological mechanism is not well understood. The handful of cases of misoplegia described in the literature, frequently presented a right hemispheric damage. However, patients with chronic spinal cord injury may also present this symptomatology. Not only the modification of behavior by this organic injury, but also the patient reaction to disability and previous personality, may provoke the emergence of misoplegia, probably from other right hemispheric self-unawareness syndromes. No data exists related to treatment option, but we have to remember that the lack of awareness of the deficits in these patients makes the rehabilitation process difficult. Misoplegia is one of the passionate syndromes of the still "not-enough well-known" self-awareness syndromes of the right hemisphere, which shows how brain damage goes much further beyond neurological deficit.

Acute cervical artery dissection after a dental procedure due to a second inferior molar infection.

Periodontal infections might represent one of the causative factors for cervical artery dissection. We present a case of a 49-year-old woman admitted due to headache. The patient had been suffering from a right second inferior molar infection with a cervical phlegmon for 1 week prior to admission. On 2 October 2014, the patient went to the dentist and a molar extraction was performed in the morning. In the afternoon, the patient began to experience right hemifacial pain that progressed towards an intense and bilateral headache. Neurological status at the time of admission revealed right miosis, ptosis and conjuntival hyperaemia. A CT angiography showed a right internal carotid artery dissection provoking a high-degree stenosis. The relationship between periodontal infection and vascular disease has been previously presented. Microbial agents may directly, and inflammatory and immunological host response indirectly, influence inflammatory changes in cervical arteries favouring dissections with minor traumas.

Antiphospholipid Syndrome of Late Onset: A Difficult Diagnosis of a Recurrent Embolic Stroke.

A 77-year-old woman with atrial fibrillation (AF) treated with warfarin had a cortical left middle cerebral artery (MCA) stroke (October 2009, international normalized ratio [INR], 1.6) and a cortical left frontal stroke (October 2011, INR, 1.9). Anticoagulation was adjusted. In October 2011, she had a right frontal stroke (INR, 2.3). Acetylsalicylic acid (ASA) was temporally added to the treatment. In June 2013, she had a left occipital stroke (INR, 2.3). Warfarin was changed to rivaroxaban. In August 2013, she had a right occipital stroke. ASA 100 was added to the treatment. On all occasions, repeated neurovascular studies and echocardiography were normal. Diagnoses were cardioembolic stroke. In November 2013, she was admitted because of a left MCA stroke. A complete blood analysis showed the presence of anticardiolipin, anti-b2-glycoprotein antibodies, and lupus anticoagulant. Primary antiphospholipid syndrome (APS) was later confirmed. APS should be considered in young stroke patients, however is not frequent in stroke patients older than 70 years with several cerebrovascular risk factors. The existence of AF in our patient with several embolic strokes made the cardiembolic etiology likely. Uncommon causes of stroke were not considered despite the repetition of the ischemic events. Thus, a wider etiological study should be made in all patients with a recurrent stroke regardless of age, such as a complete blood analysis including immunology study in order to exclude an APS of late onset.

Late spontaneous recanalization of symptomatic atheromatous internal carotid artery occlusion.

INTRODUCTION: Definitive treatment of symptomatic atheromatous internal carotid artery occlusion remains controversial, as far as in rare cases, late spontaneous recanalization has been seen. METHODS: We consecutively studied 182 patients (January 2003 to August 2012) with an ischemic stroke in the internal carotid artery territory and diagnosis of atheromatous internal carotid artery occlusion during hospitalization. FINDINGS: Seven patients presented a late spontaneous recanalization (>3 months) of the internal carotid artery. We described therapeutic attitude according to usual care in these patients. CONCLUSIONS: The authors attempt to highlight the unusual condition of recanalization after a symptomatic atheromatous chronic internal carotid artery occlusion. If these patients can be treated similar to patients with asymptomatic carotid pathology, then this needs to be clarified. However, due to the risk of ipsi- and contralateral ischemic strokes, revascularization techniques should be considered in certain cases. More studies are needed to establish the most appropriate therapeutical approach in order to avoid arbitrary treatment of these patients.

Complex partial status epilepticus in a patient with Crohn's disease.

Few cases of Crohn's disease complicated with meningitis and epidural abscess have been described in literature. We present a case of a 42-year-old former smoker female patient diagnosed with Crohn's disease in September 1995 (with severe nutritional problems). On 20 February 2012, she was admitted due to a probable sepsis (without any previous treatment). After several days she developed a confusion syndrome (probable Wernicke's disease). On 5 March 2012, the patient presented with a febrile episode of 39 ° C. Two days later, the patient presented aphasia and paraparesis, and 3 days later she presented a complex partial status epilepticus. A lumbar puncture was performed and showed 131 leucocytes (63% granulocytes) and proteins 296.3. The abdominopelvic CT scan revealed a presacral collection that seem to extend cranially towards the lumbosacral spine. The lumbar MRI confirmed the lumbar epidural abscess secondary to the fistulisation of the presacral abscess.

Recurrent confusional episodes associated with hypomagnesaemia due to esomeprazol.

In February 2011, the Food and Drug Administration informed that prescription of proton pump inhibitor (PPI) drugs may cause low serum magnesium levels if taken for prolonged periods of time. We present an ex-smoker, 76-year-old man, with high blood pressure, diabetes mellitus and Barrett's oesophagus (treated with esomeprazole since 2003) admitted due to fluctuating aphasia. Neurovascular and neuroimaging studies were normal. Dyslipidemia and atrial arrhythmia were discovered. The patient was discharged with the diagnosis of left middle cerebral artery transient ischaemic attack and anticoagulation treatment was recommended. The patient returned to the emergency department on further two occasions (confusional episodes) and was admitted in order to complete the neurological study that was normal. The patient was discharged with the diagnosis of probable epileptic seizures. After a week, he was admitted due to generalised temblor and unsteadiness. A complete blood test was performed and showed a severe hypomagnesaemia (not previously performed).

'Distorteidolias' - fantastic perceptive distortion. A new, pure dorsomedial thalamic syndrome.

The role of the thalamus in the pathogenesis of the visual and auditory hallucinations has been reported under the name of peduncular hallucinosis, usually with coexisting midbrain involvement. These hallucinations typically take the form of dreamy de novo productions (phanteidolias), less often that of transformations of perceptions into new items (such as seeing faces in clouds) called pareidolias. However, hallucinations taking the form of a complex distortion of perception is a different phenomenon, which to our knowledge has not been reported. We studied 2 patients with complex, 'fantastic', perceptive distortion involving the visual and auditory systems after thalamic stroke limited to the region of the dorsomedial nucleus, sparing the intralaminar nuclei and the midbrain (explaining the lack of disorders of consciousness and confusional state). Our patients reported the modification of usual stimuli (face, body, voices) into unreal, fantastically distorted perceptions (monstrous change of shapes or sounds without appearance of new items). While the exact mechanism leading to such perceptive distortions remains unknown, a release phenomenon due to damage to the dorsomedial thalamus (probably affecting cholinergic system) responsible for a disinhibition of cortical function involved in familiarity of perception seems likely. We suggest that these hallucinations should be called 'distorteidolias'.

Fluctuating neurological symptoms in demyelinating disease mimicking an acute ischaemic stroke.

Fluctuating neurological symptoms in an older patient most often point towards a cerebral ischaemic pathology. The authors present a 66-year-old male patient suffering from a fluctuating right hemiparesis, with an initial diagnosis of ischaemic stroke. The brain and cervical MRI showed demyelinating lesions with abnormal cerebrospinal fluid (CSF) and visual evoked potentials and the patient was successfully treated with intravenous corticosteroids. Demyelinating disease in older patients could be more frequent than expected. It should be considered even in older patients with fluctuating neurological symptoms. MRI and CSF analysis are critical to provide an accurate diagnosis.

Massive pulmonary thromboembolism after intravenous stroke thrombolysis.

The authors present a 76-year-old female with high blood pressure and hypercholesterolaemia as cerebrovascular risk factors, who received intravenous thrombolysis for an ischaemic stroke with a progressive neurological improvement. She was asymptomatic at 48 h and she was transferred to the neurology department where antithrombotic treatment was initiated. She began to sit the following day when she suffered a massive pulmonary embolism (PE). Cardiological study showed patent foramen oval persistence and the presence of an atrial septa aneurysm, and paroxysmal atrial fibrillation. The delay of the onset of the antithrombotic treatment could have been determinant for the massive PE. Thromboembolic complications may be seen after intravenous thrombolysis for ischaemic stroke. An accurate treatment is needed in order to avoid potentially threatening complications such as massive PE.

CT angiography helps to differentiate acute from chronic carotid occlusion: the "carotid ring sign".

INTRODUCTION: Currently, there is no reliable method to differentiate acute from chronic carotid occlusion. We propose a novel CTA-based method to differentiate acute from chronic carotid occlusions that could potentially aid clinical management of patients. METHODS: We examined 72 patients with 89 spontaneously occluded extracranial internal carotids with CT angiography (CTA). All occlusions were confirmed by another imaging modality and classified as acute (imaging <1 week of presumed occlusion) orchronic (imaging >4 weeks), based on circumstantial clinical and radiological evidence. A neuroradiologist and a neurologist blinded to clinical information determined the site of occlusion on axial sections of CTA. They also looked for (a) hypodensity in the carotid artery (thrombus), (b) contrast within the carotid wall (vasa vasorum), (c) the site of the occluded carotid, and (d) the "carotid ring sign" (defined as presence of a and/or b). RESULTS: Of 89 occluded carotids, 24 were excluded because of insufficient circumstantial evidence to determine timing of occlusion, 4 because of insufficient image quality, and 3 because of subacute timing of occlusion. Among the remaining 45 acute and 13 chronic occlusions, inter-rater agreement (kappa) for the site of proximal occlusion was 0.88, 0.45 for distal occlusion, 0.78 for luminal hypodensity, 0.82 for wall contrast, and 0.90 for carotid ring sign. The carotid ring sign had 88.9% sensitivity, 69.2% specificity, and 84.5% accuracy to diagnose acute occlusion. CONCLUSION: The carotid ring sign helps to differentiate acute from chronic carotid occlusion. If further confirmed, this information may be helpful in studying ischemic symptoms and selecting treatment strategies in patients with carotid occlusions.

Floating thrombus as a marker of unstable atheromatous carotid plaque.

Floating thrombus in a carotid artery is an uncommon pathology with a high risk of embolism. We present three patients diagnosed with acute stroke, with a floating thrombus complicating an atheromatous plaque, who were treated with anticoagulants and statins. Although two patients had satisfactory results, one patient suffered a stroke related to plaque progression nearly 3 years after initial presentation. Medical treatment seems to be a good initial option, although late cerebral ischemic complications may be seen due to carotid plaque instability. Delayed carotid endarterectomy or stenting should be considered in cases with subsequent plaque progression.

CADASIL: how to avoid the unavoidable?

All three siblings (one female/two males) of a family presented successively with cerebrovascular events at the ages of 55, 63 and 65. The first one manifested extensive left subcortical haemorrhage and both the second and third patient, showed left lacunar ischemic stroke. Their mother had died from vascular dementia at the age of 60 after several subcortical ischaemic strokes. Their maternal grandfather had died in his fifties from haemorrhagic stroke. All of them showed extensive white matter involvement. The genetic study revealed a mutation in exon 11 of the Notch3 gene in two family members. They were diagnosed with cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL). Although CADASIL is a well-established disease, little is known about this disorder. The fact that all three siblings presented with CADASIL successively may appear disheartening, further studies are needed in order to control the clinical course of this devastating and unavoidable disorder.