Lyme disease presenting as multiple ischaemic strokes.

A 46-year-old man presented with recurrent left hemiparesis and headache. MRI of brain showed an acute right pontine and subacute right thalamic infarcts and MR angiogram showed multiple intracranial arterial stenoses, suggesting cerebral vasculopathy. There was a cerebrospinal fluid lymphocytic pleocytosis with Borrelia burgdorferi antibodies. Central nervous system Lyme disease occasionally presents with ischaemic strokes; this case is unusual in showing vasculopathy on brain imaging, supporting meningovasculitis as the likely mechanism.

Spinal cord stroke: acute imaging and intervention.

Spinal cord infarction is an uncommon disease and as such is often a diagnostic challenge for clinicians. It can vary in its onset, severity, outcome, and recovery from patient to patient. Treatment options for this relatively rare condition also remain elusive. Current consensus recommendations are antiplatelet therapy and the symptomatic management of associated complications such as paraplegia and thromboembolic disease. There are multiple studies in surgical literature of a variety of interventions and adjuncts used for reducing the risk of ischemic spinal cord neurological injury, seen most often in the setting of thoracoabdominal aortic repair operations. We report two cases of acute non-surgical-related spinal cord infarcts, where early diagnosis was made and aggressive, early treatments instituted. With often devastating outcomes, we highlight the need for early detection and that interventions, commonly used in preventing neurological injury after high-risk aneurysm repairs, may be beneficial in treating and reducing the severity of disability in acute spinal cord stroke.

Patterns of cerebral perfusion in patients with asymptomatic internal carotid artery disease.

BACKGROUND: The perfusion profile of patients with asymptomatic internal carotid artery (ICA) disease has not been well studied. The purpose of this study is to describe the perfusion patterns of patients with asymptomatic ICA disease using computed tomography perfusion (CTP) and its potential value in identifying patients at higher risk for transient ischemic attacks (TIAs) or strokes. METHODS: We analyzed 32 patients with asymptomatic high grade ICA disease who had CTP and computed tomography angiography (CTA) of the head and neck. Twenty-four patients had severe ICA stenosis and eight had ICA occlusion. The degree of ipsilateral external carotid artery (ECA) and contralateral ICA stenosis, patency of the anterior communicating artery (ACOM), A1 segment and posterior communicating artery (PCOM) were evaluated in all patients. RESULTS: Sixteen patients had normal CTP and the other 16 patients had cerebral hypoperfusion, characterized by abnormalities in one or more of the three perfusion maps. Ipsilateral hypoplastic A1 segment was more frequent in the group with cerebral hypoperfusion (p = 0.025). Ipsilateral TIAs occurred in two patients, both with cerebral hypoperfusion. CONCLUSION: Cerebral hypoperfusion is present in half of the patients with asymptomatic ICA disease, predominantly in patients with a hypoplastic ipsilateral A1 segment. These patients likely represent a higher-risk group for symptomatic brain ischemia.

Percutaneous carotid artery angioplasty and stenting for ocular ischemic syndrome.

PURPOSE: To describe percutaneous carotid angioplasty and stenting to treat ocular ischemic syndrome resulting from severe intracranial carotid artery stenosis. DESIGN: Retrospective case series of 3 patients with ocular ischemic syndrome and intracranial carotid artery stenosis. INTERVENTION: All patients underwent carotid artery evaluation, including ultrasound, transcranial Doppler, magnetic resonance imaging or magnetic resonance angiography,and angiography. Carotid angioplasty and stenting was performed in all patients. MAIN OUTCOME MEASURES: Carotid angiography, fluorescein angiography, and transcranial Doppler imaging were used to evaluate cerebral and ocular perfusion. RESULTS: Cerebral perfusion improved in all patients. Fluorescein angiography arteriovenous transit times improved in 2 patients. One patient had a correction in the reversal of flow through the ophthalmic artery. Visual acuity remained stable or improved in all patients. There were no complications associated with the procedure. CONCLUSIONS: Intracranial carotid artery stenosis is a rare cause of ocular ischemic syndrome. With the advent of carotid angioplasty and stenting, stenotic lesions previously not amenable to carotid endarterectomy are now treatable with stenting. A complete work-up of the carotid artery is necessary in all cases of ocular ischemic syndrome to ensure evaluation of the entire carotid artery system. Early diagnosis of intracranial carotid stenosis is important for preservation of visual function and reducing risk of cerebral vascular event.