Internuclear Ophthalmoplegia as an Isolated Symptom of Brainstem Wake-up Stroke Responsive to Intravenous Thrombolysis: Evidence from MRI.

BACKGROUND: Internuclear ophthalmoplegia (INO) is a disorder of eye movements caused by a lesion involving the medial longitudinal fasciculus (MLF) within the brainstem, and it is characterized by adduction impairment combined with contralateral dissociated abduction nystagmus. The frequency of acute ischemic stroke (AIS) presenting with INO as a predominant symptom is very low, and many patients suffering from this brainstem AIS are precluded from intravenous thrombolysis (IVT). OBJECTIVE: To provide for the first time a magnetic resonance imaging (MRI) evidence of response to the IVT in brainstem wake-up stroke presenting with INO as an isolated symptom. METHODS: Here, we described a rare case of pons AIS presenting with INO as a unique symptom of awakening. In order to differentiate an ischemic stroke from other stroke mimics, and to determine whether the patient was within the therapeutic window for IVT (wake-up stroke), brain MRI including DWI and FLAIR sequences was acquired. RESULTS: A left paramedian pontine DWI/FLAIR mismatch was detected and the patient was considered eligible for IVT. After IVT, the patient made a full recovery with complete resolution of INO. Follow-up MRI at 1 month demonstrates the absence of ischemic lesions. CONCLUSION: Our case provides neuroradiological evidence of IVT efficacy in brainstem stroke, and it should prompt clinicians to rapidly perform MRI in wake-up onset INO and to just as quickly administer IVT, since INO is a functionally disabling deficit. Finally, this case demonstrates the value of MRI in diagnostic, prognostic, and therapeutic workup of posterior circulation wake-up stroke.

Transvenous Endovascular Treatment of a Dural Arteriovenous Fistula Involving an Isolated Segment of the Superior Sagittal Sinus Through Recanalization of the Occluded Sinus.

A 75-year-old man presented with bilateral frontal hematomas owing to a dural arteriovenous fistula involving an isolated segment of the superior sagittal sinus. After an unsuccessful attempt of transarterial endovascular embolization of the dural arteriovenous fistula, the fistula was occluded using a transvenous approach through recanalization of the occluded superior sagittal sinus.

Mucinous metastases from occult breast carcinoma.

The case of a 34-year-old female patient come to the Emergency Department for neurological symptoms of recent onset is presented. No-contrast CT documented the presence of a neoformation approximately 3 cm in size in the 4th ventricle. For an in-depth diagnostic study of the lesion contrast enhanced MRI was performed. The examination detected a second minute (< 1cm) intraparenchymal nodule highly suspicious of metastasis from primary extra-cerebral neoplasm. The differential diagnosis of infratentorial lesions is discussed. It is concluded that the diagnostic combination of standard MRI with contrast sequences in the three conventional planes plays a major role in typing the nature of focal brain lesions.

Multiple watershed cerebral infarcts.

The case of a 63-year-old female patient affected by arterial hypertension under home therapy, with disordered consciousness and confusion, is discussed. At the emergency department of another hospital she underwent cranial CT which showed mild swelling of right cerebral hemisphere. Based on the clinical suspicion of herpes simplex encephalitis compatible with a first MRI examination of the brain, the patient was admitted to the department of infectious disease of the polyclinic to confirm the diagnosis and plan the therapeutic approach. MRI was repeated and completed with EPI-DWI sequences and PRESS spectroscopy. It did not rule out categorically the infectious/inflammatory pattern but, based on a careful evaluation of the anatomic distribution of acute lesions, the most likely diagnostic hypothesis was the presence of multiple watershed cerebral infarcts on the right side.

Unusual lesion of the thalamic pineal region: role of conventional MRI and DWI in the differential diagnosis.

The case of a 53-year-old female patient admitted to the Emergency department with symptoms from right third cranial nerve of acute onset, is presented. Cranial CT, performed in emergency, documented an intra-axial mass which required an in-depth diagnostic study with cranial MRI after contrast administration. Conventional MRI and DWI helped in correct lesion characterization and in the differential diagnosis with other brain disorders.

Primary central nervous system lymphoma: role of DWI in the differential diagnosis.

The case of a female patient admitted to the hospital for a syncopal episode characterized by mental confusion, retrograde amnesia, agnosia, lack of sphincter control and behavior disorders, is presented. Cranial CT showed a frontal bihemispheric lesion. MRI completed with DWI was then performed to better define the nature of the lesion and for an in-depth diagnostic study. The diagnostic role of conventional MRI combined with DWI and the importance of the latter in the differential diagnosis between primary central nervous system lymphoma (confirmed at histology) and glioblastoma multiforme is discussed.