Cerebral Autosomal Dominant Arteriopathy With Subcortical Infarcts and Leukoencephalopathy (CADASIL) Syndrome: A Case Report and Review of Literature.

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is an autosomal dominant genetic disorder of the small arteries that causes ischemic vascular events, subcortical dementia, behavioral changes, and migraine-like headaches. It is caused by a mutation in the NOTCH3 gene; this disease was first described in 1955 by van Bogaert. We present a 29-year-old woman who presented to the neurology department. She has no history of chronic degenerative diseases. She has been complaining of migraine-like headaches for the past six months. She has cognitive impairment with arithmetic and executive function deficits on neurological examination. Blood biometry and blood chemistry are within normal parameters in her laboratory studies. A viral panel and immunological profile were also performed and were not reactive. A lumbar puncture was performed, and the composition of the cerebrospinal fluid was within normal limits. An MRI was performed, which showed bilateral and symmetric white matter hyperintensities consistent with CADASIL syndrome. There is no specific treatment. Management of these patients is based on symptom control. Neurological sequelae have an important impact on the quality of life and mortality of these patients. For this reason, pharmacological preventive therapies have been sought with controversial evidence.

Bilateral Middle Cerebral Artery Occlusion: A Successful Case of Bilateral Thrombectomy.

Single-vessel occlusions often cause an acute ischemic stroke (AIS) but can rarely be caused by multi-vessel occlusions. Although bilateral AIS is rare, these patients often undergo mechanical thrombectomy as long as they are within the 24-hour window since symptom presentation. We present a case of a female in her 70s who presented to an outside facility with right-sided weakness in her upper and lower extremities, drooping of the right lower face, and aphasia. The patient developed bilateral symptoms on transfer to a tertiary center with neuro-interventional capabilities. Due to concern for a possible bilateral stroke, magnetic resonance imaging was ordered and was remarkable for bilateral middle cerebral artery occlusion. The patient underwent a successful bilateral mechanical thrombectomy within 24 hours of the last known normal. This case demonstrates that mechanical thrombectomy is an excellent treatment option for patients with bilateral occlusions that present within the recommended 24 hours from the last known normal.

A Young Female Newly Diagnosed With Takayasu's Arteritis Masquerading As Cerebrovascular Stroke.

The condition known as Takayasu's disease or Takayasu's arteritis is a type of vascular inflammation that affects the large and medium arteries. It can lead to a reduction in blood flow to various parts of the body, and it can cause severe complications. Patients with this disease may not have specific symptoms, which can lead to their diagnosis not being confirmed. Takayasu's disease is believed to be a probable cause of stroke in young patients. Although stroke is a common cause of morbidity, it is usually not an initial presentation in Takayasu's disease. In this study, a young female with left-sided hemiparesis was diagnosed with Takayasu's disease after a clinical and angiographic examination.

Neurological Complications Secondary to Intimate Partner Violence: A Brief Review and Case of Posterior Cerebral Artery Cerebrovascular Accident Following Domestic Abuse.

Intimate partner violence (IPV) is a growing public health concern, with millions of individuals experiencing IPV each year. Consequences of IPV include psychological disturbances, changes in physical health, and in extreme cases, severe disablement or death. Here, we describe a case of a patient who experienced IPV, leading to a variety of neurological symptoms, and was diagnosed with a posterior cerebral artery (PCA) cerebrovascular accident (CVA) 10 days later. While cases of traumatic brain injury leading to CVA, or stroke, have been documented, there is currently limited reported literature on the neurological complications, specifically stroke, secondary to IPV in adults. Due to this limited reporting, future studies on IPV will be needed to fully understand the long-term neurological complications that may occur.

Anesthesia for a Patient With Cerebrovascular Accident with Seizure Disorder Undergoing Medical Termination of Pregnancy: A Case Report.

The term "total intravenous anesthesia" refers to the preservation of an anesthetic plane with the use of an injectable anesthetic, a sedative that is often given in intermittent boluses. The tendency to have recurrent unprovoked seizures is known as epilepsy. Its prevalence ranges from 0.5% to 1%. The highest incidence rates are in those with anatomical or developmental brain abnormalities, as well as at the extremes of age. The most common triggering factors for epilepsy are stress and fear. The main advantage of total intravenous anesthesia is the patient's rapid recovery and early ambulatory. Conscious sedation is a strategy for giving patients excellent anesthesia and analgesia. In this case report, we will describe a high-risk epileptic patient who required conscious sedation to perform a medical termination.

The Value of Interdisciplinary Collaboration in Lateral Medullary Syndrome Rehabilitation: A Case Report.

Wallenberg's syndrome, also known as lateral medullary syndrome (LMS), is a neurological condition resulting from damage to the lateral portion of the medulla oblongata. We present a case of a 64-year-old man with Wallenberg's syndrome who presented for acute rehabilitation after sustaining a cerebrovascular accident (CVA). As seen in our patient, common symptoms of LMS include difficulty swallowing, hoarseness, ipsilateral weakness, and ipsilateral loss of sensation or numbness. Although the prognosis following infarction is often good, dysfunction in swallowing is one of the key deficits that have a long-term impact on patient quality of life. We aim to emphasize the significance of the interdisciplinary approach to achieving favorable health outcomes in patients with LMS.

An Unfortunate Miss of Undiagnosed Arterial Ischemic Stroke (AIS) in the Setting of Diabetic Ketoacidosis in an Adult: A Case Report.

We present the case of a 43-year-old male with a history of poorly controlled type II diabetes who presented with altered mental status, urinary incontinence, and diabetic ketoacidosis (DKA). Initial brain imaging studies were negative for acute intracranial pathology; however, the next day, the patient was found to have left-sided paralysis. Repeat imaging studies revealed a right middle cerebral artery infarct with hemorrhagic conversion. Given that the rate of reported strokes in the setting of DKA in adults is limited, this case report affirms to discuss the importance of prompt recognition, evaluation, and adequate treatment of DKA to prevent neurological complications, as well as the pathophysiology behind the etiology of DKA-induced stroke. This case also underscores the importance of early recognition and missed strokes in the emergency department (ED) and emphasizes the need for stroke evaluation in patients with altered mental status even though an alternative diagnosis is apparent to avoid anchor bias.

Predictors of Outcomes After Coronary Artery Bypass Grafting: The Effect of Concomitant Mitral Repair.

Background Ischemic mitral regurgitation (IMR) or functional MR intensity with or without repair increases the risk of coronary artery bypass grafting (CABG), and if the contaminant is undertaken, it doubles the risk of the surgery. This study aimed to characterize patients with concomitant CABG and mitral valve repair (MVR) and assess the surgical and long-term outcomes. Methods We conducted a cohort study from 2014 to 2020 on 364 patients who underwent CABG. A total of 364 patients were enrolled and divided into two groups. Group I (n= 349) included patients with isolated CABG, and Group II included patients who underwent CABG with concomitant mitral valve repair (MVR) (n= 15). Results Regarding preoperative presentation, most patients were male: 289 (79.40%), hypertensive 306 (84.07%), diabetic 281 (77.20%), dyslipidemic 246 (67.58%), presenting with NYHA classes III-IV: 200 (54.95%), and upon angiography, found to have the three-vessel disease: 265 (73%). Regarding their age mean± SD and Log EuroSCORE median (Q1-Q3), they had a mean age of 60.94± 10.60 years and a median score of 1.87 (1.13-3.19). The most prevalent postoperative complications were low cardiac output 75 (20.66%), acute kidney injury (AKI) 63 (17.45%), respiratory complications 55 (15.32%), and atrial fibrillation (AF) 55 (15.15%). Regarding long-term outcomes, most patients reported class I NYHA 271 (83.13%) and an echocardiographic decrease in MR severity. Patients with a CABG + MVR were significantly younger (53.93± 15.02 vs. 61.24± 10.29 years; P= 0.009), had a lower ejection fraction (33.6 [25-50] vs. 50 [43-55] %; p= 0.032), and had a higher prevalence of LV dilation (32 [9.17%]). EuroSCORE was significantly higher in patients with mitral repair (3.59 [1.54-8.63] vs. 1.78 (1.13-3.11); P= 0.022). The mortality percentage was higher with MVR but did not attain statistical significance. Intraoperative CPB and ischemic durations were longer in the CABG + MVR group. Furthermore, neurological complications were higher in patients with mitral repair (4 (28.57%) vs. 30 (8.65%), P= 0.012). The study's follow-up duration median was 24 (9-36) months. The composite endpoint occurred more frequently in older patients (HR: 1.05 [95% CI: 1.02-1.09]; 0.001), patients with low ejection fraction (HR: 0.96 [95% CI: 0.93-0.99]; P= 0.006) and in patients with preoperative myocardial infarction (MI) (HR: 2.3 [95%: 1.14- 4.68]; P= 0.021). Conclusion Most IMR patients benefited from CABG and CABG + MVR, as evident by NYHA class and echocardiographic follow-up. CABG + MVR had a higher Log EuroSCORE risk with increased intraoperative cardiopulmonary bypass (CPB) and ischemic durations, which may have played a role in increasing the incidence of postoperative neurological complications. On follow-up, no differences were reported between the two groups. However, age, ejection fraction, and a history of preoperative MI were identified as factors affecting the composite endpoint.

Cerebral Air Embolism: A Case of a Rare Transthoracic Needle Biopsy Complication.

Transthoracic needle biopsy (TNB) is a fundamental procedure in the diagnosis of a wide spectrum of thoracic diseases replacing more invasive surgical procedures. The procedure may be performed with computed tomography (CT) or ultrasound imaging guidance, with CT being the more commonly utilized. Although less invasive than surgery, there is still a complication risk associated with this procedure. These can be local such as pneumothorax, parenchymal hemorrhage, tumor seeding, and hemoptysis, or systemic such as air embolism. The authors report a case of cerebral circulation air embolism as a complication of TNB in a 54-year-old male with suspected lung tumor followed by a brief review of the current literature.

Cognitive Impairment in Strategic Infarct Dementia: A Report of Three Cases.

Strokes involving specific areas regulating cognition and behavioral functions constitute strategic infarct vascular dementia. We present three patients with acute behavioral changes and cognitive impairment following a strategic infarct. Case 1 is of a 59-year-old male, a known patient of diabetes mellitus under treatment, who presented with acute onset of memory deficit along with difficulty in recognizing faces, and left hemispatial neglect. Case 2 is of a 62-year-old male, a smoker, who presented with acute onset of behavioral abnormalities, gait apraxia, and decreased word output. Case 3 is of a 64-year-old female, a known patient of type 2 diabetes mellitus and cerebrovascular accident with left hemiparesis, who presented with psychomotor withdrawal, depression, and cautious gait. One of the most prevalent forms of dementia in adults is vascular dementia, often caused by multiple small strokes, termed multi-infarct dementia. Strategic infarct dementia, on the other hand, is usually caused by a small, single cerebral infarct. The strategic brain regions specifically involved in post-stroke cognitive impairment requires detailed clinical examination along with radiological imaging for accurate localization. Thus the cognitive impact of ischemic strokes can be understood and predicted by clinicians with the help of maps of strategic brain regions associated with global and domain-specific cognitive functions.

Internal Carotid Artery Pseudofenestration: A Case Report.

Congenital internal carotid artery (ICA) fenestrations are extremely rare, with only four cases described in the literature. The embryological mechanism leading to ICA fenestration is merely a hypothesis. Thus, some authors question its existence. The differentiation between an ICA fenestration and pseudofenestration (dissection with persistent true and false lumina) is a serious matter given the possibility of neurological deterioration with the latter and the potential need for endovascular intervention and antiplatelet therapy. We here present the interesting case of a middle-aged patient who presented with acute stroke symptoms and was found to have an intracranial hemorrhage on non-contrast head CT as well as an unusual, somewhat tortuous appearance of the distal left ICA.

Risk of Stroke With Mitral Stenosis: The Underlying Mechanism, Treatment, and Prevention.

Mitral stenosis (MS), a valvular heart disease, is defined by the narrowing of the mitral valve orifice. The common risk factors for stroke include mitral annular calcification (MAC), diabetes mellitus (DM), male gender, hypertension (HTN), hyperlipidemia, and obesity. Endothelial damage, hypercoagulability, and blood stasis in the left atrium promote the development of the thrombus. Among all the risk factors described, MAC is the independent predictor of stroke. The complicated mechanisms responsible for thromboembolism, predisposing factors for thromboembolism, the risk of cerebrovascular accident (CVA) in MS patients, advanced standardized assessment models for identifying those at risk for stroke, and the possible advantages and disadvantages of available therapies have all been discussed in this review article. We have also discussed newer oral anticoagulants (NOACs) like dabigatran, edoxaban, apixaban, and rivaroxaban. Non-pharmacological therapies are also highlighted such as left atrial appendage ligation and occlusion devices. We also conducted a thorough review of the literature on the efficacy and safety of various NOACs in reducing the risk of stroke.

A Cerebrovascular Accident Presenting With Bilateral Vocal Cord Paresis.

Diagnosing a stroke requires careful attention to clinical indicators on physical exam, especially the more subtle manifestations of cerebellar lesions. An 85-year-old male with vascular risk factors and new-onset atrial fibrillation was admitted for left upper extremity weakness, headaches, and tremors. The patient developed stridor during hospitalization and was found to have a new cerebellar infarct with hemorrhagic transformation on computed tomography (CT) of the head, with laryngoscopy showing bilateral vocal cord paresis. While strokes outside of the cerebellum are a known cause of unilateral vocal cord paresis, cerebellar strokes are a rare culprit and rarely cause bilateral cord paresis. Consideration beyond the more common pulmonary and iatrogenic causes of vocal cord paresis should be considered, with particular attention to stroke.

An Unexpected Case of Posterior Reversible Encephalopathy Syndrome.

This study presents an 86-year-old gentleman who was admitted under the acute stroke team for a possible posterior cerebral infarct. Radiologic imaging revealed that the diagnosis was in fact posterior reversible encephalopathy syndrome (PRES). Through a process of elimination by means of investigations, the most likely cause was found to be mild hypertension on a background of vascular dementia causing a possible exacerbation of PRES symptoms. A multidisciplinary approach was found to be beneficial, providing safe and effective care for this patient, allowing a brief recovery period and restoration of baseline function and thus minimising permanent sequelae.

Hot Aortic Nodules.

Atherosclerotic cardiovascular disease is the leading cause of death worldwide. Morbidity of the dreaded thrombotic complications of atherosclerosis such as cerebrovascular accident and myocardial infarction may be severe. Early detection of fulminant disease is therefore important for risk stratification and selecting a treatment strategy. In this report we present four patients in which 18-fluorodeoxyglucose uptake was identified in atherosclerotic plaques at positron emission tomography, performed for other indications. The study aims to showcase the potential implications of 18-fluorodeoxyglucose avid plaques, which may be otherwise overlooked at positron emission tomography. Early detection may aid in prevention of complications of atherosclerotic cardiovascular disease through aggressive lifestyle modification, as well as pharmacologic or other intervention, such as endovascular atherectomy.

Epidemiological Profile of Intracerebral Hemorrhage during a 10-Year Period in a Southern Brazilian Region

Objective Spontaneous intracerebral hemorrhage is responsible for 20% of all cases of cerebrovascular accidents, which might lead to functional disabilities and death. There are few epidemiological data on spontaneous intracerebral hemorrhage in Brazil, and more specifically in the southern region of the country. Methods We reviewed data of 221 patients with intracerebral hemorrhage who attended our department between January of 2004 and December of 2013 and were registered as I61 and I62 according to the 10th edition of the International Classification of Diseases and Related Health Problems (ICD-10). Results From the 221 cases, 53.8% were male, and the median age was 63 years old. Arterial hypertension was reported in 62.4% of the patients. Surgical treatment was performed in 28.9% of all cases and pneumonia affected 19.9%. In 73.4% of the cases, the patients died or were severely disabled at discharge. We found an association of heart disease, coagulopathies, chronic kidney disease, anticoagulant drugs use, surgical treatment, and pneumonia with a poorer outcome. Conclusion The present study describes the epidemiological profile of intracerebral hemorrhage in a southern Brazilian population during a 10-year period.

Introdução A hemorragia cerebral espontânea é responsável por 20% de todos os acidentes vasculares cerebrais e acarreta grande número de óbitos e incapacidade funcional. Poucos são os dados epidemiológicos da hemorragia cerebral espontânea no Brasil, e especificamente no Sul do Brasil. Metodologia Foram revisados 221 casos de hemorragia cerebral espontânea atendidos entre janeiro de 2004 e dezembro de 2013, selecionados aleatoriamente dentre os casos registrados como I61 e I62 de acordo com a 10a revisão da Classificação Estatística Internacional de Doenças e Problemas Relacionados à Saúde (CID-10) nesse período. Resultados Dos 221 casos, 53,8% eram do sexo masculino. A idade média foi de 63 anos e a distância média do local de residência até o centro de tratamento foi de 78,7 Km. Hipertensão arterial sistêmica foi relatada em 62,4% dos casos, diabetes mellitus em 20,4% e tabagismo em 15,4%. Tratamento cirúrgico foi realizado em 28,9% dos casos; pneumonia ocorreu em 19,9%, e 73,4% evoluíram com óbito ou incapacidade grave. Encontramos uma associação entre cardiopatia, coagulopatias, insuficiência renal crônica, uso de anticoagulantes, tratamento cirúrgico, pneumonia e sepse com um pior desfecho. Conclusão O presente estudo descreve o perfil epidemiológico da hemorragia cerebral espontânea de uma população do Sul do Brasil e os fatores prognósticos encontrados no período de 10 anos.

Perfil das vítimas de afecções neurológicas atendidas por um serviço pré-hospitalar móvel de urgência / Profile of individuals with neurological disorders assisted by a prehospital mobile emergency care service / Perfil de víctimas de afecciones neurológicas atendidas por servicio prehospitalario móvil de urgencia

Este artigo tem por objetivo caracterizar o perfil epidemiológico das vítimas de afecções neurológicas atendidas por um Serviço de Atendimento Móvel de Urgência. Trata-se de estudo exploratório, descritivo e de abordagem quantitativa dos dados. A coleta foi realizada no período de janeiro a junho de 2016, em um hospital referência em atendimentos de urgência e emergência do estado do Rio Grande do Norte. Foram analisadas 73 ocorrências neurológicas, 38 (52,1%) do sexo masculino, 43 (58,9%) entre a faixa etária de 68 a 101 anos. Quanto à característica da afecção neurológica, 59 (80,8%) sofreram Acidente Vascular Encefálico, oito (11%) crise convulsiva, três (4,1%) lombalgia associada a lesão medular e três (4,1%) eram de outra natureza neurológica. Quanto ao tempo resposta para o atendimento, a média foi de 31 minutos. O perfil epidemiológico identificado foi de homens idosos, que sofreram Acidente Vascular Encefálico e que não receberam atendimento no tempo resposta adequado (AU).

This article aims to characterize the epidemiological profile of individuals with neurological disorders assisted by a prehospital mobile emergency care service. Exploratory and descriptive study with quantitative approach. Data was collected from January to June 2016, in an emergency and urgent care referral center in the state of Rio Grande do Norte. Seventy-three (73) neurological disorders were analyzed: 38 (52.1%) patients were male individuals, 43 (58.9%) were aged between 68 and 101 years. Regarding the characteristics of the neurological condition, 59 (80.8%) patients had a cerebrovascular accident (CVA), eight (11%) had seizures, three (4.1%) had low back pain related to spinal cord trauma and three (4.1%) patients had other types of neurological conditions. As for the response time to care, the average time was 31 minutes. The epidemiological profile identified was elderly men who had CVA (stroke) and whose care needs were not responded within an appropriate time (AU).

Artículo que objetiva caracterizar el perfil epidemiológico de víctimas de afecciones neurológicas atendidas por un Servicio de Atención Móvil de Urgencia. Estudio exploratorio, descriptivo, de abordaje cuantitativo de datos. La recolección se realizó de enero a junio de 2016, en hospital de referencia en atención de urgencias y emergencias del estado de Rio Grande do Norte. Fueron analizados 73 sucesos neurológicos, 38 (52,1%) en pacientes masculinos; 43 (58,9%) pertenecientes a faja etaria de 68 a 101 años. Respecto a características de la afección, 59 (80,8%) sufrieron Accidente Cerebrovascular, 8 (11%) crisis convulsiva, 3 (4,1%) lumbalgia asociada a lesión medular, y 3 (4,1%) fueron de otra naturaleza neurológica. Acerca del tiempo de respuesta, el promedio fue de 31 minutos. El perfil epidemiológico identificado fue de hombres ancianos, que sufrieron Accidente Cerebrovascular y que no recibieron atención en el tiempo de respuesta adecuado (AU).