A retrospective review of sex differences of white matter hyperintensities in brain MRI of patients with migraine.

OBJECTIVES: The primary objective of this study was to evaluate the prevalence of white matter hyperintensities (WMHs) in patients who experience migraine and compare findings between adult male and female patients. Specific symptoms and comorbidities also were analyzed to determine whether they were associated with WMH prevalence or the sex of patients with migraine. We hypothesized that females would have a higher prevalence of WMHs, experience more frequent and more severe migraine headaches, and be more likely to have certain comorbidities associated with migraine than males. BACKGROUND: An increased prevalence of WMHs in patients with migraine has been proposed, although this relation is not well-supported by data from population-based MRI studies. The difference in brain morphology between males and females is of research interest, and females in the general population appear to have a higher prevalence of WMHs. Sex differences and various comorbidities in patients with migraine relative to the number of WMHs on brain imaging have not been fully investigated. METHODS: This was a cross-sectional study of 177 patients aged 18 years and older with a diagnosis of migraine who were seen in the Lehigh Valley Fleming Neuroscience Institute's Headache Center between January 1, 2000, and January 1, 2017. Patients' baseline characteristics were extracted from electronic medical records, including demographics, review of systems documentation, and brain imaging from MRI. Variables including headache severity, frequency of head pain, insomnia, and comorbidities (anxiety, depression, diabetes, hyperlipidemia, hypertension, and neck pain) also were analyzed for associations with the presence of WMHs. RESULTS: Females were found to have a significantly higher number of WMHs than males (median 3 [IQR: 0-7] vs. 0 [IQR: 0-3], p = 0.023). Patients with WMHs were significantly more likely than those without WMHs to have hypertension (39.8% of patients with WMHs vs. 20.3% without WMHs, p = 0.011), constipation (20.9% vs. 8.3%, p = 0.034), and sleep disorder (55.7% vs. 37.3%, p = 0.022). Females with migraine were significantly more likely to experience constipation than males (20.0% vs. 2.9%, p = 0.015). None of the migraine characteristics studied (frequency, severity, presence of aura) were different between sexes, nor were they significantly associated with the presence of WMHs. CONCLUSION: This study suggests that females with migraine may be more likely to have WMHs and experience constipation than males with migraine. Migraine frequency and severity were not different between sexes, nor were they significantly associated with the presence of WMHs. The findings of this study do not support a specific etiology of WMH development in individuals with migraine that differs from findings in the general population. Further studies are warranted.

The Effect of Regional Anesthetic Sphenopalatine Ganglion Block on Self-Reported Pain in Patients With Status Migrainosus.

BACKGROUND: Status migrainosus (SM) is defined as a debilitating migraine attack lasting more than 72 hours in patients previously known to suffer from migraine headache. Typically, these attacks fail to respond to over the counter and abortive medications. The sphenopalatine ganglion (SPG) plays a critical role in propagating both pain and the autonomic symptoms commonly associated with migraines. SPG block via transnasal lidocaine is moderately effective in reducing migraine symptoms, but this approach is often poorly tolerated and the results are inconsistent. We proposed that an SPG block using a suprazygomatic injection approach would be a safe and effective option to abort or alleviate pain and autonomic symptoms of SM. METHODS: Through a retrospective records review, we identified patients with a well-established diagnosis of migraine, based on the International Headache Society criteria. Patients selected for study inclusion were diagnosed with SM, had failed to respond to 2 or more abortive medications, and had received a suprazygomatic SPG block. Patients had also been asked to rate their pain on a 1-10 Likert scale, both before and 30 minutes after the injection. RESULTS: Eighty-eight consecutive patients (20 men and 68 women) received a total of 252 suprazygomatic SPG block procedures in the outpatient headache clinic after traditional medications failed to abort their SM. At 30 minutes following the injections, there was a 67.2% (±26.6%) reduction in pain severity with a median reduction of 5 points (IQR= -6 to -3) on the Likert scale (ranging from 1 to 10). Overall, patients experienced a statistically significant reduction in pain severity (P < .0001). CONCLUSION: The SPG is known to play an integral role in the pathophysiology of facial pain and the trigeminal autonomic cephalalgias, although its exact role in the generation and maintenance of migraine headache remains unclear. Regional anesthetic suprazygomatic SPG block is potentially effective for immediate relief of SM. We believe the procedure is simple to perform and has minimal risk.

Open Heart Surgery Does Not Increase the Incidence of Ipsilateral Ischemic Stroke in Patients with Asymptomatic Severe Carotid Stenosis.

BACKGROUND AND PURPOSE: We evaluated the incidence of perioperative stroke following the institution's 2007 practice change of discontinuing combined carotid endarterectomy and open heart surgery (OHS) for patients with severe carotid stenosis. METHODS: In this retrospective cohort study, we compared 113 patients undergoing coronary artery bypass grafting, aortic valve replacement, or both from 2007 to 2011 with data collected from 2001 to 2006 from a similar group of patients. Our aim was to assess whether the practice change led to a greater incidence of stroke. RESULTS: A total of 7350 consecutive patients undergoing OHS during the specified time period were screened. Of these, 3030 had OHS between 2007 and 2011 but none were combined with carotid artery surgery (new cohort). The remaining 4320 had OHS before 2007 and 44 had combined procedures (old cohort). Of patients undergoing OHS during the 10-year period of observation, 230 had severe (>80%) carotid stenosis. In the old cohort (before 2007), carotid stenosis was associated with perioperative stroke in 2.5% of cases. None of the 113 patients having cardiac procedures after 2007 received combined carotid artery surgery; only 1 of these patients harboring severe carotid stenosis had an ischemic stroke (.9%) during the perioperative period. The difference in stroke incidence between the 2 cohorts was statistically significant (P = .002). CONCLUSION: The incidence of stroke in patients with severe carotid artery stenosis undergoing OHS was lower after combined surgery was discontinued. Combined carotid and OHS itself seems to be an important risk factor for stroke.

The role of carotid ultrasound in patients with non-lateralizing neurological complaints.

OBJECTIVES: In the United States, approximately 18-25% of carotid duplex ultrasound (CUS) studies are ordered to assess patients with non-lateralizing neurological complaints such as syncope, blurry vision, lightheadedness, headache, and altered mental status. The purpose of this study is to evaluate the benefit of CUS in the evaluation of patients presenting with non-lateralizing signs or symptoms. MATERIALS AND METHODS: We conducted a retrospective analysis to assess the degree and laterality of carotid stenosis among patients with non-lateralizing neurological complaints who underwent CUS interpreted by certified vascular neurologists over a period of 3 years. The primary endpoint was to identify the prevalence of moderate-to-severe carotid artery stenosis among 280 patients who met inclusion criteria. RESULTS: A total of 17.7% of CUS studies were ordered for non-lateralizing symptoms. Two hundred and sixty-one patients (93.21%) had either normal imaging or mild carotid stenosis of <50%. Nineteen patients (6.79%) were found to have stenosis of ≥50%. In this subgroup, age and known preexisting carotid artery atherosclerotic disease were the only variables found to have a statistically significant association with the level of stenosis found on CUS. Two patients with asymptomatic stenosis of >70% underwent a revascularization procedure. CONCLUSION: At least 17.7% of CUS studies were completed for non-lateralizing symptoms. The study is of low-yield with the prevalence of moderate-to-severe stenosis being comparable to that in the general asymptomatic population. We conclude that there is minimal clinical value in the use of CUS to investigate non-lateralizing neurological complaints, resulting in unnecessary healthcare costs.

Spectrum and potential pathogenesis of reversible posterior leukoencephalopathy syndrome.

BACKGROUND: Controversy still exists over the etiology and pathophysiology of reversible posterior leukoencephalopathy syndrome (RPLS). This large single-center case series aims to describe the clinical and imaging features of RPLS in an attempt to deduce the etiology of the disorder and the mechanisms of brain injury. METHODS: A retrospective chart and imaging review was conducted on 59 cases of RPLS in 55 patients. RESULTS: Five RPLS imaging patterns were observed: posterior predominant (n = 40), anterior predominant (n = 7), diffuse lesion (n = 7), basal ganglia predominant (n = 3), and brainstem/cerebellum predominant patterns (n = 2). RPLS resulted in permanent neurologic deficits in 14 patients and death in 4 patients. Hypertension was seen in 57 (97%) cases, and mean arterial blood pressure exceeded 140 mm Hg in 30 (51%) cases. Follow-up magnetic resonance imaging scans revealed a significant worsening of vasogenic edema in 2 cases, both with persistent hypertension. Magnetic resonance imaging scans revealed areas of ischemia in 14 cases, all within or at areas closely adjacent to vasogenic edema. Diffuse vasculopathy was seen in 8 cases. There was a lack of correlation between the presence of vasculopathy and the degree of vasogenic edema (P = .62), but a correlation was suggested between ischemia and vasculopathy (P = .02). CONCLUSIONS: This study strongly suggests that hypertension-induced vasodilation rather than vasoconstriction-mediated hypoxia is likely the major mechanism responsible for the development of vasogenic edema, and that vasoconstriction may contribute to the development of ischemia in RPLS.

Is carotid artery disease responsible for perioperative strokes after coronary artery bypass surgery?

The coronary and extracranial carotid vascular beds are often simultaneously affected by significant atherosclerotic disease, and stroke is one of the potential major complications of coronary artery surgery. As a result, there is no shortage of reports in the vascular surgery literature describing simultaneous coronary and carotid artery revascularizations. Generally, these reports have found this combination of operations safe, but have stopped short of proving that it is necessary. Intuitively, simultaneous carotid endarterectomy and coronary artery bypass surgery could be justified if most perioperative strokes were the result of a significant carotid stenosis, either directly or indirectly. At first glance this appears to be a fairly straightforward issue; however, much of the evidence on both sides of the argument is circumstantial. One significant problem in analyzing outcome by choice of treatment in patients presenting with both coronary and carotid disease is the multiple potential causes of stroke in coronary bypass patients, which include hemorrhage and atheroemboli from aortic atheromas during clamping. But this controversial subject is now open to discussion, and our debaters have been given the challenge to clarify the evidence to justify their claims.

Sulcal artery syndrome after vertebral artery dissection.

Sulcal artery syndrome is a rare cause of spinal cord infarction. We describe a case of sulcal artery syndrome due to traumatic vertebral artery dissection and review the known literature on this rare syndrome.

Analysis of death and disability due to golf cart crashes in The Villages, Florida: 2011-2019.

OBJECTIVE: More than 18 000 Golf Cart (GC)-related injuries occur in the United States (US) annually. However, very few studies have analyzed the causes of such crashes. This study represents the largest single-center analysis of GC crashes performed within the largest GC community in the US, a community in which they are used extensively for local transportation. We examine the nature of these crashes and present potential preventative measures. METHODS: All GC crashes reported in The Villages, Florida, from July 1, 2011 to July 1, 2019 were analyzed in this study. Data were obtained from multiple sources to create a comprehensive collection of all recorded GC crashes in the area of study. Sources included The Villages Property Owners' Association (POA), The Villages Sun Daily Newspaper, The Villages Public Safety Department (VPSD), Police Dispatch records, and the Sumter County Police data base. RESULTS AND CONCLUSIONS: During the observation period, a total of 875 GC-related crashes occurred, representing an average of 136 crashes, 65 hospitalizations, and 9 dead or disabled annually. Of all crashes, 48% resulted in hospitalization, severe trauma, or death. Of these, ejection occurred in 27%, hospitalization in 55%, and death or disability in 15% of crashes. Virtually all death and disability occurred within the setting of GC used on streets or road pathways. Death and disability, particularly due to ejection during GC crashes, occur at an alarming rate when GCs are used for local transportation. We believe public awareness and the use of 3-point seatbelts in these vehicles would significantly reduce death and disability caused by these crashes.

The combined approach to lysis utilizing eptifibatide and rt-PA in acute ischemic stroke: the CLEAR stroke trial.

BACKGROUND AND PURPOSE: Multiple approaches are being studied to enhance the rate of thrombolysis for acute ischemic stroke. Treatment of myocardial infarction with a combination of a reduced-dose fibrinolytic agent and a glycoprotein (GP) IIb/IIIa receptor antagonist has been shown to improve the rate of recanalization versus fibrinolysis alone. The combined approach to lysis utilizing eptifibatide and recombinant tissue-type plasminogen activator (rt-PA) (CLEAR) stroke trial assessed the safety of treating acute ischemic stroke patients within 3 hours of symptom onset with this combination. METHODS: The CLEAR trial was a National Institutes of Health/National Institute of Neurological Disorders and Stroke-funded multicenter, double-blind, randomized, dose-escalation and safety study. Patients were randomized 3:1 to either low-dose rt-PA (tier 1=0.3 mg/kg, tier 2=0.45 mg/kg) plus eptifibatide (75 microg/kg bolus followed by 0.75 microg/kg per min infusion for 2 hours) or standard-dose rt-PA (0.9 mg/kg). The primary safety end point was the incidence of symptomatic intracerebral hemorrhage within 36 hours. Secondary analyses were performed regarding clinical efficacy. RESULTS: Ninety-four patients (40 in tier 1 and 54 in tier 2) were enrolled. The combination group of the 2 dose tiers (n=69) had a median age of 71 years and a median baseline National Institutes of Health Stroke Scale (NIHSS) score of 14, and the standard-dose rt-PA group (n=25) had a median age of 61 years and a median baseline NIHSS score of 10 (P=0.01 for NIHSS score). Fifty-two (75%) of the combination treatment group and 24 (96%) of the standard treatment group had a baseline modified Rankin scale score of 0 (P=0.04). There was 1 (1.4%; 95% CI, 0% to 4.3%) symptomatic intracranial hemorrhage in the combination group and 2 (8.0%; 95% CI, 0% to 19.2%) in the rt-PA-only arm (P=0.17). During randomization in tier 2, a review by the independent data safety monitoring board demonstrated that the safety profile of combination therapy at the tier 2 doses was such that further enrollment was statistically unlikely to indicate inadequate safety for the combination treatment group, the ultimate outcome of the study. Thus, the study was halted. There was a trend toward increased clinical efficacy of standard-dose rt-PA compared with the combination treatment group. CONCLUSIONS: The safety of the combination of reduced-dose rt-PA plus eptifibatide justifies further dose-ranging trials in acute ischemic stroke.

The Lowering of Vascular Atherosclerotic Risk (LOVAR) program: an approach to modifying cerebral, cardiac, and peripheral vascular disease.

More than 1 million US citizens die of cerebral, cardiac, and peripheral vascular disease (collectively, CVD) each year. Basic science and clinical outcome research aimed at reducing the burden of this illness is widespread, but the knowledge gleaned from controlled trials has not fully translated into everyday clinical practice and care of patients with CVD and their inherent risk factors. The Lowering of Vascular Atherosclerotic Risk (LOVAR) program was a 5-year observational study that evaluated the feasibility of a high-intensity multidisciplinary program of risk factor reduction in a population with known symptoms of CVD. The population comprised patients with documented clinically symptomatic cerebral, cardiac, or peripheral vascular disease and at least two modifiable risk factors for stroke, myocardial infarction, or peripheral vascular occlusive disease. Final outcomes were evaluated by comparing primary and secondary end points and quality of life. A total of 271 patients were enrolled in the intervention group, and 242 were enrolled in the standard care group (control). At 3 years, significant improvements in several risk factors were seen in the intervention group, with no significant improvements for the control group. The rate of patient retention was 95% at 3 years, and overall rates of physician and patient satisfaction were high. We believe that the Lowering of Vascular Atherosclerotic Risk program is generalizable to a sufficiently motivated population targeted as high risk for vascular disease.

Predicting mortality after intracerebral hemorrhage: comparison of scoring systems and influence of withdrawal of care.

OBJECTIVE: The Broderick system and the intracerebral hemorrhage (ICH) score are two systems for predicting 30-day mortality in patients with spontaneous ICH. No previous study has compared two ICH scoring systems in an independent patient cohort. Our purpose was to externally validate and directly compare these two systems and evaluate the effect of withdrawal of care on system performance. METHODS: In all, 307 consecutive patients admitted with ICH between 1998 and 2002 were evaluated. Broderick exclusion criteria were used, resulting in a cohort of 241 patients. Admission Glasgow Coma Scale score, ICH volume, 30-day mortality, and day-30 location were collected. The sensitivity, specificity, receiver operator characteristic curves, and model explained variance (R2) of the two systems were directly compared. The statistical performances of both systems were then compared in subsets that included or excluded patients from whom care was withdrawn. RESULTS: Overall mortality was 76 of 241 (31.5%). The ICH score had significantly higher sensitivity (66% v 45%, P = .001) and higher receiver operator characteristic curves (0.814 v 0.773, P < .001) for predicting 30-day mortality. The model R2 and specificity were not significantly different between systems. Both systems were significantly associated with 30-day location stratified as home, acute rehabilitation, skilled nursing facility, or death (ICH score Chi square = 79.28, P < .001; Broderick Chi square = 60.63, P < .001). Inclusion or exclusion of patients who had supportive care withdrawn did not significantly affect overall statistical performance. CONCLUSIONS: The ICH score performed significantly better than the Broderick system. Overall statistical performance of both systems was not influenced by withdrawal of care.

Physician attitudes regarding cardiovascular risk reduction: the gaps between clinical importance, knowledge, and effectiveness.

Reducing risk factors for patients with vascular disease can reduce the subsequent incidence of cerebro-cardiovascular disease. While physicians have had extensive training in the importance of atherosclerotic vascular disease risk factor modification, evidence suggests that they systematically miss opportunities for clinical prevention during routine practice. The aim of this study was to identify whether physicians felt confident in their knowledge and effectiveness regarding counseling patients to reduce cardiovascular risk and to determine barriers to prevention interventions in the office setting. Surveys were mailed to 509 physicians affiliated with an academic community hospital. Nonrespondents were sent reminders and a second survey. Comparisons were made using chi-square analysis. Two hundred and five surveys were returned (40.3%). Thirty-six percent of physicians felt knowledgeable about weight management techniques, compared to 3% who were confident that they succeeded in their practice (p < 0.001). Similar patterns were found for Tobacco Cessation (62% versus 14%, p = 0.001), Alcohol Reduction (46% versus 7%, p < 0.001), Stress Management (35% versus 5%, p < 0.001), Exercise (53% versus 10%, p < 0.001), Nutrition (36% versus 8%, p < 0.001), Diabetes Management (48% versus 23%, p < 0.001), Blood Pressure Management (57% versus 43%, p < 0.001) and Lipid Management (59% versus 38%, p < 0.001). We identified a significant gap between physician confidence in their knowledge about risk factors and their effectiveness at providing counseling and obtaining results in their office. Most physicians felt that the routine office follow-up visit was an ineffective method for instituting vascular risk factor reduction. Alternate settings for risk factor reduction may be needed for improving atherosclerosis prevention.

Postictal Todd's Paralysis Associated with Focal Cerebral Hypoperfusion on Magnetic Resonance Perfusion Studies.

BACKGROUND: The exact underlying physiology of postictal motor deficits, known as Todd's paralysis, is not well understood and its vascular perfusion physiology is not well studied. Reversible postictal perfusion abnormalities have been sparsely described in the literature. METHODS: We report abnormal brain magnetic resonance perfusion maps in a 9-year-old boy who presented with postictal left hemiparesis. This case correlates postictal hemispheric cerebral hypoperfusion with clinical evidence of Todd's paralysis. CONCLUSIONS: Our case provides an insight into the potential pathophysiology mechanism underlying Todd's paralysis and the practicality of magnetic resonance perfusion studies in localizing an epileptogenic zone in the postictal patient.

Pathogenesis, clinical course and neuro-radiological signs of Proprionibacterium acnes cerebritis: Case report and literature review.

The clinical and neuroimaging characteristics of brain infections related to Propionibacterium acnes are not well-characterized, making early diagnosis and treatment a challenge. More recently, life-threatening central nervous system infections with P. acnes are being reported with increasing frequency as complications of neurointerventional procedures. We present a rare case of P. acnes cerebritis that occurred as a sequela of bare platinum aneurysm coiling and a contaminant of percutaneous angiographic intervention. We include an extensive review of the literature describing the pathogenesis of P. acnes and neuro-radiological signs of brain infections related to this pathogen.

Pennsylvania comprehensive stroke center collaborative: Statement on the recently updated IV rt-PA prescriber information for acute ischemic stroke.

OBJECTIVE: Recently, the FDA guidelines regarding the eligibility of patients with acute ischemic stroke to receive IV rt-PA have been modified and are not in complete accord with the latest AHA/ASA guidelines. The resultant differences may result in discrepancies in patient selection for intravenous thrombolysis. METHODS: Several comprehensive stroke centers in the state of Pennsylvania have undertaken a collaborative effort to clarify and unify our own recommendations regarding how to reconcile these different guidelines. RESULTS: Seizure at onset of stroke, small previous strokes that are subacute or chronic, multilobar infarct involving more than one third of the middle cerebral artery territory on CT scan, hypoglycemia, minor or rapidly improving symptoms should not be considered as contraindications for intravenous thrombolysis. It is recommended to follow the AHA/ASA guidelines regarding blood pressure management and bleeding diathesis. Patients receiving factor Xa inhibitors and direct thrombin inhibitors within the preceding 48 h should be excluded from receiving IV rt-PA. CT angiography is effective in identifying candidates for endovascular therapy. Consultation with and/or transfer to a comprehensive stroke center should be an option where indicated. Patients should receive IV rt-PA up to 4.5h after the onset of stroke. CONCLUSIONS: The process of identifying patients who will benefit the most from IV rt-PA is still evolving. Considering the rapidity with which patients need to be evaluated and treated, it remains imperative that systems of care adopt protocols to quickly gather the necessary data and have access to expert consultation as necessary to facilitate best practices.

Diagnosis and neuroimaging of acute stroke producing distal arm monoparesis.

Strokes which result in the isolated, pure motor weakness of an upper extremity are unusual and under-recognized cerebrovascular syndromes. Few reports in the literature describe the syndrome adequately or provide substantive clinical or anatomical correlation. Moreover, it may be misdiagnosed as a disorder of the peripheral nervous system because of the lack of pyramidal tract signs or the involvement of speech, the face, or lower limbs. We describe 35 patients who presented with sudden isolated pure motor weakness of an arm or hand caused by stroke, and provide clinical anatomic correlation of the lesion, stroke etiology, and outcome. Between December 1997 and November 2002, we prospectively identified 35 cases of distal arm monoparesis (DAMP) from among 4818 acute stroke and stroke related admissions to the Lehigh Valley Hospital. We included all patients with isolated weakness of one arm or hand unassociated with objective sensory, coordination, or language deficit, and no significant involvement of speech, the ipsilateral face, or leg. We examined clinical features, neuroimaging, etiology of stroke, and the prognosis of patients with the syndrome over a mean follow-up of 1.7 years. DAMP is an unusual form of cortical infarct which occurs in the parietal lobe or central sulcus region, comprising less than 1% of stroke cases. The infarcts are not caused by classical deep white matter lacunar infarctions, and are clearly delineated as superficial small cortical infarcts by magnetic resonance imaging (MRI)/diffusion-weighted imaging (DWI). Although the prognosis for recovery is uniformly good, the recurrent stroke risk was 14% over 1.7 year mean follow-up.

Reversible confluent deep white matter abnormalities: a new variant of posterior reversible encephalopathy syndrome.

We describe a confluent deep white matter abnormalities variant of PRES, further strengthening the notion that PRES is a disorder of radiological heterogeneity. We present 2 cases of PRES with findings of diffuse but reversible vasogenic edema located in the deep periventricular white matter regions of bilateral hemispheres without a clearly posterior distribution. We feel that this represents a rare variant of PRES on imaging, thus adding to the existing radiological spectrum for this entity. Both of our patients presented with malignant hypertension (mean arterial blood pressure of 200 mmHg) and developed neurological symptoms that included encephalopathy, seizure, headache, and vision changes. Additionally, both patients presented with significant subcortical white matter edema that improved dramatically on follow-up imaging. The clinical and radiological improvement in both patients occurred following successful blood pressure management. It is possible that the deep white matter changes of PRES are seen exclusively in the setting of severe accelerated hypertension. Our case reports reveal that, in patients with hypertensive encephalopathy, a deep white matter pattern of diffuse signal changes may not necessarily indicate chronic ischemic changes and follow-up imaging studies are essential to rule out a diagnosis of PRES.

Posterior reversible encephalopathy syndrome: clinicoradiological spectrum and therapeutic strategies.

Posterior reversible encephalopathy syndrome (PRES) is a clinical syndrome of encephalopathy, headache, visual disturbance, and seizures. In most cases, symptoms present acutely or subacutely in the setting of accelerated hypertension, eclampsia, autoimmune disease, immunosuppressive treatment, or cancer chemotherapy. One essential feature of PRES is the presence of reversible cerebral vasogenic edema that has a predominantly posterior distribution on brain imaging. Atypical imaging features are commonly described, including involvement of the anterior brain or brainstem and the coexistence of ischemia or hemorrhage. In most cases, both clinical and radiological findings are reversible, although permanent imaging abnormalities and residual neurological sequelae can be seen in a minority of patients. The syndrome is thought to be caused by a breakdown of the blood-brain barrier and an extravasation of the intravascular fluid. Treatment of hypertension and seizures, and withdrawal of causative agents are the mainstays of therapy in PRES.

Thrombolytic therapy for ischemic stroke secondary to paradoxical embolism in pregnancy: a case report and literature review.

INTRODUCTION: Thrombolysis for acute ischemic stroke has been rarely administrated during pregnancy. Paradoxical embolism through a patent foramen ovale (PFO) or pulmonary arteriovenous malformation (AVM) is an identified risk factor for ischemic stroke. CASE REPORT: We report a 24-year-old woman at 11 weeks gestation who developed a sudden onset of dysarthria, hemiparesis, and hemisensory loss. She was diagnosed as having an ischemic stroke in the left middle cerebral artery (MCA) territory. She was treated with intra-arterial recombinant tissue plasminogen activator with subsequent resolution of her neurological deficits. Further workup revealed the presence of a PFO with a large right-to-left shunt. After being put on antithrombotic therapy, she presented again at 13 gestational weeks with a new ischemic infarction in the vertebrobasilar territory. Her PFO was closed percutaneously under ultrasonic guidance but the right-to-left shunt persisted. After a normal delivery, she was found to have a large pulmonary AVM which was successfully resected without complication. CONCLUSIONS: This report describes the successful usage of intra-arterial tissue plasminogen activator for acute ischemic stroke during early pregnancy. In patients with presumed paradoxical embolism, careful attention should be paid to rule out a coexistence of PFO and pulmonary AVM.