Haitham Dababneh

Hemiparesis, encephalopathy, and extrapontine osmotic myelinolysis in the setting of hyperosmolar hyperglycemia

Osmotic demyelination syndrome (ODS) is a recognized complication of rapid correction of hyponatremia. However, other medical conditions have been associated recently with the development of ODS in the absence of changes in serum sodium. We present a 23-year-old man who developed left hemiparesis and encephalopathy after treatment of hyperglycemia. MRI demonstrated changes in the splenium of the corpus callosum and the posterior limb of the right internal capsule. This report, together with others, suggests that the full spectrum of lesions of ODS, pontine and extrapontine, can occur in the setting of any rapid change in osmolar state.

Vessel wall enhancement in herpes simplex virus central nervous system vasculitis.

Infection is a well-known cause of cerebral vasculopathy and vasculitis. We report a 36-year-old woman with cerebral vasculitis and ischemic stroke secondary to herpes simplex virus (HSV). MRI studies revealed a pontine stroke with basilar artery stenosis and vessel wall gadolinium enhancement. This case demonstrates the ability of HSV to cause a focal brainstem vasculitis and the utility of enhanced MRI in the diagnosis of stroke related to HSV central nervous system vasculitis.

Management of tandem occlusion stroke with endovascular therapy

OBJECT Approximately 25% of patients with middle cerebral artery (MCA) occlusion will have a concomitant internal carotid artery (ICA) occlusion, and 50% of patients with an ICA occlusion will have a proximal MCA occlusion. Cervical ICA occlusion with MCA embolic occlusion is associated with a low rate of recanalization and poor outcome after intravenous thrombolysis. The authors report their experience with acute ischemic stroke patients who suffered tandem ICA/MCA (TIM) occlusions and underwent intravenous thrombolysis followed by extracranial ICA angioplasty and intracranial MCA mechanical thrombectomy. METHODS In a retrospective analysis of their stroke database (2008-2011), the authors identified 2 patients with TIM occlusion treated with intravenous thrombolysis followed by extracranial ICA angioplasty and intracranial mechanical thrombectomy. They examined early neurological improvement defined by a greater than 10-point reduction of National Institutes of Health Stroke Scale (NIHSS) score and an improved modified Rankin Scale (mRS) score at 60 days. Successful recanalization based on thrombolysis in cerebral infarction (TICI) score of 2 or 3 was also evaluated. RESULTS In both patients a TICI score of 2b or 3 was achieved, signifying successful recanalization. In addition, both patients had a reduction in the NIHSS score by greater than 10 points and an mRS score of 0 at 60 days. CONCLUSIONS Tandem occlusions of the cervical ICA and MCA may be successfully treated using the multimodality approach of intravenous thrombolysis followed by extracranial ICA angioplasty and intracranial mechanical thrombectomy.

Observation of Mean Transit Time (Mtt) Perfusion Maps on a 320-Detector Row Ct Scanner and its Potential Application in Acute Ischemic Stroke

Background and Purpose: We present three patients with acute ischemic stroke who underwent computed tomography perfusion (CTP) imaging utilizing an Aquilion ONE (Toshiba Medical Systems, Nasu, Japan) 320-dectector row CT scanner using a Singular Value Decomposition Plus (SVD+) algorithm to generate perfusion maps. These MTT maps may prove to be a sensitive and specific predictor of ischemic penumbra (IP) and infarct core (IC). Methods: Patients, who presented with an acute ischemic stroke, received high quality whole-brain CTP scans and a follow up MRI or non-contrast CT (NCCT) scan, and underwent successful pharmacological and/ or interventional reperfusion procedures were selected for evaluation. A neuroradiologist utilizing Vitrea FX 3.1 software reviewed images, and the IC volumes were calculated. Results: A comparison was made between the volumes of infarct core utilizing SVD+ MTT maps and DWI MR sequences or a sub-acute NCCT. There was a correlation between the infarct core volume measured on MTT and final infarct volume on follow up imaging. However due to limitations associated with a small sample size, a statistical correlation cannot be definitively calculated from this data set. Conclusions: Utilization of the SVD+ MTT map may allow for a more accurate assessment of the infarct core and surrounding salvageable tissue as compared to cerebral blood flow/cerebral blood volume (CBF/CBV) mismatch though further studies are required to validate this observation.

The role of perfusion CT in identifying stroke mimics in the emergency room: a case of status epilepticus presenting with perfusion CT alterations

Emergency medicine physicians are often faced with the challenging task of differentiating true acute ischemic strokes from stroke mimics. We present a case that was initially diagnosed as acute stroke. However, perfusion CT and EEG eventually led to the final diagnosis of status epilepticus. This case further asserts the role of CT perfusion in the evaluation of patients with stroke mimics in the emergency room setting.

Stress-induced cardiomyopathy complicating a stroke caused by an air embolism.

Systemic air embolism is a very rare (<0.1%) complication of computed tomography-guided transthoracic needle aspiration and can result in serious neurological and/or cardiac sequelae. Stroke and stress cardiomyopathy can have a variety of etiologies; however, an association of Takotsubo cardiomyopathy with cerebrovascular events precipitated by an air embolus has not been reported. We report a patient with stress-induced cardiomyopathy after an air embolus-induced stroke. The patient was managed with hyperbaric oxygenation and her cardiomyopathy was initially treated as per the acute coronary syndrome protocol until coronary angiography confirmed patent arteries. We review the pathophysiology and management recommendations for both events. Prompt recognition of air embolism-induced cerebrovascular events and stress cardiomyopathy by clinicians is imperative to the timely initiation of appropriate management and a successful treatment outcome.

Teaching NeuroImages: Comatose patient with bilateral thalamic infarct due to internal carotid artery occlusion

An 88-year-old woman with a medical history of diabetes, hypertension, and atrial fibrillation presented to the emergency room after being found unresponsive with a NIH Stroke Scale score of 23 and Glasgow Coma Scale score of 3. She was unresponsive to painful stimuli. Noncontrast CT demonstrated bilateral thalamic infarcts (figure 1A).

Teaching NeuroImages: Intracranial dural arteriovenous fistula presenting as ascending paralysis

A 50-year-old woman presented with 4 weeks of ascending paralysis associated with nausea, vomiting, hypophonia, and dyspnea. Examination revealed hypophonia, diminished strength in the upper and lower extremities, increased reflexes throughout, and a T10 sensory level. Imaging ([figures 1][1] and [2