Madoka Okamura

Co-occurrence of multiple cerebral infarctions due to hypercoagulability associated with malignancy and meningeal carcinomatosis as the initial manifestation of gastric cancer.

BackgroundMeningeal carcinomatosis and hypercoagulability associated with malignancy are typical late stage complications in cancer patients. The co-occurrence of meningeal carcinomatosis and cerebral infarction related to hypercoagulability associated with malignancy in an individual as the initial manifestation of malignancy has not been previously reported.Case presentationHerein, we report the case of an 80-year-old patient who presented with meningeal carcinomatosis and hypercoagulability related to malignancy as the initial manifestation of occult gastric cancer. The patient displayed consciousness disturbance, mild left facial paralysis, and bilateral positive Babinski’s sign. Using brain magnetic resonance imaging, the patient was diagnosed as having acute multiple cerebral infarctions. Cerebrospinal fluid (CSF) cytology showed adenocarcinoma and upper gastrointestinal endoscopy disclosed scirrhous gastric cancer. The patient presented with headache, fever, and meningeal irritation with a subacute course. Tuberculous or fungal meningitis was initially suspected; however, cytological evidence of adenocarcinoma in the CSF led to the diagnosis of meningeal carcinomatosis.ConclusionThe comorbidity of hypercoagulability associated with malignancy and meningeal carcinomatosis should be considered in a patient presenting with multiple cerebral infarctions, progressive disturbance of consciousness, fever, and meningeal irritation.

Isolated Shoulder Palsy due to Cortical Infarction: A Case Report and Literature Review of Clinicoradiological Correlations

Clinicoradiological correlations observed in patients with small cortical infarctions have supported somatotopic representation of different parts of body areas in primary motor cortex. However, isolated shoulder weakness because of infarction in precentral gyrus has rarely been described. We report an 80-year-old woman with isolated shoulder palsy because of cortical ischemic infarction in the base of the left precentral gyrus as confirmed by brain magnetic resonance imaging. In our patient, cardiogenic embolism or Trousseau syndrome associated with lung cancer was considered the cause of ischemic infarction. Physicians should consider small cortical infarction, when a patient complains of sudden onset of shoulder weakness without pain. In line with the previous reports, a responsible cortical lesion in our patient corresponded to motor shoulder area in the motor homunculus reported to be located more medially to the hand area.

Isolated Body Lateropulsion in a Patient with Pontine Infarction

A 72-year-old man with diabetes mellitus and hypertension was admitted to our hospital with lightheadedness. The patient showed lateropulsion to the right side, but his neurological findings were otherwise normal. Brain magnetic resonance images showed a fresh ischemic infarct in the left dorsal part of the lower pons. Body lateropulsion is characterized by an irresistible falling to one side and has been reported in lesions in several brain regions. However, it has rarely been reported in pontine lesions. We suggest that physicians should be aware that pontine lesions can cause isolated body lateropulsion without other neurological deficits.

Cerebral infarction associated with diabetic ketoacidosis in an elderly patient

A 79-year-old woman who had diabetes mellitus for 22 years developed coma 1 day after influenza A virus infection. Diabetic ketoacidosis (DKA) was diagnosed based on high serum glucose levels (902 mg/dL), an arterial pH of 7.19 and large urine ketone (3 + ). Subsequently, the patient was treated with insulin and fluid therapy. After improvement in serum glucose levels, diffusion-weighted magnetic resonance imaging (MRI) showed acute infarction in the bilateral middle and posterior cerebral artery territories (Fig. 1). No severe stenosis in major cerebral arteries on magnetic resonance angiography was detected. Transthoracic and transesophageal echocardiography did not show any potential cardiac source of embolism including patent foramen ovale or thrombi in the left ventricle. In the present patient, brain lesions on MRI were located in the white matter, but not in cortices, suggesting microcirculatory impairment by hyperglycemia-induced hypercoagulability and/or hyperviscosity. DKA is associated with thrombotic risks, such as abnormalities in coagulation factors, platelet activation and blood volume, and cerebral edema as a result of DKA might predispose to stroke; however, DKA associated with stroke is rare in adults.

The ‘Mickey Mouse ears’ sign: a bilateral cerebral peduncular infarction

The literature rarely reports bilateral cerebral peduncular infarction. We report the unique magnetic resonance imaging (MRI) finding of a bilateral cerebral peduncular infarction that simulated a ‘Mickey Mouse ears’ sign. A 62-year-old man with a history of diabetes and hypertension was admitted to our hospital with acute onset vertigo and an unsteady gait. At admission, his blood pressure was 198/118 mmHg, and his pulse rate was 60 beats/min. A neurological examination revealed truncal and bilateral limb ataxia. A diffusionweighted MRI showed an acute infarction in the bilateral cerebellum and occipital lobes (Fig. 1a). On the third day of hospitalization, despite anticoagulation and antiplatelet therapies, consciousness disturbance developed. Although the patient’s extraocular movement was preserved, his light reflexes were sluggish bilaterally. Tetraparesis with bilateral Babinski’s sign was noted. A diffusion-weighted MRI identified an acute bilateral cerebral peduncular infarction that looked like a ‘Mickey Mouse ears’ (Fig. 1b). An MR angiography showed decreased flow signals of the proximal bilateral P1 segments compared with images taken at admission, which showed severe stenosis at the proximal basilar artery and the absence of flow signals from the bilateral P1–P2 junctions of the posterior cerebral artery (Fig. 1c and d). The patient’s neurological symptoms progressed, and the patient died 2 days later. Bilateral cerebral peduncular infarction is extremely rare, and is associated with locked-in syndrome and a persistent vegetative state [1–4]. Table 1 demonstrates previously reported brain computed tomographic (CT) scans, MRI-confirmed bilateral cerebral peduncular infarcts [2,4–7] and pathologically confirmed cases [3,8]. Out of nine patients, five individuals showed locked-in syndrome, and two patients initially had unilateral cerebral peduncular infarcts that progressed bilaterally. Typically, locked-in syndrome has been attributed to ventral pontine lesions [9]. Although additional pontine involvements are shown in Table 1, the reported cases of bilateral cerebral peduncular infarcts without the involvement of the pons or thalamus [6,8], or with small pontine infarcts [7], suggest that cerebral peduncular infarcts are the cause of locked-in syndrome. The bilateral cerebral peduncular lesions without the involvement of the ventral portion of the pons that result in locked-in syndrome are also found in patients with multiple sclerosis [10]. Cerebral peduncles are supplied with blood via the perforating branches of the posterior communicating, posterior cerebral and superior cerebellar arteries or the anterior choroidal artery that branches from the internal carotid artery. In our patient, a decrease in the flow signals of the proximal portions of the P1 segments on the MR angiography corresponded to the occurrence of a bilateral cerebral peduncular infarction. This result suggests that perforating branches of the P1 segments, such as the directly perforating branches and the short circumflex branches, play a major role in supplying the ventral portions of the midbrain. Although rare, the ‘Mickey Mouse ears’ sign might be a reproducible finding. Furthermore, it provides clinical significance for predicting a patient’s symptoms and prognosis.

Recurrent juvenile ischemic stroke caused by bow hunter’s stroke revealed by carotid duplex ultrasonography

Bow hunter’s stroke (BHS) is a rare cause of vertebrobasilar insufficiency due to rotational vertebral artery (VA) occlusion associated with head turning. We report a juvenile patient presenting with recurrent ischemic stroke caused by BHS, which was revealed by carotid duplex ultrasonography. Carotid duplex ultrasonography performed in the neutral position showed normal findings. However, disappearance of end-diastolic blood flow of contralateral VAs was observed with head rotation. Digital subtraction angiography confirmed occlusion at C1/2 levels in the VA contralateral to the head rotation, bilaterally. Importantly, our patient did not recognize the association of head rotation and previous episodes of stroke. We suggest that BHS should be considered in patients with cryptogenic stroke occurring in the vertebrobasilar artery territory.

Conjugate eye deviation due to pontine infarction: Report of 2 cases

Highlights • We report 2 patients with pontine infarcts showing transient conjugate eye deviation.• Conjugate eye deviation resolved within a few days in both patients.• Small restricted dorsomedial pontine lesions can produce conjugate eye deviation.

Human herpesvirus 6 encephalitis followed by acute disseminated encephalomyelitis in an immunocompetent adult

A 26-year-old, otherwise healthy man presented with visual abnormality followed by loss of consciousness and convulsion. The patient then developed headache and fever 14 days later. Brain MRI showed hyperintensities in the left cingulate cortex. The cerrebrospinal fluid examinations showed mononuclear pleocytosis and positive PCR results for human herpesvirus 6 (HHV-6). A diagnosis of HHV-6 encephalitis and symptomatic epilepsy was made. The patients clinical symptoms improved promptly following acyclovir treatment. However, 3 months later the patient noticed dysesthesia in the trunk, the left upper limb and the right lower limb. Brain and spine MRI showed multiple brain white matter lesions, the middle cerebellar peduncle and cervical spinal lesions. The symptoms resolved following methylprednisolone pulse therapy only. We report an adult patient with HHV-6 encephalitis followed by acute disseminated encephalomyelitis whose initial presentation was epilepsy. HHV-6 encephalitis should be included in the differential diagnosis of encephalitis of unknown etiology in an immunocompetent adult.

Influence of pulsed wave doppler angle on diagnosis of internal carotid artery stenosis

WCN17-1276 SHIFT 3 STROKE Significance of hyperintense vessels in negative DWI area as a prognostic factor after thrombolysis M. Ichijo, S. Ishibashi, K. Miki, S. Itaya, T. Amino, T. Kamata, T. Yokota. Musashino Red Cross Hospital, Department of Neurology, Tokyo, Japan; Tokyo Medical and Dental University, Department of Neurology and Neurological Science, Tokyo, Japan; Tokyo Medical and Dental University, Department of Endovascular Surgery, Tokyo, Japan

Hyperostosis Frontalis Interna in Myotonic Dystrophy

A 68 year-old-woman presented with a 20-year history of progressive difficulty in walking. A neurological examination showed hatchet face, impaired extraocular movement and facial and limb weakness with percussion and grip myotonia. Brain computed tomography (Picture A, C) and T1weighted magnetic resonance imaging (Picture B, D) showed the symmetrical thickening of the inner table of the frontal bone, “hyperostosis frontalis interna” (HFI). Her serum creatine kinase level was within the normal range (65 U/L). Her serum calcium level was normal (9.3 mg/dL; normal range, 8.6-10.6), but her phosphorus level was low (2.0 mg/dL; normal range, 2.5-4.5). Large cytosine-thymine-