Richard B. Libman

Myasthenia mimicking vertebrobasilar stroke.

Abstract. The advent of thrombolysis has offered a remarkable opportunity for treatment of acute ischemic stroke. Other therapies involving neuro-protection may be forthcoming. These treatments, however, are not without risk, making accurate diagnosis of stroke all the more important. Several conditions may mimic stroke in the emergency department, with myasthenia being an uncommon stroke mimic. We present two cases of myasthenia presenting as posterior circulation stroke. In one case, the tempo suggested basilar thrombosis. Treatment decisions regarding thrombolysis for stroke must be made rapidly. Stroke mimics continue to present a diagnostic challenge, myasthenia included. Accurate diagnosis is essential to avoid unnecessary hazard, as well as to implement effective treatment for the appropriate diagnosis.

Recurrent intracerebral hemorrhage from sarcoid angiitis

BACKGROUND Sarcoid affecting the central nervous system may cause granulomatous angiitis. Nevertheless, neurosarcoid manifesting as intracerebral hemorrhage has been infrequently reported. CASE DESCRIPTION A 48-year-old woman with systemic sarcoid developed recurrent intracerebral hemorrhages culminating in death despite treatment with corticosteroids. Pathological examination of the brain revealed inflammatory changes of blood vessels including multinucleated giant cells. CONCLUSION Sarcoid cerebral angiitis may result in intracerebral hemorrhage. This emphasizes one potentially devastating neurological outcome of this disorder.

Stroke Outcome in Patients Already Taking Aspirin

UNLABELLED Background Although aspirin (ASA) has been shown to be effective for secondary (but not primary) stroke prevention and to have some beneficial influence on outcome when taken early after stroke onset, studies regarding the impact of prior use of ASA on stroke severity are conflicting. OBJECTIVES To determine whether ASA therapy begun before stroke onset lessens the severity of stroke. METHODS Prospective clinical information was collected for all patients admitted with their first acute ischemic stroke between July 1996 and July 1998. National Institutes of Health Stroke Scale (NIHSS) scores were noted on admission and at discharge. Barthel Index (BI), Modified Rankin Scale (MRS), and Glasgow Outcome Scale (GOS) scores were also noted at discharge. Stroke severity was classified as severe if the NIHSS score was 9 or greater, BI score was 55 or less, the MRS score was 4 or greater, or the GOS score was 3 or greater. Group comparisons were performed by using the X(2) tests. RESULTS 178 patients were evaluated. Forty-two were taking ASA and 136 were not taking ASA or any other anti-thrombotic drug. There were no differences between the 2 groups in terms of age, gender, baseline hematocrit or blood glucose, history of hypertension, diabetes, atrial fibrillation, smoking, or stroke subtype. There were no significant differences between the 2 groups on any of the scales, either on admission or at discharge. CONCLUSION Our data do not suggest that ASA use before stroke onset lessens the severity of first stroke. Until this question is definitively settled, however, it would be prudent to ensure balanced distribution of recent ASA use in acute stroke treatment trials.

Hashimot's encephalopathy-response to intravenous immunoglobulin.

BACKGROUND Hashimotos encephalopathy is an unusual brain disorder consisting of focal and diffuse cerebral dysfunction that may present in a stroke-like fashion. Treatment has consisted of steroids and immunosuppression. Treatment with a potentially less toxic modality such as intravenous immunoglobulin (IVIG), if found to be effective, might offer an alternative approach to these patients. CASE DESCRIPTION We present an 82-year-old woman who developed headache, changes in mental status, and multifocal neurological deficits. Investigation revealed significantly elevated titers of antithyroid antibodies. Treatment with prednisone and methotrexate was unsuccessful. Treatment with monthly courses of IVIG resulted in marked clinical improvement. CONCLUSION Hashimotos encephalopathy may be more common than is generally recognized. A trial of IVIG should be considered for patients with this devastating condition.

Hypersexuality and Stroke: A Role for the Basal Ganglia?

Hyposexuality after stroke has been frequently observed, but hypersexuality as a sequela of stroke has been less commonly documented. Damage to limbic structures, especially in the temporal lobes, has

Posterior cerebral artery infarction associated with carotid dissection

UNLABELLED Posterior circulation stroke may rarely be associated with occlusive disease in the anterior circulation, such as in the context of a direct (fetal) origin of the posterior cerebral artery (PCA) from the internal carotid artery (ICA), or in the presence of a persistent trigeminal artery. Carotid dissection is an increasingly recognized cause of anterior circulation ischemia. It is possible that in the setting of certain cerebral hemodynamics, embolism from carotid dissection could cause PCA infarction via a patent posterior communicating artery. CASE DESCRIPTION We report the MR and MR angiography findings of cerebral dynamics whereby a patient presents with posterior circulation symptoms from anterior circulation pathology: left ICA dissection with subsequent left PCA territory infarction. CONCLUSIONS Cerebral hemodynamics may allow PCA infarction from carotid disease even in the absence of a fetal PCA origin. This report also broadens the spectrum of stroke associated with carotid dissection.