Case Reports in Neurological Medicine The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Cerebral Venous Air Embolism due to a Hidden Skull Fracture Secondary to Head Trauma Thu, 26 Nov 2015 14:19:19 +0000 Cerebral venous air embolism is sometimes caused by head trauma. One of the paths of air entry is considered a skull fracture. We report a case of cerebral venous air embolism following head trauma. The patient was a 55-year-old man who fell and hit his head. A head computed tomography (CT) scan showed the air in the superior sagittal sinus; however, no skull fractures were detected. Follow-up CT revealed a fracture line in the right temporal bone. Cerebral venous air embolism following head trauma might have occult skull fractures even if CT could not show the skull fractures. Ai Hosaka, Tetsuto Yamaguchi, Fumiko Yamamoto, and Yasuro Shibagaki Copyright © 2015 Ai Hosaka et al. All rights reserved. Susac’s Syndrome: A Case with Unusual Cardiac Vestibular and Imaging Manifestations Wed, 25 Nov 2015 07:20:04 +0000 Susac’s syndrome (SS) is a disease of the microvasculature of the retina, brain, and inner ear. We describe a patient with unusual manifestations of SS with possible involvement of the brainstem, cardiac arrhythmia, and MRI findings lacking the characteristic lesions found in Susac’s syndrome. Yaron River, Avi Shupak, Beatrice Tiosano, Vika Danilov, and Itzhak Braverman Copyright © 2015 Yaron River et al. All rights reserved. Artery of Percheron Infarction as an Unusual Cause of Korsakoff’s Syndrome Tue, 24 Nov 2015 09:57:25 +0000 The Korsakoff syndrome is defined as “an abnormal mental state in which memory and learning are affected out of all proportion to other cognitive functions in an otherwise alert and responsive patient.” Confabulation refers to false or erroneous memories arising, not deliberately, in the context of a neurological amnesia and is often thought of as pathognomonic of the Korsakoff syndrome. Although the exact pathophysiology is unknown, various studies have identified brain lesions in the thalami, mammillary bodies, and frontal cortex. We report a case of a 68-year-old male presenting with acute altered mental status on July 16, 2015. The neuropsychological dysfunctions included prominent Korsakoff’s syndrome, which became apparent when the altered mental status resolved. Amnesia was accompanied by prominent confabulation, disorientation, and lack of insight into his own disability. Neuroradiological data indicated that the intralaminar and dorsomedial nuclei in bilateral thalami were infarcted by occlusion of the artery of Percheron. We believe that ours is one of few reported cases of Korsakoff syndrome in a patient with infarction involving the territory of the artery of Percheron. We conclude that bilateral thalamic lesions could cause Korsakoff’s syndrome and the intralaminar and dorsomedial nuclei might be important structures in the pathogenesis of confabulation. Yongxing Zhou, Derrick Fox, Abhishek Anand, Amal Elhaj, Arushi Kapoor, Faranak Najibi, Han Kim, Roger Weir, and Annapurni Jayam-Trouth Copyright © 2015 Yongxing Zhou et al. All rights reserved. Clinical Significance of Human Metapneumovirus in Refractory Status Epilepticus and Encephalitis: Case Report and Review of the Literature Wed, 18 Nov 2015 13:54:59 +0000 Encephalitis is a complex neurological disease that is associated with significant morbidity and mortality, and the etiology of the disease is often not identified. Human metapneumovirus (hMPV) is a common cause of upper and lower respiratory tract infections in children. Few reports are available showing possible involvement of hMPV in development of neurologic complications. Here, we describe an infant, the youngest case in literature, with refractory status epilepticus and severe encephalitis in whom hMPV was detected in respiratory samples and review diagnostic workup of patient with encephalitis. Aysel Vehapoglu, Ozden Turel, Turkan Uygur Sahin, Nurettin Onur Kutlu, and Akın Iscan Copyright © 2015 Aysel Vehapoglu et al. All rights reserved. Longitudinal Follow-Up of Mirror Movements after Stroke: A Case Study Sun, 15 Nov 2015 08:40:07 +0000 Mirror movement (MM), or visible involuntary movements of a relaxed hand during voluntary fine finger movements of an activated opposite hand, can be observed in the hand that is on the unaffected side of patients with stroke. In the present study, we longitudinally examined the relationship between voluntary movement of the affected hand and MM in the unaffected hand in a single case. We report a 73-year-old woman with a right pontine infarct and left moderate hemiparesis. MM was observed as an extension movement of the unaffected right index finger during extension movement of the affected left index finger. The affected right index movement was found to increase, while MM of the unaffected left index finger was observed to decrease with time. These results indicate that the assessment of MM might be useful for studying the process of motor recovery in patients with stroke. Hiroyuki Ohtsuka, Daisuke Matsuzawa, Daisuke Ishii, and Eiji Shimizu Copyright © 2015 Hiroyuki Ohtsuka et al. All rights reserved. Changes over Time in Intracranial Air in Patients with Cerebral Air Embolism: Radiological Study in Two Cases Thu, 12 Nov 2015 11:54:57 +0000 Cerebral air embolism can be easily identified on computed tomography (CT) scans. However, changes in the distribution and amount of intracranial air are not well known. We report two patients with cerebral air embolism and present imaging findings on the serial changes in the intracranial air. We thought that the embolic source was venous in one patient because CT showed air inflow in cortical veins in the bilateral frontal areas, reflecting air buoyancy. In the other patient, CT showed air inflow into not only the cortical veins but also the bilateral cerebral hemispheres and we thought this to be a paradoxical cerebral air embolism. We found that intracranial air can be promptly absorbed and while cerebral infarcts due to air are clearly visualized on diffusion-weighted images (DWI), the air may rapidly disappear from images. In patients with suspected cerebral air embolism whose CT findings show no intracranial air, DWI should be performed because it may reveal cerebral infarction due to cerebral air embolism. Yoko Kaichi, Shingo Kakeda, Yukunori Korogi, Tomohisa Nezu, Shiro Aoki, Masayasu Matsumoto, Makoto Iida, and Kazuo Awai Copyright © 2015 Yoko Kaichi et al. All rights reserved. Fatal Vertebral Artery Injury in Penetrating Cervical Spine Trauma Thu, 12 Nov 2015 10:56:24 +0000 Study Design. This case illustrates complications to a vertebral artery injury (VAI) resulting from penetrating cervical spine trauma. Objectives. To discuss the management of both VAI and cervical spine trauma after penetrating gunshot wound to the neck. Summary of Background Data. Vertebral artery injury following cervical spine trauma is infrequent, and a unilateral VAI often occurs without neurologic sequela. Nevertheless, devastating complications of stroke and death do occur. Methods. A gunshot wound to the neck resulted in a C6 vertebral body fracture and C5–C7 transverse foramina fractures. Neck CT angiogram identified a left vertebral artery occlusion. A cerebral angiography confirmed occlusion of the left extracranial vertebral artery and patency of the remaining cerebrovascular system. Following anterior cervical corpectomy and stabilization, brainstem infarction occurred and resulted in death. Results. A fatal outcome resulted from vertebral artery thrombus propagation with occlusion of the basilar artery triggering basilar ischemia and subsequent brainstem and cerebellar infarction. Conclusions. Vertebral artery injury secondary to cervical spine trauma can lead to potentially devastating neurologic sequela. Early surgical stabilization, along with anticoagulation therapy, contributes towards managing the combination of injuries. Unfortunately, despite efforts, a poor outcome is sometimes inevitable when cervical spine trauma is coupled with a VAI. Chadi Tannoury and Anthony Degiacomo Copyright © 2015 Chadi Tannoury and Anthony Degiacomo. All rights reserved. Lymphoma Presenting as Acute-Onset Dysphagia Mon, 09 Nov 2015 07:48:30 +0000 A 61-year-old man with recent Bell’s palsy developed acute vocal cord paralysis causing severe dysphagia. CSF analysis showed elevated protein and a normal cell count; contrast-enhanced MRI of the brain was normal. He was treated with IVIG for a presumed bulbar-variant AIDP and gradually improved. Six months later, the patient developed rapidly progressive hearing loss and vestibular dysfunction. Repeat MRI revealed bilateral enhancement of the eighth cranial nerves and a hypercellular mass in the left temporal lobe. Biopsy of the mass confirmed the diagnosis of diffuse large B-cell lymphoma. Lymphomatous invasion of the cranial nerves should be considered in cases of relapsing cranial neuropathies. Daniel B. Simmons and Andrew W. Bursaw Copyright © 2015 Daniel B. Simmons and Andrew W. Bursaw. All rights reserved. Three Siblings with Prader-Willi Syndrome: Brief Review of Sleep and Prader-Willi Syndrome Tue, 03 Nov 2015 09:54:31 +0000 Prader-Willi syndrome (PWS) is a genetic disorder characterized by short stature, mental retardation, hypotonia, functionally deficient gonads, and uncontrolled appetite leading to extreme obesity at an early age. Patients with this condition require multidisciplinary medical care, which facilitates a significant improvement in quality of life. PWS is the first human disorder to be attributed to genomic imprinting. Prevalence varies in the literature, ranging from 1 in 8,000 in the Swedish population to 1 in 54,000 in the United Kingdom. Rarely, the genetic mechanism responsible for Prader-Willi syndrome can be inherited. We report a highly unique case of three siblings who share this condition. This report describes a case of two brothers and one half sister with PWS. All three siblings have sleep-related complaints. The sister died at the age of 24 years in her sleep, with the cause of death reported as obstructive sleep apnea. The outcome was positive in both of the brothers’ cases as a result of professional medical care and specific tailored recommendations implemented by their mother. A review of the relevant literature vis-à-vis sleep and PWS is provided. Arina Bingeliene, Colin M. Shapiro, and Sharon A. Chung Copyright © 2015 Arina Bingeliene et al. All rights reserved. GABAB Encephalitis: A Fifty-Two-Year-Old Man with Seizures, Dysautonomia, and Acute Heart Failure Mon, 02 Nov 2015 13:45:36 +0000 Autoantibodies to the -aminobutyric acid receptor, subtype B (), are a known cause of limbic encephalitis. The spectrum of clinical manifestations attributable to this antibody is not well defined at the present time. Here we present a case of encephalitis presenting with encephalopathy, status epilepticus, dysautonomia, and acute heart failure. To our knowledge, heart failure and dysautonomia have not yet been reported with this syndrome. Matthew C. Loftspring, Eric Landsness, Lindsey Wooliscroft, Robert Rudock, Sally Jo, and Kevin R. Patel Copyright © 2015 Matthew C. Loftspring et al. All rights reserved. Central Pontine Myelinolysis with Minimal Hyponatremia in the Setting of AIDS Thu, 29 Oct 2015 12:40:22 +0000 Central pontine myelinolysis (CPM) is classically attributed to overly rapid correction of profound hyponatremia. However, there are case reports of this disease in the setting of normal serum sodium or minimal hyponatremia. These cases have been hypothesized to be secondary to other metabolic disturbances such as hyperglycemia or hypophosphatemia. Eunatremic CPM has also been described in patients with advanced acquired immune deficiency syndrome (AIDS). The mortality risk in this special population is significantly higher than those with hyponatremia-associated CPM, but the mechanisms are unclear. We discuss a case of a man with AIDS who developed CPM with minimal hyponatremia and no other metabolic disturbances. Common variables within this population, such as hypoalbuminemia and lymphoma, are discussed as potential factors contributing to the pathophysiology. Reporting these atypical cases is crucial to our understanding of how to prevent future cases. Joseph M. Carrington, Galo Sanchez, and Jennifer L. Berkeley Copyright © 2015 Joseph M. Carrington et al. All rights reserved. Brain Herniation in Neurofibromatosis with Dysplasia of Occipital Bone and Posterior Skull Base Tue, 27 Oct 2015 08:39:55 +0000 A 22-year-old female, a known case of neurofibromatosis 1 (NF1), presented with a congenital swelling in the left occipital region. She had developed recent onset dysphagia and localized occipital headache. Neuroradiology revealed a left occipital meningoencephalocele and a left parapharyngeal meningocele. This was associated with ventriculomegaly. She was advised on cranioplasty along with duraplasty which she denied. She agreed to a lumbar-peritoneal shunt. She described a dramatic improvement in her symptoms following the lumbar-peritoneal shunt. Occipital dysplasias, though uncommon, have been reported in the literature. We review this case and its management and discuss relevant literature on occipital dysplasias in NF1. Vithal Rangarajan, Amit Mahore, Manoj Patil, Prashant Sathe, Amol Kaswa, Sandeep Gore, Pralhad Dharurkar, and Juhi Kawale Copyright © 2015 Vithal Rangarajan et al. All rights reserved. Prolonged Survival following Repetitive Stereotactic Radiosurgery in a Patient with Intracranial Metastatic Renal Cell Carcinoma Tue, 27 Oct 2015 07:34:56 +0000 Patients with metastatic renal cell carcinoma (RCC) to the brain have a very poor prognosis of three months if left untreated. SRS is an effective treatment modality in numerous patients. This case exemplifies the utility of stereotactic radiosurgery (SRS) in prolonging survival and maintaining quality of life in a patient with RCC. This 64-year-old female patient initially presented to her primary care physician 22 months after a left nephrectomy for RCC with complaints of mild, intermittent headaches and difficulty with balance. An MRI revealed five cerebellar lesions suspicious for intracranial metastasis. The patient’s first GKRS treatment targeted four lesions with 22 Gy at the 50% isodose line. She underwent a total of seven GKRS treatments over the next 60 months for recurrent metastases to the brain. 72 months and 12 months have now passed since her brain metastases were first discovered and since her last GKRS treatment, respectively, and this woman is alive with considerable quality of life and no evidence of metastatic reoccurrence. This case shows that repeated GKRS treatments, with minimal surgical intervention, can effectively treat multiple intracranial lesions in select patients, prolonging survival and avoiding iatrogenic neurocognitive decline while maintaining a high quality of life. Ethan A. Ferrel, Andrew T. Roehrig, Wayne T. Lamoreaux, Alexander R. Mackay, Robert K. Fairbanks, Jason A. Call, Jonathan D. Carlson, Benjamin C. Ling, John J. Demakas, Barton S. Cooke, Aaron Wagner, and Christopher M. Lee Copyright © 2015 Ethan A. Ferrel et al. All rights reserved. Short-Term Memory Impairment and Left Dorsolateral Prefrontal Cortex Dysfunction in the Orthostatic Position: A Single Case Study of Sinking Skin Flap Syndrome Tue, 27 Oct 2015 07:11:47 +0000 We describe the case of a patient who underwent craniectomy for hemorrhage of the left parietal lobe. Three weeks later, orthostatic memory impairment was detected as initial symptom of sinking skin flap syndrome (SSFS). This deficit was examined by neuropsychological testing and associated with a posture-dependent increase in the delta/alpha ratio at the F3 electrode, an electroencephalographic (EEG) index related to brain hypoperfusion. This EEG spectral alteration was detected in a brain region that includes the left dorsolateral prefrontal cortex, an area known to be involved in memory processing; therefore we hypothesize that SSFS induced reversible hypoperfusion of this otherwise undamaged cortical region. Neither of these findings was present after cranioplasty. This case suggests that SSFS may induce neuropsychological deficits potentially influencing outcome in the postacute phase and is further evidence supporting the clinical benefits of early cranioplasty. Luca Sebastianelli, Verena Stoll, Viviana Versace, Sara Martignago, Stephan Obletter, Marco Lavoriero, Kathrin Malfertheiner, Gertraud Gisser, and Leopold Saltuari Copyright © 2015 Luca Sebastianelli et al. All rights reserved. A Potential Role for Felbamate in TSC- and NF1-Related Epilepsy: A Case Report and Review of the Literature Thu, 22 Oct 2015 13:51:36 +0000 A 15-year-old girl with maternal inheritance of neurofibromatosis type 1 (NF1) and paternal inheritance of tuberous sclerosis complex (TSC) developed intractable epilepsy at age 5. Her seizures were refractory to adequate doses of four antiepileptic medications until felbamate was initiated at age 7. She has since remained seizure-free on felbamate monotherapy. Although felbamate has multiple mechanisms of action, it is thought to have its most potent antiepileptic effects through inhibition of the N-methyl-D-aspartate receptor (NMDAR). Previous studies have shown that the NMDAR is altered in varying epilepsy syndromes and notably in the cortical tubers found in TSC. The aim of this paper is to examine how felbamate monotherapy was able to achieve such robust antiepileptic effects in a unique patient and possibly offer a novel therapeutic approach to patients suffering from TSC- and NF-related epilepsy. Natanya M. Mishal, Dimitrios Arkilo, Ju Tang, John R. Crawford, and Sonya G. Wang Copyright © 2015 Natanya M. Mishal et al. All rights reserved. CPAP Therapy Improves Intractable Hemifacial Spasm Thu, 15 Oct 2015 13:20:34 +0000 The correlation between obstructive sleep apnea (OSA) and hemifacial spasm has never been reported in the literature. Here, we report a case of OSA-induced hypertension with intractable hemifacial spasm in which both conditions improved after continuous positive airway pressure treatment. Narongrit Kasemsap, Sittichai Netwijitpan, Panita Limpawattana, Kannikar Kongbunkiat, Somsak Tiamkao, Verajit Chotmongkol, Noppadol Aekphachaisawat, and Kittisak Sawanyawisuth Copyright © 2015 Narongrit Kasemsap et al. All rights reserved. Focal 123I-FP-CIT SPECT Abnormality in Midbrain Vascular Parkinsonism Thu, 15 Oct 2015 09:31:50 +0000 Cerebrovascular diseases are considered among possible causes of acute/subacute parkinsonism, representing up to 22% of secondary movement disorders. In cases of suspected vascular parkinsonism (VP), dopamine transporter SPECT has been highly recommended to exclude nigrostriatal dopaminergic degeneration. We report the case of a hemiparkinsonism related to a left midbrain infarct with focal lateralized putaminal abnormalities at 123I-FP-CIT SPECT imaging. The asymmetric uptake at dopamine transporter SPECT was different to findings commonly observed in typical PD pattern, because the ipsilateral striatum, in opposite to idiopathic PD, showed normal tracer binding. However, this selective parkinsonism after infarction of the midbrain was responsive to levodopa. In conclusion, we retain that there is a need of more functional imaging studies in VP addressed to a more consistent classification of its different clinical forms and to a better understanding of the adequate pharmacological management. Paolo Solla, Antonino Cannas, Roberta Arca, Davide Fonti, Gianni Orofino, and Francesco Marrosu Copyright © 2015 Paolo Solla et al. All rights reserved. Heading Disorientation after Right Posteromedial Infarction Wed, 07 Oct 2015 11:25:18 +0000 We report the case of heading disorientation following ischemic stroke involving the right posteromedial areas. The patient was administered a new test named the Card Placing Test during which a subject was required to recreate an array of three cards, each of which was randomly placed on eight grids around the subject, before and after the subject’s rotation. Qualitative analysis of his performance after rotation revealed that over half of the errors comprised transposition and rotational offset. His score on the Card Placing Test was compared with those of normal controls . The results showed that his score on Card Placing Test after rotation was significantly lower than those of controls, whereas there was no significant difference between the case and controls in profile of error types. We infer that the heading disorientation observed in the present case was a result of a derangement of a short-term buffer that integrated information on spatial locations of objects with changes in body directions. Ritsuo Hashimoto, Noriyo Komori, and Masako Abe Copyright © 2015 Ritsuo Hashimoto et al. All rights reserved. Acquired Hemophilia A with a Rare Presentation of Acute Subdural Hematoma Tue, 29 Sep 2015 06:43:50 +0000 An 80-year-old man was admitted for acute subdural hematoma caused by a mild brain injury. His coagulation test showed an isolated prolongation of activated partial thromboplastin time (aPTT). Though the subdural hematoma did not progress, oozing bleed from the wound of tracheostomy continued. Failure of correction on aPTT mixing test supported the presence of an inhibitor to a coagulation factor. Once the diagnosis of acquired hemophilia A (AHA) was made, steroid therapy was performed, which leads him to complete remission of AHA. Isolated prolongation of aPTT can be the key to diagnose a rare coagulopathy, such as AHA. Yoshihide Sehara, Yuka Hayashi, and Jun Mimuro Copyright © 2015 Yoshihide Sehara et al. All rights reserved. Extraintracranial Bypass as a Rescue Therapy for Symptomatic Flow Diverter Thrombosis Thu, 17 Sep 2015 08:09:20 +0000 A 56-year-old female with a giant partially thrombosed unruptured carotid-ophthalmic aneurysm was treated with a Pipeline flow diverter. Three months after the procedure, in concomitance with the discontinuation of one of the antiplatelet medications, the patient suffered from a minor stroke and relapsing transient ischemic attacks. The angiography demonstrated the occlusion of the internal carotid artery, and a perfusion-weighted CT scan showed a condition of hypoperfusion. The patient underwent a double-barrel extraintracranial bypass. The postoperative course was uneventful and she has experienced no further ischemic events to date. Luigi A. Lanterna, Alessandro Lunghi, Carlo Brembilla, Paolo Gritti, and Claudio Bernucci Copyright © 2015 Luigi A. Lanterna et al. All rights reserved. Systemic Sarcoidosis Mimicking a Behavioural Variant of Frontotemporal Dementia Wed, 09 Sep 2015 11:11:05 +0000 Among rare neurological manifestations, a progressive dementia may exceptionally be the revealing clinical feature of a sarcoidosis. Diagnosis may then be difficult, especially when systemic signs are missing or latent, with a risk of therapeutic delay. We report the first case of sarcoidosis mimicking a frontotemporal dementia. A 53-year-old man presented with a dementia clinically suggestive of frontotemporal dementia, progressing slowly for about 2 years. However, MRI revealed unusual aspects, mainly large areas of T2/FLAIR hypersignal within temporal regions and cerebellum, with nodular leptomeningeal and juxtacortical Gadolinium enhancement. The patient was finally diagnosed with a systemic sarcoidosis. We discuss the differential diagnosis based on MRI aspects and review the literature on the clinical, biological, and imaging features of sarcoidosis presenting with dementia. This case demonstrates that brain imaging remains mandatory in the exploration process of a patient with dementia. Although the patient presented with rather typical features of a behavioural variant of frontotemporal dementia, the MRI aspect was the key exploration that leaded to the diagnosis. Anne De Maindreville, Line Bedos, and Serge Bakchine Copyright © 2015 Anne De Maindreville et al. All rights reserved. A Case of Subacute Combined Degeneration of the Spinal Cord with Infective Endocarditis Mon, 07 Sep 2015 11:04:02 +0000 Background. Subacute combined degeneration (SCD) is a rare cause of demyelination of the dorsal and lateral columns of spinal cord and is a neurogenic complication due to cobalamin deficiency. Anemia of chronic disease (ACD) occurs in patients with acute or chronic immune activation, including infective endocarditis. It remains to be elucidated whether ACD patients are more sensitive to suffer from SCD. Little cases about SCD patients accompanied with ACD have been reported till now. Here we reported a 36-year-old man with SCD with a medical history of mitral inadequacy over 20 years, who was admitted and transported from another hospital to our hospital due to an 8-month history of gait disturbance, lower limb weakness and paresthesia, and loss of proprioception. Significant laboratory results and echocardiography suggest iron deficiency anemia and infective endocarditis (IE). The SCD diagnosis was confirmed by MRI, which showed selective demyelination in the dorsal and lateral columns of spinal cord. In conclusion, the ACD patients may suffer from SCD, which can be diagnosed by 3 Tesla magnetic resonance imaging. Xiao-Jiang Huang, Jia He, Wen-sheng Qu, and Dai-Shi Tian Copyright © 2015 Xiao-Jiang Huang et al. All rights reserved. STA-MCA Bypass as a “Bridge” to Pituitary Surgery in a Patient with an Adenoma Occluding the Internal Carotid Artery: Case Report and Review of the Literature Sun, 06 Sep 2015 11:52:19 +0000 Occlusion of the intracranial internal carotid artery (ICA) by a pituitary adenoma with resulting cerebral ischemia is a very rare but devastating occurrence. The authors present a case in which a condition of symptomatic ICA occlusion due to a giant pituitary adenoma was successfully treated using a preliminary extraintracranial bypass as a “bridge” to the tumor removal. A 52-year-old patient presented with a minor stroke followed by pressure-dependent transient ischemic attacks consistent with a condition of hypoperfusion. MR imaging and a digital subtraction angiography revealed a pituitary adenoma occluding the ICA on the right side. He underwent a superficial temporal artery to middle cerebral artery (STA-MCA) bypass with the aim of revascularizing the ischemic hemisphere and reducing the risk of perioperative stroke or stroke evolution. The patient was subsequently operated on to remove the adenoma through a transsphenoidal approach. The postoperative course was uneventful and the patient has suffered no further ischemic events. When there are no emergency indications to decompress the optical pathways but the patient is at risk of impending stroke because of ICA occlusion, a two-step strategy consisting of a bypass and subsequent removal of the pituitary adenoma may be a valuable option. Luigi A. Lanterna, Carlo Brembilla, Antonio Signorelli, Paolo Gritti, Emanuele Costi, Gianluigi Dorelli, and Claudio Bernucci Copyright © 2015 Luigi A. Lanterna et al. All rights reserved. Modulation of the Left Prefrontal Cortex with High Frequency Repetitive Transcranial Magnetic Stimulation Facilitates Gait in Multiple Sclerosis Wed, 02 Sep 2015 08:38:32 +0000 Multiple Sclerosis (MS) is a chronic central nervous system (CNS) demyelinating disease. Gait abnormalities are common and disabling in patients with MS with limited treatment options available. Emerging evidence suggests a role of prefrontal attention networks in modulating gait. High-frequency repetitive transcranial magnetic stimulation (rTMS) is known to enhance cortical excitability in stimulated cortex and its correlates. We investigated the effect of high-frequency left prefrontal rTMS on gait parameters in a 51-year-old Caucasian male with chronic relapsing/remitting MS with residual disabling attention and gait symptoms. Patient received 6 Hz, rTMS at 90% motor threshold using figure of eight coil centered on location (using 10-20 electroencephalography (EEG) lead localization system). GAITRite gait analysis system was used to collect objective gait measures before and after one session and in another occasion three consecutive daily sessions of rTMS. Two-tailed within subject repeated measure t-test showed significant enhancement in ambulation time, gait velocity, and cadence after three consecutive daily sessions of rTMS. Modulating left prefrontal cortex excitability using rTMS resulted in significant change in gait parameters after three sessions. To our knowledge, this is the first report that demonstrates the effect of rTMS applied to the prefrontal cortex on gait in MS patients. Amer M. Burhan, Priya Subramanian, Luljeta Pallaveshi, Brittany Barnes, and Manuel Montero-Odasso Copyright © 2015 Amer M. Burhan et al. All rights reserved. Bilateral Intracranial Vertebral Artery Stenosis Presenting as Recurrent Prolonged Presyncopal Episodes Tue, 01 Sep 2015 11:47:44 +0000 Amongst various mechanisms of presyncopal events, posterior circulation disease needs to be considered. This particular mechanism has been underrecognized. We describe a case of a 76-year-old patient with recurrent posterior circulation TIAs, presenting as recurrent prolonged presyncopal events. Banu Sundar, Majaz Moonis, Ajay Wakhloo, and Ajit Puri Copyright © 2015 Banu Sundar et al. All rights reserved. Atypical Miller Fisher Syndrome with Anisocoria and Rapidly Fluctuating Pupillary Diameter Mon, 24 Aug 2015 11:25:26 +0000 Miller Fisher syndrome is a variant of Guillain-Barre syndrome characterized by the classic triad of ophthalmoplegia, ataxia, and areflexia. Pupillary involvement is common in MFS and has been reported in 35–42% of MFS patients. Although case reports have discussed isolated ophthalmoplegia as a presentation of MFS, anisocoria and rapid fluctuation of pupillary diameter have not been reported in anti-GQ1b antibody positive individuals. Here we describe an individual who presented with diplopia and was found to have progressive internal and external ophthalmoplegia with frequent fluctuations in pupillary diameter and anisocoria. These exam findings are not commonly described even in atypical presentations of MFS. The onset of symptoms was preceded by an upper respiratory infection but no gastrointestinal symptoms. Imaging and CSF studies were unremarkable; however serum levels of immunoglobulin G anti-GQ1b antibody and anti-GAD antibody were elevated confirming the diagnosis of MFS. The patient was treated with IVIG and intravenous steroids with mild resolution of external ophthalmoplegia. He did not go on to develop more typical features of MFS such as ataxia or areflexia. This demonstrates that isolated external and internal ophthalmoparesis with rapidly fluctuating pupillary diameter and associated anisocoria can be the sole manifestation of atypical MFS. Garima Gupta and Antonio Liu Copyright © 2015 Garima Gupta and Antonio Liu. All rights reserved. Gabapentin-Induced Urinary Incontinence: A Rare Side Effect in Patients with Neuropathic Pain Sun, 16 Aug 2015 14:04:40 +0000 Gabapentin is a first-line agent for neuropathic pain management and has a favorable safety profile. The literature includes a few cases of gabapentin-induced incontinence, and most of them involved patients with epilepsy who were between the ages of 12 and 43 years. Herein, we present three patients with neuropathic pain due to different diagnoses, and, to our knowledge, these are the oldest reported cases of urinary incontinence caused by gabapentin therapy. A 56-year-old female patient who underwent hip arthroplasty developed a sciatic nerve injury and neuropathic pain postoperatively. Ten days after she began taking gabapentin to relieve her pain, she experienced daily urinary incontinence. In another instance, a 63-year-old female patient was diagnosed with complex regional pain syndrome, and seven days after the initiation of gabapentin therapy, urinary incontinence developed. In addition, a 66-year-old male patient with neuropathic pain due to cervical disc pathology complained of urinary incontinence after the onset of gabapentin therapy. After discontinuing this drug, the incontinence symptoms resolved in these patients on the seventh, the first, and the second days, respectively. Physicians who administer gabapentin should inform their patients about the potential risk of gabapentin-induced incontinence and its negative impact on quality of life. Sibel Kibar, Sibel Demir, Nebahat Sezer, Belma Füsun Köseoğlu, Meltem Dalyan Aras, and Bilge Kesikburun Copyright © 2015 Sibel Kibar et al. All rights reserved. Cerebral Amyloid Angiopathy-Related Inflammation: Report of a Case with Very Difficult Therapeutic Management Sun, 16 Aug 2015 08:49:30 +0000 Background. Cerebral amyloid angiopathy-related inflammation (CAA-ri) results from autoimmune response to beta-amyloid deposits in cerebral vessels. Its clinical course and complications have seldom been described in literature. Case Report. In a patient presenting with delirium and left hemiparesis the diagnosis of CAA-ri was supported by the finding of elevated anti-amyloid autoantibodies in the cerebrospinal fluid (CSF). Steroid therapy produced significant improvements in clinical and investigational assessments, but after two months, it caused Acute Respiratory Distress Syndrome. After steroid therapy discontinuation the patient presented a rapidly progressive dementia, Guillain-Barré syndrome, new cerebral ischemic lesions, and thrombosis of the right cephalic and subclavian veins that were treated with subcutaneous heparin. After a week the patient died because of brain hemorrhage. Conclusion. This case suggests caution in steroid therapy discontinuation and antithrombotic therapy administration in patients with CAA-ri. The CSF search of anti-amyloid autoantibodies could be helpful to support the diagnosis. Francesca Crosta, Berardino Orlandi, Federica De Santis, Gianni Passalacqua, Jacopo C. DiFrancesco, Fabrizio Piazza, Alessia Catalucci, Giovambattista Desideri, and Carmine Marini Copyright © 2015 Francesca Crosta et al. All rights reserved. Isolated Hyperreligiosity in a Patient with Temporal Lobe Epilepsy Thu, 13 Aug 2015 13:33:42 +0000 A 40-year-old man with history of temporal lobe epilepsy presented to the emergency department with hyperreligiosity after medication noncompliance. After medications were resumed, he returned to baseline. Many famous prophets are believed to have suffered epilepsy. Waxman and Geschwind described a group of traits in patients with temporal lobe epilepsy consisting of hyperreligiosity, hypergraphia, altered sexual behavior, aggressiveness, preoccupation with details, and circumstantiality. The incidence of religious experiences ranges from 0.3 to 3.1 percent in patients with epilepsy. Religious experiences can be ictal, interictal, or postictal. Treatment is aimed at the underlying seizure etiology. Rocio Garcia-Santibanez and Harini Sarva Copyright © 2015 Rocio Garcia-Santibanez and Harini Sarva. All rights reserved. Diagnostic Dilemma in a Young Woman with Acute Headache: Delayed Diagnosis of Third Ventricular Colloid Cyst with Hydrocephalus Sun, 09 Aug 2015 11:41:59 +0000 Objectives. To highlight the importance of early diagnosis of colloid cyst of the third ventricle and its early management. Clinical Presentation and Intervention. This is a young lady who presented with sudden onset headache. She attended a local clinic and also her area hospital. Her diagnosis was delayed several hours due to a diagnostic dilemma initially. No surgical intervention was tried since the patient developed early signs of brainstem coning by the time she was seen by neurosurgeon. Patient died after few days in spite of intensive ICU measures. Conclusion. Sudden onset headache in young adults should be looked at carefully. Early imaging is mandatory to prevent mortality. Jasem Y. Al-Hashel, Azza A. H. Rady, Doaa Y. Soliman, and Periasamy Vembu Copyright © 2015 Jasem Y. Al-Hashel et al. All rights reserved.