Case Reports in Neurological Medicine The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Resolution of Internal Carotid Dissection with Middle Cerebral Artery Occlusion in Pregnancy Mon, 30 Mar 2015 07:03:37 +0000 Introduction. Cervical artery dissection (CAD) is a common cause of stroke in younger patients. While the incidence of stroke in pregnancy is increasing, CAD remains a rare cause of ischemic stroke in the pregnant population, with only 30 cases described in the literature, most in the postpartum period. Methods. The case of a pregnant patient at 18 weeks of gestation presenting with CAD and ischemic stroke following intercourse is discussed. Discussion. CAD results from an intimal tear in the carotid artery, allowing accumulation of blood in the vessel wall. Stroke results from embolization of thrombogenic material in the wall. Etiology includes minor trauma, connective tissue disorders, or anatomic variations of the carotid artery. Most patients present with headache and/or neck pain, while ischemic symptoms are seen in at least 50% of patients. In the pregnant population, imaging with MRI or MRA of the head and neck aids in diagnosis. Once the diagnosis is made, patients are treated with either anticoagulation or antiplatelet medications. The optimal treatment in both pregnant and nonpregnant patients has not been well-studied. Conclusion. CAD is an important diagnosis to consider in a pregnant patient with persistent headache, especially if neurological symptoms are present. Imaging should be quickly obtained so treatment can be initiated. Nicole Ulrich, Amanda Johnson, Dominique Jodry, Chi Dola, Sheryl Martin-Schild, and Ramy El Khoury Copyright © 2015 Nicole Ulrich et al. All rights reserved. Idiopathic Generalized Epilepsy and Hypokalemic Periodic Paralysis in a Family of South Indian Descent Sun, 29 Mar 2015 05:47:27 +0000 Inherited channelopathies are a heterogeneous group of disorders resulting from dysfunction of ion channels in cellular membranes. They may manifest as diseases affecting skeletal muscle contraction, the conduction system of the heart, nervous system function, and vision syndromes. We describe a family of South Indian descent with hypokalemic periodic paralysis in which four members also have idiopathic generalized epilepsy. Hypokalemic periodic paralysis is a genetically heterogeneous channelopathy that has been linked to mutations in genes encoding three ion channels CACNIAS, SCN4A, and KCNJ2 predominantly. Although data on specific gene in idiopathic generalized epilepsy is relatively scarce, mutations of voltage gated sodium channel subunit genes (CACNB4) and nonsense mutations in voltage gated calcium channels (CACNA1A) have been linked to idiopathic generalized epilepsy in two families. We speculate that gene mutations altering the ability of the beta subunit to interact with the alpha subunit of the CaV1.1 channel and mutations in the pore-forming potassium channel subunit may be possible explanations for the combined manifestation of both diseases. Functional analysis of voltage gated calcium channel and other ion channels mutations may provide additional support and insight for the causal role of these mutations. The understanding of mutations in ion-channel genes will lead to improved diagnosis and treatment of such inherited channelopathies. Muthiah Subramanian, N. Senthil, and S. Sujatha Copyright © 2015 Muthiah Subramanian et al. All rights reserved. Minor Trauma Causing Stroke in a Young Athlete Thu, 26 Mar 2015 12:38:54 +0000 A 17-year-old Caucasian male presented with sudden dizziness, ataxia, vertigo, and clumsiness lasting for a couple of hours. He had a subtle trauma during a wrestling match 2 days prior to the presentation. A CT Angiogram (CTA) and MRI showed left vertebral artery dissection (VAD). The patient was treated with anticoagulation with heparin drip in the ICU. The patient was discharged home on the third day on Lovenox-warfarin bridging. This case underscores the importance of considering VAD as a differential diagnosis in patients with sports-related symptoms especially in activities entailing hyperextension or hyperrotation of neck. Due to a varied latent period, often minor underlying trauma, and subtle presentation, a low index of suspicion is warranted in timely diagnosis and treatment of VAD. Considering recent evidence in treatment modality, either antiplatelet therapy or anticoagulation may be used for treatment of VAD. Vineet Gupta, Naveen Dhawan, and Jaya Bahl Copyright © 2015 Vineet Gupta et al. All rights reserved. Relapsing Remitting Multiple Sclerosis in X-Linked Charcot-Marie-Tooth Disease with Central Nervous System Involvement Wed, 25 Mar 2015 11:34:55 +0000 We report a patient with relapsing remitting multiple sclerosis (MS) and X-linked Charcot-Marie-Tooth disease (CMTX), carrying a GJB1 mutation affecting connexin-32 (c.191G>A, p. Cys64Tyr) which was recently reported by our group. This is the third case report of a patient with CMTX developing MS, but it is unique in the fact that other family members carrying the same mutation were found to have asymptomatic central nervous system (CNS) involvement (diffuse white matter hyperintensity on brain MRI and extensor plantars). Although this may be a chance association, the increasing number of cases with CMTX and MS, especially with mutations involving the CNS, may imply some causative effect and provide insights into MS pathogenesis. Georgios Koutsis, Georgia Karadima, Paraskewi Floroskoufi, Maria Raftopoulou, and Marios Panas Copyright © 2015 Georgios Koutsis et al. All rights reserved. GH-Producing Pituitary Adenoma and Concomitant Rathke’s Cleft Cyst: A Case Report and Short Review Wed, 25 Mar 2015 08:32:44 +0000 Concomitant pituitary adenoma (PA) and Rathke’s cleft cyst (RCC) are rare. In some cases, such PA is known to produce pituitary hormones. A 53-year-old man was admitted to our hospital with a diagnosis of lacunar infarction in the left basal ganglia. Magnetic resonance imaging (MRI) incidentally showed a suprasellar mass with radiographic features of RCC. When he consulted with a neurosurgical outpatient clinic, acromegaly was suspected based on his appearance. A diagnosis of growth hormone- (GH-) producing PA was confirmed from hormonal examinations and additional MRI. Retrospectively, initial MR images also showed intrasellar mass that is compatible with the diagnosis of PA other than suprasellar RCC. The patient underwent endonasal-endoscopic removal of the PA. Since we judged that the RCC of the patient was asymptomatic, only the PA was completely removed. The postoperative course of the patient was uneventful and GH levels gradually normalized. Only 40 cases of PA with concomitant RCC have been reported to date, including 13 cases of GH-producing PA. In those 13 cases, RCC tended to be located in the sella turcica, and suprasellar RCC like this case appears rare. In a few cases, concomitant RCCs were fenestrated, but GH levels normalized postoperatively as in the cases without RCC fenestration. If radiographic imaging shows typical RCC, and PA is not obvious at first glance, the possibility of concomitant PA still needs to be considered. In terms of treatment, removal of the RCC is not needed to achieve hormone normalization. Ryota Tamura, Satoshi Takahashi, Katsura Emoto, Hideaki Nagashima, Masahiro Toda, and Kazunari Yoshida Copyright © 2015 Ryota Tamura et al. All rights reserved. JC Virus PCR Detection Is Not Infallible: A Fulminant Case of Progressive Multifocal Leukoencephalopathy with False-Negative Cerebrospinal Fluid Studies despite Progressive Clinical Course and Radiological Findings Thu, 12 Mar 2015 09:31:15 +0000 We describe a case with a false-negative PCR-based analysis for JC virus in cerebrospinal fluid (CSF) in a patient with clinical and radiological findings suggestive of progressive multifocal leukoencephalopathy (PML) who was on chronic immunosuppressive therapy for rheumatoid arthritis. Our patient developed rapidly progressive global decline with clinical and radiographic findings suggestive of PML, but JC virus PCR in CSF was negative. The patient passed away 3 months from the onset of her neurological symptoms. Autopsy confirmed the diagnosis of PML with presence of JC-polyoma virus by immunohistochemical staining. This case highlights the potential of false-negative JC virus PCR in CSF when radiographic and clinical features are suggestive of “possible PML.” We review the plausible causes of potential false-negative CSF results and suggest that when the clinical presentation is suspicious for PML repeat CSF analysis utilizing ultrasensitive PCR assay and subsequent brain biopsy should be considered if CSF remains negative. Additionally, appropriate exclusion of other neurologic conditions is essential. Mohamed-Ali Babi, William Pendlebury, Steven Braff, and Waqar Waheed Copyright © 2015 Mohamed-Ali Babi et al. All rights reserved. Acute Aortic Occlusion Presenting as Flaccid Paraplegia Wed, 11 Mar 2015 13:47:28 +0000 A 67-year-old male known to be hypertensive and diabetic had a sudden onset of severe low back pain and flaccid paraplegia with no sensory level or bladder affection and the distal pulsations were felt. Acute compressive myelopathy was excluded by MRI of the dorsal and lumbar spines. The nerve conduction study and CSF analysis was suggestive of acute demyelinating polyneuropathy. The patient developed ischemic changes of the lower limb and CT angiography revealed severe stenosis of the abdominal aorta and both common iliac arteries. We emphasize the importance of including acute aortic occlusion in the differential diagnosis of acute flaccid paraplegia especially in the presence of severe back pain even if the distal pulsations were felt. Ayman Kilany, Jasem Y. Al-Hashel, and Azza Rady Copyright © 2015 Ayman Kilany et al. All rights reserved. A CADASIL-Like Case with a Novel Noncysteine Mutation of the NOTCH3 Gene and Granular Deposits in the Renal Arterioles Thu, 05 Mar 2015 12:03:00 +0000 We herein report the finding of a 62-year-old male, who developed dysarthria and dysphagia, with cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy- (CADASIL-) like cerebral lesions. He also suffered from slowly progressive renal failure with the findings of granular deposits similar to electron-dense granular osmiophilic material in the renal arterioles. We found a novel heterozygous missense mutation of the NOTCH3 gene, c.4039G>C in exon 24, resulting in a p.Gly1347Arg substitution in its extracellular domain. The noncysteine substitution may underlie the pathogenesis of white matter lesions in the brain and of the chronic renal failure in the present case. Kuniyuki Nakamura, Tetsuro Ago, Akihiro Tsuchimoto, Nozomi Noda, Asako Nakamura, Toshiharu Ninomiya, Takeshi Uchiumi, Kazuhiko Tsuruya, Masahiro Kamouchi, Hiroaki Ooboshi, and Takanari Kitazono Copyright © 2015 Kuniyuki Nakamura et al. All rights reserved. Acute Dysphasia and Reversible Cognitive Decline in a Patient with Probable Cerebral Amyloid Angiopathy-Related Inflammation Mon, 02 Mar 2015 13:23:48 +0000 Cerebral amyloid angiopathy related inflammation (CAAri) is becoming increasingly recognised as a subset of cerebral amyloid angiopathy (CAA). CAAri generally presents with subacute cognitive decline, headaches, seizures, behavioral changes, and focal neurological deficits. We describe a patient who developed acute dysphasia and reversible cognitive decline due to probable CAAri. CT brain showed bilateral vasogenic edema in the cerebral hemispheres, predominantly involving the parietal and temporal lobes, left greater than right without enhancement. Magnetic resonance brain imaging showed extensive multifocal areas of subcortical white matter T2 hyperintensity in the frontal and temporal regions with associated mass effect, negligible enhancement, and multiple foci of microhemorrhage on susceptibility weighted imaging sequences consistent with a diagnosis of probable CAAri. She responded dramatically to a course of intravenous methylprednisolone followed by further immunosuppression with pulse intravenous cyclophosphamide. Her dysphasia resolved within 5 days of intravenous methylprednisolone therapy. Her MMSE improved from 11/30 at day 5 of admission to 28/30 at 6-month follow-up. The notable features of our case were the unusual CT findings, which were inconsistent with stroke and diagnostic utility of susceptibility-weighted magnetic resonance imaging in confirming the diagnosis which allowed for prompt institution of immunosuppression. Louise Rigney, Dale Sebire, and Dennis Cordato Copyright © 2015 Louise Rigney et al. All rights reserved. A Case of Apoplexy of Rathke’s Cleft Cyst Followed by Cerebral Infarction Wed, 25 Feb 2015 09:40:23 +0000 Rathke’s cleft cyst (RCC) apoplexy is a rare clinical entity. We report a case of apoplexy of an RCC followed by cerebral infarction. A 67-year-old woman was found lying on the street unconscious. She had fallen from her motorbike. On referral to our hospital she gradually regained consciousness and presented with no neurological deficits. CT showed a round and slightly hyperdense area in the suprasellar region. However, the attending physician did not find this abnormal finding on CT and the patient was discharged the same day. Thirteen days after the first emergency visit she developed left hemiparesis and dysarthria. CT showed a round hypodense area in the suprasellar region. The change of the density in the suprasellar region on CT suggested the pituitary apoplexy. CT also showed a low density area in the territory of the right middle cerebral artery, which indicated the cerebral infarction. MR angiography revealed poor visibility and stenotic changes of right middle cerebral arteries. Transsphenoidal surgery was performed. Histopathological findings confirmed a hemorrhagic RCC. Postoperative MR angiography showed that the visibility and stenosis of right middle cerebral arteries were recovered. This is the rare case of apoplexy of an RCC followed by cerebral infarction. Yu-ichiro Ohnishi, Yasunori Fujimoto, Koichi Iwatsuki, and Toshiki Yoshimine Copyright © 2015 Yu-ichiro Ohnishi et al. All rights reserved. Posterior Reversible Encephalopathy Syndrome as Presenting Form of Very Early Systemic Sclerosis Mon, 23 Feb 2015 09:35:07 +0000 Introduction. Posterior Reversible Encephalopathy Syndrome (PRES) is an increasingly recognized clinical and radiological entity with a wide spectrum of symptoms. Its mechanism depends on failure of the blood-brain barrier due to high systemic blood pressure (BP) and loss of integrity of vascular endothelium related with different triggers. Methods. We aim to report a case of PRES induced by arterial hypertension and very early systemic sclerosis (SSc) not previously known. Results. A 64-year-old female was admitted due to 1-week pulsating headache more prominent on frontal scalp, accompanied by phonophobia, photophobia, and facial flushing. Neurological exam revealed brisk deep tendon reflex. Brain magnetic resonance imaging (MRI) showed subcortical lesions mainly located in posterior regions. BP was monitored and episodic arterial hypertension was detected. In laboratory tests positive anti-topoisomerase I antibodies were detected. BP was controlled with angiotensin-converting-enzyme inhibitors and headache improved. In a new MRI a month later improvement of white matter lesions was observed. Capillaroscopy showed “active pattern,” considered typical of SSc. Conclusion. In SSc anti-endothelial cell antibodies impair vascular endothelium and liberation of vasoconstrictors leads to BP increasing and disruption of blood-brain barrier autoregulation mechanisms. PRES can be the first manifestation of very early SSc and this entity should be considered even in absence of skin lesions or Raynaud phenomenon. María Isabel Pedraza, Julia Barbado, Marina Ruiz, and Ángel Luis Guerrero Copyright © 2015 María Isabel Pedraza et al. All rights reserved. Deep Brain Stimulation for Pantothenate Kinase-Associated Neurodegeneration Mon, 23 Feb 2015 08:13:05 +0000 Pantothenate kinase-associated neurodegeneration (PKAN) is usually associated with dystonia, which is typically severe and progressive over time. Pallidal stimulation (GPi DBS) has been carried out in selected cases of PKAN with drug-resistant dystonia with variable results. We report a 30-month follow-up study of a 30-year-old woman with PKAN-related dystonia treated with GPi DBS. Postoperatively, the benefit quickly became evident, as the patient exhibited a marked improvement in her dystonia, including her writing difficulty. This result has been maintained up to the present. GPi DBS should be considered in dystonic PKAN patients provided fixed contractures and/or pyramidal symptoms are not present. Pedro J. Garcia-Ruiz, Joaquin Ayerbe, Lydia Vela Desojo, Cici E. Feliz, and Javier del Val Fernandez Copyright © 2015 Pedro J. Garcia-Ruiz et al. All rights reserved. Meningioma of Foramen Magnum Causing Drop Attacks Sun, 22 Feb 2015 14:30:42 +0000 A 52-year-old female presented with frequent episodes of falls without loss of consciousness. These episodes lasted for brief period followed by full neurological recovery. Magnetic resonance imaging (MRI) of the brain showed foramen magnum meningioma encasing left vertebral artery. The patient had dramatic improvement after excision of the tumor. Amit Mahore, Raghvendra Ramdasi, Sandip Mavani, Vithal Rangarajan, Manoj Patil, Prashant Sathe, Juhi Kawale, and Vishakha Tikeykar Copyright © 2015 Amit Mahore et al. All rights reserved. Crossed-Brain Representation of Verbal and Nonverbal Functions Sat, 31 Jan 2015 14:27:27 +0000 A 74-year-old, left-handed man presented with a rapidly evolving loss of strength in his right leg associated with difficulty in walking. MR images disclosed an extensive left hemisphere tumor. A neuropsychological examination revealed that language was broadly normal but that the patient presented with severe nonlinguistic abnormalities, including hemineglect (both somatic and spatial), constructional defects, and general spatial disturbances; symptoms were usually associated with right hemisphere pathologies. No ideomotor apraxia was found. The implications of crossed-brain representations of verbal and nonverbal functions are analyzed. Esmeralda Matute, Alfredo Ardila, Monica Rosselli, Jahaziel Molina Del Rio, Ramiro López Elizalde, Manuel López, and Angel Ontiveros Copyright © 2015 Esmeralda Matute et al. All rights reserved. Late Occurrence of PML in a Patient Treated for Lymphoma with Immunomodulatory Chemotherapies, Bendamustine, Rituximab, and Ibritumomab Tiuxetan Thu, 29 Jan 2015 09:27:50 +0000 PML caused by John Cunningham (JC) virus is a rare but an increasingly recognized entity. With the advent of newer immunomodulatory therapies with monoclonal antibodies, there is an increasing incidence of PML. Initially concern was restricted to patients treated for multiple sclerosis with natalizumab but more case reports are being reported during treatment for other conditions like Crohn’s disease and lymphoma with agents such as rituximab. We report the case of a 66-year-old woman who developed PML a year after completion of therapy with rituximab, ibritumomab, and bendamustine. Michael A. Lane, Vijay Renga, Andrew R. Pachner, and Jeffrey A. Cohen Copyright © 2015 Michael A. Lane et al. All rights reserved. Funicular Myelosis in a Butcher: It Was the Cream Cans Wed, 28 Jan 2015 15:44:33 +0000 Background. Funicular myelosis is a known consequence of exposure to nitrous oxide. Nevertheless, there are only a few clinical trials assessing its long-term effects and there is no literature about the role of nutritional vitamin B12 supplementation in the context of nitrous oxide abuse. Case Descriptions. We diagnosed funicular myelosis in a young butcher, who consumed high amounts of meat regularly. Since the diagnostic process did not reveal any metabolic causes, reinterrogation of the patient uncovered recreational abuse of nitrous oxide out of whipped cream can gas cartridges. After stopping abuse and supplementation of vitamin B12, the patient recovered almost completely. Conclusions. In our case, even high nutritional vitamin B12 uptake could not compensate the noxious effects of nitrous oxide. Since there are emerging reports of increasing misuse, this should be considered in the diagnostic and therapeutic care of patients with nitrous oxide abuse. Furthermore, our case emphasizes that patients with vitamin B12 deficiency should be assessed for nitrous oxide abuse. Fabian Wolpert, Krisztina Baráth, Janis Brakowski, Roland Renzel, Michael Linnebank, and Andreas R. Gantenbein Copyright © 2015 Fabian Wolpert et al. All rights reserved. Cerebral Metastasis from Breast Cancer in a Male Patient with HIV Wed, 28 Jan 2015 11:27:14 +0000 Context. Breast cancer (BC) in men is a rare condition, corresponding to 1% of all neoplasms in this gender. Some studies show that up to 93% of BC cases in men are advanced disease. If its occurrence constitutes an uncommon fact, the appearance of a metastasis to the central nervous system (CNS) is extremely rare. The objective of the present study is to present the case of a male patient, bearer of HIV infection, who presented with BC and later metastasis to the CNS. We also include a brief review of the literature. Case Report. We describe a case of a male patient, 59 years old, with HIV infection and a history of BC treated 4 years earlier, which progressed into headache and vertigo. Neuroimaging exams showed lesions suggestive of cerebral metastasis and a stereotaxic biopsy confirmed BC metastasis. Conclusion. Breast cancer in men with metastasis to the CNS is a rare condition and similar reports were not found in the available databases. It should be pointed out that even though rare, it should be considered among the differential diagnoses for SNC metastases in men, although HIV infection favors the appearance of some types of cancer. Guilherme Lellis Badke, Guilherme Brasileiro de Aguiar, João Miguel de Almeida Silva, Aline Lariessy Campos Paiva, Eduardo Urbano da Silva, and José Carlos Esteves Veiga Copyright © 2015 Guilherme Lellis Badke et al. All rights reserved. Syringomyelia with Chiari I Malformation Presenting as Hip Charcot Arthropathy: A Case Report and Literature Review Tue, 27 Jan 2015 06:52:29 +0000 Neuroarthropathy (neuropathic osteoarthropathy), also known as Charcot joint, is a condition characterized by a progressive articular surface destruction in the setting of impaired nociceptive and proprioceptive innervation of the involved joint. It is seen most commonly in the foot and ankle secondary to peripheral neuropathy associated with diabetes mellitus. Cases of hip (Charcot) neuroarthropathy are rare and almost exclusively reported in patients with neurosyphilis (tabes dorsalis). We report a case of a 36-year-old man who presented to the emergency department complaining of right hip pain. On physical examination, pain and thermal sensory deficits were noted in the upper torso with a cape-like distribution, as well as signs of an upper motor neuron lesion in the left upper and lower extremities. A magnetic resonance imaging study (MRI) of the right hip showed evidence of early articular surface destruction and periarticular edema consistent with hip Charcot arthropathy. An MRI of the spine revealed an Arnold-Chiari type I malformation with extensive syringohydromyelia of the cervical and thoracic spine. Roya Memarpour, Basheer Tashtoush, Lydia Issac, and Fernando Gonzalez-Ibarra Copyright © 2015 Roya Memarpour et al. All rights reserved. Intraosseous Lipomatous Meningioma Mon, 26 Jan 2015 14:38:24 +0000 A 49-year-old man with intermittent headaches and right sided parietal lump was found to have an intraosseous right parietal lesion on computed tomography (CT) and magnetic resonance imaging (MRI). A stereotactic craniectomy and excision of the lesion were performed with histopathology confirming features consistent with primary lipomatous meningioma with intraosseous extension. Lipomatous meningiomas are very uncommon subtype of meningiomas, with ongoing discussions as to their true pathogenesis. To our knowledge this case represents the first reported case of a lipomatous meningioma with predominant intraosseous extension. Lauren Kim, Christopher Huang, Adrienne L. Morey, and Mark J. Winder Copyright © 2015 Lauren Kim et al. All rights reserved. Occipital Neuralgia after Hair Transplantation and Its Treatment Mon, 26 Jan 2015 07:01:40 +0000 While undergoing full thickness tissue harvest from the posterior scalp, a 72-year-old man experienced immediate severe pain in the right occiput and was unable to complete the procedure. The pain was constant “sharp” and “shocking” with numbness in the distribution of the lesser occipital nerve, exacerbated by physical activity, and local anesthetic blocks provided temporary complete relief. After numerous treatments over several years, including oral analgesics, botulinum toxin injections, and acupuncture, proved ineffective, pulsed radiofrequency neuromodulation provided greater than 80% relief for 5 months. Jason Siefferman and Yury Khelemsky Copyright © 2015 Jason Siefferman and Yury Khelemsky. All rights reserved. Papillary Tumor of the Pineal Region: MR Signal Intensity Correlated to Histopathology Thu, 22 Jan 2015 10:05:04 +0000 Tumors of the pineal region are rare and can be challenging to differentiate by imaging. Papillary tumor of the pineal region (PTPR) was recently recognized as a neoplasm in the World Health Organization (WHO) 2007 classification, arising from specialized ependymocytes in the subcommissural organ, which is located in the pineal region. It is a rare histological type of pineal tumor with only a few cases reported. Here, we describe a case of histologically confirmed PTPR in a 17-year-old man who presented with a headache. A literature review was performed to clarify the clinical, radiological, and pathological features of PTPR. Pineal neoplasms do not have pathognomonic imaging findings; however, we discuss T1 hyperintensity, which is a key for imaging diagnosis according to recent reports. In particular, if the hyperintensity in T1 is not due to fat, calcification, melanin, or hemorrhage in a mass of the posterior commissure or pineal region, the diagnosis of a PTPR may be suggested, as observed in this case. Marcos Rosa Junior, Antonio Jose da Rocha, Adriano Zanon da Silva, and Sergio Rosemberg Copyright © 2015 Marcos Rosa Junior et al. All rights reserved. Massive Cerebral Gas Embolism under Discectomy due to Hydrogen Peroxide Irrigation Tue, 20 Jan 2015 10:50:41 +0000 Massive cerebral and spinal gas embolism occurs rarely as a complication of discectomy. We report a 54-year-old female who had undergone a discectomy (L3/4 and L4/5) under epidural anesthesia in a local hospital developed multiple massive gas embolisms. At closure, surgeons irrigated the incision wound with hydrogen peroxide. Soon after the irrigation, the patient suddenly developed tachycardia, hypotension, and rapid oxygen desaturation. Subsequently, patient progressed into unconsciousness and right hemianopsia quadriplegia. Computed tomography (CT) scan showed multiple hypointensity spots around the brain due to cerebral gas embolism, which indicated the pneumoencephalos. The likely mechanism was the absorption of hydrogen peroxide into blood. When the amount of oxygen evolved exceeded its maximal blood solubility, venous embolization occurred. Though the patient was treated with supportive treatments and hyperbaric oxygen, she did not get full recovery and was left with severe long-term cerebral injury. Junjie Zhang, Chengliang Zhang, and Jianqin Yan Copyright © 2015 Junjie Zhang et al. All rights reserved. Subarachnoid Hemorrhage Secondary to Forceful Sneeze Sun, 18 Jan 2015 10:22:20 +0000 Subarachnoid hemorrhage (SAH) is a relatively less common but important neurological condition comprising 5% of all the cerebrovascular accidents. In most populations the reported incidence is 6-7 per 100,000 person-years and one-third of survivors become dependent. It is a serious but potentially treatable cause of neurological morbidity. Multiple authors have identified the most unusual novel associations and triggers of subarachnoid bleeds over the past decade. We herein report a rare case of subarachnoid hemorrhage leading to focal neurological deficit in a middle aged man secondary to forceful sneeze. Ali Zohair Nomani, Haris Majid Rajput, Mansoor Iqbal, Zakir Jan, Muhammad Irshad, Mazhar Badshah, and Rao Sohail Yasin Khan Copyright © 2015 Ali Zohair Nomani et al. All rights reserved. Consideration of Two Cases of Ascending Aortic Dissection That Began with Stroke-Like Symptoms Sun, 18 Jan 2015 06:26:21 +0000 We recently experienced two patients with stroke-like symptoms and ascending aortic dissection (AAD) in our outpatient department. Both patients were transferred to our hospital presenting with neurological deficit such as hemiparesis and conjugate deviation. They did not complain from any chest or abdominal pain. Their MRI did not show fresh infarction or main branch occlusion. A chest CT image showed AAD. The former patient was immediately transferred to a tertiary hospital and the latter received conservative management in the cardiovascular department. Discussion. As neither patient was experiencing any pain, we initially diagnosed them with ischemic stroke and began treatment. Fortunately, bleeding complications did not occur. In such cases, problems are caused when intravenous tissue plasminogen activator (t-PA) injection is administered with the aim of reopening the occluded intracranial arteries. In fact, patients with AAD undergoing t-PA injection have been reported to die from bleeding complications without any recognition of the dissection. These findings suggest that confirmation using carotid ultrasound, carotid MR angiography, and a D-dimer test is crucial and should be adopted in emergency departments. Chiaki Takahashi and Takashi Sasaki Copyright © 2015 Chiaki Takahashi and Takashi Sasaki. All rights reserved. Intradural Solitary Fibrous Tumor of the Lumbar Spine: A Distinctive Case Report Wed, 14 Jan 2015 13:25:41 +0000 Background. Solitary fibrous tumors are ubiquitous mesenchymal neoplasms of putative fibroblastic origin. They were originally described in the pleura but subsequently have been reported in many extraserosal sites. Solitary fibrous tumors may also occur in the meninges, central nervous system parenchyma, and spinal cord. Case. A 67-year-old male patient with progressive lower extremity weakness, urinary urgency, and sexual dysfunction has been admitted to our hospital. On his lumbar MRI, we detected an intradural lesion posterior to the L3 vertebral corpus. We resected the lesion by L3 total laminectomy. Immunohistological findings revealed strong and diffuse immunopositivity with vimentin, CD34, and bcl-2. Ki-67 proliferation index was 5–8%. We did not detect any recurrence 12 months after his operation. Conclusion. SFT is mostly seen in young and middle-aged patients and should be considered among differential diagnosis in cases suffering from pain, hypoesthesia, and urinary dysfunction. Gross total resection should be primary treatment. Tumors that have high Ki-67 labeling should be followed up for potential recurrences. Recep Basaran, Mustafa Kaksi, Mustafa Onoz, Ece Balkuv, and Aydin Sav Copyright © 2015 Recep Basaran et al. All rights reserved. Acupuncture Alleviated the Nonmotor Symptoms of Parkinson’s Disease including Pain, Depression, and Autonomic Symptoms Wed, 31 Dec 2014 12:30:15 +0000 A woman started to feel intractable pain on her lower legs when she was 76. At the age of 78, she was diagnosed as having Parkinson’s disease (PD). The leg pain was suspected to be a symptom of PD after eliminating other causes. The patient also suffered from nonmotor symptoms, depression, anxiety, hot flashes, and paroxysmal sweating. Though the patient had received pharmacotherapy including levodopa for 5 years, she still suffered from the nonmotor symptoms and was referred to our department. We treated her with acupuncture based on the Chinese traditional medicine and electroacupuncture five times per week. After the 2-week treatment, the assessment for the symptoms was as follows; visual analogue scale (VAS) score of the leg pain was 16 mm (70 mm, before), Hamilton’s rating scales for depression (HAM-D) score was 9 (18, before), timed 3 m Up and Go took 20 steps in 30 sec (24 steps in 38 sec, before), and the Movement Disorder Society-sponsored revision of the Unified Parkinson’s Disease Rating Scale (MDS-UPDRS) Part 1 score was 13 (21, before). Autonomic symptoms, hot flashes and paroxysmal sweating, were also alleviated. Acupuncture may be a good treatment modality for nonmotor symptoms in PD. Chifumi Iseki, Taiga Furuta, Masao Suzuki, Shingo Koyama, Keiji Suzuki, Tomoko Suzuki, Akiyo Kaneko, and Tadamichi Mitsuma Copyright © 2014 Chifumi Iseki et al. All rights reserved. Thyroid-Induced Worsening of Parkinsonian Tremor Resistant to Drugs and Subthalamic Nucleus Deep Brain Stimulation Wed, 31 Dec 2014 11:18:24 +0000 Introduction. Symptoms of both hypothyroidism and thyrotoxicosis can be easily overlooked in patients with Parkinson’s disease (PD). We report on a patient whose parkinsonian tremor worsened and proved refractory not only to common treatment, but also to deep brain stimulation (DBS). Case Presentation. A 61-year-old woman with advanced PD underwent bilateral subthalamic DBS, with an excellent outcome. Twenty-one months after the surgery, however, patient’s resting/postural tremor markedly worsened. There was a slight improvement for 1 month after repeated adjustments of DBS parameters, but then the tremor worsened again. Since even a minimal increase of the dose of dopaminergic drugs caused extremely severe dyskinesias, an anticholinergic drug biperiden and benzodiazepine clonazepam were introduced, what helped for another month. With the onset of severe diarrhoea, a laboratory workup was performed. Thyrotoxicosis was detected. During treatment with the antithyroid agent carbimazole, the parkinsonian tremor clearly improved within two weeks. Conclusion. A hyperthyroid state can markedly exaggerate all forms of tremor, as well as other types of movement disorders. This condition can be overlooked or masked by other symptoms. Therefore, if the tremor in a patient with PD gradually worsens and proves resistant to the usual treatment, examine the thyroid gland. Michal Minár and Peter Valkovič Copyright © 2014 Michal Minár and Peter Valkovič. All rights reserved. Varicella Zoster Virus Meningitis in a Young Immunocompetent Adult without Rash: A Misleading Clinical Presentation Mon, 29 Dec 2014 06:53:32 +0000 Meningitis caused by varicella zoster virus (VZV) is rare in healthy population. Predominantly immunocompromised patients are affected by reactivation of this virus with primary clinical features of rash and neurological symptoms. Here we report a young otherwise healthy man diagnosed with a VZV meningitis without rash. He complained of acute headache, nausea, and vomiting. The clinical examination did not show any neurological deficits or rash. Cerebrospinal fluid (CSF) analysis revealed a high leukocyte cell count of 1720 cells/µL and an elevated total protein of 1460 mg/L misleadingly indicating a bacterial infection. Further CSF analyses, including polymerase chain reaction (PCR) and detection of intrathecal synthesis of antibodies, showed a VZV infection. Clinical and CSF follow-up examinations proved the successful antiviral treatment. In conclusion, even young immunocompetent patients without rash might present with VZV meningitis. CSF examination is a key procedure in the diagnosis of CNS infections but in rare cases the standard values cell count and total protein might misleadingly indicate a bacterial infection. Thus, virological analyses should be considered even when a bacterial infection is suspected. Thomas Pasedag, Karin Weissenborn, Ulrich Wurster, Tina Ganzenmueller, Martin Stangel, and Thomas Skripuletz Copyright © 2014 Thomas Pasedag et al. All rights reserved. Epidermoid Causing Ischemic Stroke in the Brainstem Mon, 15 Dec 2014 00:10:33 +0000 Intracranial tumors may rarely cause stroke. We report an epidermoid cyst causing stroke in a pediatric patient. We have also reviewed the literature and pathogenesis of stroke caused by intracranial tumors. Raghvendra Ramdasi, Amit Mahore, Abhijeet Kulkarni, Vithal Rangarajan, Manoj Patil, and Juhi Kawale Copyright © 2014 Raghvendra Ramdasi et al. All rights reserved. Clinicoradiological Correlation of Macropsia due to Acute Stroke: A Case Report and Review of the Literature Tue, 09 Dec 2014 06:57:54 +0000 Dysmetropsia (macropsia, micropsia, teleopsia, or pelopsia) most commonly results from retinal pathologies, epileptic seizure, neoplastic lesions, viral infection, or psychoactive drugs. Vascular lesions are an uncommon cause of dysmetropsia. Vascular hemimicropsia, although rare, has been more frequently described in the literature, whereas hemimacropsia from acute ischemic injury is exceedingly rare. We describe a patient presenting in the emergency room (ER) with visual perception disturbances characterized by a distorted perception of the size of objects, compatible with left hemimacropsia. Magnetic resonance imaging (MRI) of the brain showed an acute occipitotemporal ischemic injury corresponding to the posterior cerebral artery (PCA) territory. The location of the lesion is consistent with previous case reports that suggest that hemimacropsia is associated with the occipitotemporal projection, which plays a decisive role in the visual identification of objects by interconnecting the striate, prestriate, and inferior temporal areas. The difference of our case as compared to previous case reports is that the lesion in our patient spared Brodmann area 17 (calcarine cortex) and therefore did not present symptoms of quadrantanopsia. Instead, the patient presented isolated hemimacropsia, therefore suggesting that the anatomical lesion causing hemimacropsia is located in the ventral portion of the occipitotemporal projection, more specifically Brodmann areas 18 (parastriate) and 19 (peristriate). Mayra Johana Montalvo and Muhib Alam Khan Copyright © 2014 Mayra Johana Montalvo and Muhib Alam Khan. All rights reserved.