Stroke syndrome: A case of a Nine syndrome with a DWI-negative imaging

@#The brainstem contains important structures that give an array of clinical manifestations in pathologic processes. Here, we report a case of “Nine Syndrome” who was admitted in our institution with no acute findings on DWI sequence. The exact prevalence of Nine Syndrome has been accounted to only four cases reported in the literature and this is due to a pontine tegmentum lesion. Our patient is a 65 year-old male who presented with five-hour history of sudden onset of symptoms presented as ipsilateral gaze palsy, internuclear ophthalmoplegia, a lower motor neuron type of facial palsy, and a contralateral hemiparesis. Using a 1.5T MR cranial scanner and Philips scanner of the time-of-flight of the intracranial vessels, no evidence of acute territorial infarct but an old lacunar infarct was seen in the right pontine area. Both the anterior and posterior circulations are within normal course and caliber with no narrowing seen. Patient was started on dual anti-platelet, high dose statin, and anti-hypertensives on the fourth hospital day. Nine syndrome is a rare case, and its diagnosis rely on its clinical manifestations, neuroanatomy, and diagnostic imaging. An acute posterior ischemic infarct such as this may yield a negative DWI finding but should not impede the clinician in its early recognition and management.

Post-coital internal carotid artery dissection associated with acute cerebral infarction in a Filipino female: A case report

@#Carotid arterial dissections may result from spontaneous or traumatic causes. Postcoital arterial dissections have been reported in both the vertebral and coronary arteries. We report a rare case of spontaneous dissection on the extracranial internal carotid artery in a Filipino female after sexual intercourse, leading to a fulminant middle cerebral artery (MCA) territory infarct. Although postcoital carotid artery dissection is a very rare cause of neck vessel dissections, its rapid progressive course can lead to massive cerebral infarction and prompt management must be initiated.

Direct carotid-cavernous fistula in a Filipino female presenting with simultaneous orbital/ocular, cavernous and cortical symptomatology without history of trauma: A case report

@#Carotid-cavernous fistula (CCF) is a rare and dangerous neurological disorder that arises due to an abnormal communication between the internal carotid artery (ICA) or the external carotid artery (ECA) and their branches and the cavernous sinus. It can either be a direct fistula (high-flow with acute symptoms) most commonly resulting from trauma (70-90%) or an indirect fistula (low-flow with insidious symptoms) secondary to hypertension, atherosclerosis and collagen vascular disorders. The shunting of arterial blood into the venous system leads to venous hypertension causing various clinical manifestations depending on the venous drainage patterns and the shunt flow. Increased anterior, posterior and superior venous drainage results to orbital/ocular, cavernous and cortical symptomatology, respectively. This paper aims to present a case of 58-year old Filipino female with a 2-day history of sudden, severe headache, vomiting and blurring of vision followed by decrease in sensorium and sudden proptosis and chemosis of the left eye. Patient had no co-morbidities, history of trauma, surgeries, facial skin infections or prior febrile illness. The left eye had exophthalmos, subconjunctival hyperemia, scleral edema/chemosis and ocular bruit. Neurologic examination showed a stuporous patient with multiple cranial nerve deficits (impaired direct and consensual pupillary reflex left, complete ptosis left, sluggish corneal reflex left, impaired oculocephalic reflex left), right hemiplegia and meningeal signs. Cranial Computed Tomography (CT) Angiogram revealed an acute parenchymal hemorrhage in the left frontotemporal lobe with subarachnoid component, with engorged left cavernous sinus and dilated left superior ophthalmic vein. Digital Subtraction Angiography (DSA) was done revealing a direct type of left carotid-cavernous fistula with massive ICA shunting to the cavernous sinus, superior ophthalmic vein and inferior petrosal sinus. The clinical and radiographic evidence were consistent with a Direct/Type A CCF. Unique in this case was a patient with no history of trauma presenting with simultaneous orbital/ocular, cavernous and cortical symptomatology – a clinical picture of CCF that has never been documented in any literature nor included in any classification system. The presence of all three symptomatology can be explained by a direct/highflow fistula that resulted to increased anterior, posterior and superior venous drainage as documented in the DSA. In addition, spontaneous intracranial hemorrhage in CCF is exceptionally rare and it is the most daunting symptomatology of this disease. With that, this specific case may pave the way to a new classification scheme and determine its corresponding treatment approach.

Intracranial colloid cyst in a young female with neurofibromatosis type 1: A case report

INTRODUCTION@#Intracranial colloid cysts are rare benign tumors located in the region around the foramen of Monro or around the third ventricle with an annual incidence of 3 of 1,000,000. The common clinical picture is a progressive headache due to the rapid enlargement of the cyst, resulting in hydrocephalus as it obstructs the cerebrospinal flow; brain herniation may ensue, leading to death. @*OBJECTIVES@#The objectives of this report are to (1) present a case of intracranial colloid cyst in a young female with neurofibromatosis type 1, (2) emphasize the importance of early diagnosis by clinical signs and symptoms and (3) highlight the importance of neuroimaging in arriving at a neurologic diagnosis.@*CASE REPORT@#A nineteen-year-old female was seen due to a three-month history of progressive headache, with associated signs of increased intracranial pressure and with a medical history of neurofibromatosis type 1, inherited from her mother. Neurologic findings revealed papilledema and 6th cranial nerve palsy. By radiographic imaging with clinical correlation, patient was diagnosed with a colloid cyst obstructing the foramen of Monro. Surgical intervention was done and patient improved without complications. @*DISCUSSION@#Neurofibromatosis is a hereditary neurocutaneous syndrome in which the skin, nervous system, bones, endocrine glands and sometimes other organs are the sites of a variety of congenital abnormalities, often taking the form of benign tumors. Intracranial colloid cyst was seen in this case report. Colloid cysts have an incidence of 0.5 – 1% of all primary brain tumors and are the most common masses in the third ventricle and in the Foramen of Monro. They cause obstruction of CSF flow, resulting in hydrocephalus. No published case of neurofibromatosis type 1 patients with a symptomatic intracranial colloid cyst has been reported yet. Surgical resection is the treatment of choice for colloid cyst.