Primary Central Nervous System Lymphoma Presenting as Isolated Multiple Cranial Neuropathies: An Extremely Rare Case.

Primary central nervous system lymphoma (PCNSL) is an uncommon malignancy of B-cell origin that typically involves the brain, eyes, and spinal cord without systemic spread. PCNSL typically involves the cerebral hemispheres, basal ganglia, or periventricular region. Isolated leptomeningeal PCNSL without any evidence of parenchymal involvement is very rare. We present a very unusual case of PCNSL presenting as persistent bilateral Bell's palsy and trigeminal neuralgia with magnetic resonance imaging (MRI) brain showing significantly hypertrophied enhancing bilateral facial and trigeminal nerves.

A Novel Case of Deep Temporal Artery (DTA) Embolization for Recurrent Subacute-Chronic Subdural Hematoma.

Subdural hemorrhage (SDH) is a common neurological disease. In past, SDHs were managed either conservatively (non-surgically) or with surgical evacuation (burr hole versus craniotomy) depending on the severity. Surgical evacuation has major challenges including high recurrence rate, stoppage and reversal of antiplatelet or anticoagulation agents, risk of general anesthesia and surgery in elderly patients with multiple comorbidities. Given the above challenges, embolization of the distal branches of the middle meningeal artery (MMA) has recently emerged as an excellent alternate to surgical evacuation or conservative management. To the best of our knowledge, there is no literature on the embolization of the deep temporal artery (DTA) for subacute-chronic SDH. We report the first case of recurrent subdural hematoma post MMA embolization that was successfully treated with embolization of DTA.

Retrieval of Migrated Coils From Distal Cerebral Vasculature Using Stent Retriever: A Case Series.

The incidence of coil dislocation during an endovascular embolization of intracranial aneurysm is low but it can lead to serious thrombo-embolic complications. Therefore, coil displacement/migration often requires either retrieval or fixation of the errant coil with a stent. There are no standard recommended methods of coil retrieval. We present a series of three cases in which off-label application of a stent retriever allowed successful retrieval of herniated coils.

Ascending Palatine Artery Embolization for the Treatment of Surgically Refractory Post-tonsillectomy Hemorrhage.

Severe uncontrollable surgically refractory postoperative bleeding after tonsillectomy is a rare but potentially life-threatening event. The efficacy of surgical interventions tends to decline with repetition, which leads to higher morbidity and mortality. Endovascular embolization of the external carotid artery branches as an effective treatment in surgically refractory post-tonsillectomy hemorrhage has been described previously. We describe the case of a 27-year-old man who presented with surgically refractory post-tonsillectomy hemorrhage and underwent successful endovascular embolization of the ascending palatine artery with immediate hemostasis.

Internal Carotid Artery Agenesis: A Rare Entity.

Congenital absence of the internal carotid artery (ICA) is an extremely rare entity that occurs due to insult during the embryonic development of the ICA. Various intracranial collateral pathways develop to compensate for the ICA agenesis. Patients can present with aneurysmal subarachnoid hemorrhage, stroke-like symptoms, or other neurological symptoms due to compression of brain structures from enlarged collateral pathways/aneurysms. We present two cases of ICA agenesis along with an extensive review of the literature. A 67-year-old man presented with fluctuating right-sided hemiparesis and aphasia, found to have left ICA agenesis. The left middle cerebral artery (MCA) is supplied by the basilar artery through the well-developed posterior communicating artery (PCOM). Left ophthalmic artery coming from the proximal left MCA. A 44-year-old woman presented with severe headaches, found to have right ICA agenesis with bilateral MCAs and anterior cerebral arteries (ACA) supplied by left ICA. A 17-mm anterior communicating artery (ACOM) aneurysm was discovered.

Institution of Code Neurointervention and Its Impact on Reaction and Treatment Times.

BACKGROUND/OBJECTIVE: Various strategies have been implemented to reduce acute stroke treatment times. Recent studies have shown a significant benefit of acute endovascular therapy. The JFK Comprehensive Stroke Center instituted Code Neurointervention (NI) on May 1, 2014 for the purpose of rapidly assembling the NI team and rapidly providing acute endovascular therapy. DESIGN/METHODS: We performed a retrospective analysis of all patients who had Code NI (Code NI group) called from May 1, 2014 to July 30, 2018 and compared them to patients who underwent acute endovascular treatment prior to initiation of the code (pre-Code NI group) between January 2012 and April 30, 2014. The following parameters were compared: door to puncture (DTP) and door to recanalization (DTR) times, as well as preprocedure NIHSS, 24-hour postprocedure NIHSS, and 90-day modified Rankin scores. RESULTS: There were 67 pre-Code NI patients compared to 193 Code NI patients. Mean and median DTP times for pre-code NI vs Code NI patients were 161 minutes(mins) vs 115mins (p<0.0001, 31.76-58.86) and 153mins vs 112mins (p <0.0001), respectively. Mean and median DTR times were 220 mins vs 167mins (p <0.0001, 37.76-69.97) and 225mins vs 171mins (p <0.0001). Mean pre-procedure NIHSS was 16 for both groups while 24 hours post procedure NIHSS was 10.6 vs 10.8 (p =.078, 1.8-2.38). Mean 90 day mRS was 2.15 vs 1.65 (p=0.036, 0.32-0.96). CONCLUSION: Institution of Code NI significantly improved DTP and DTR times as well as mRS at 3-months postprocedure. Rapid assembly of the NI team, rapid availability of imaging and angiography suite, and streamlining of processes, likely contribute to these differences. These lessons and more widespread institution of such codes will further aid in improving acute stroke care for patients.

Safety and Clinical Outcomes after Transverse Venous Sinus Stenting for Treatment of Refractory Idiopathic Intracranial Hypertension: Single Center Experience.

BACKGROUND: Idiopathic intracranial hypertension (IIH) is a syndrome of elevated intracranial pressure of unknown etiology. Unilateral or bilateral transverse sinus (TS) or transverse-sigmoid junction stenosis is present in about 30%-93% of these patients. There is an ongoing debate on whether venous sinus stenosis is the cause of IIH or a result of it. The subset of IIH patients who continue to have clinical deterioration despite maximum medical therapy is termed as "refractory IIH." Traditionally, cerebrospinal fluid diversion surgeries (ventriculoperitoneal shunt and lumboperitoneal shunt) and optic nerve sheath fenestration (ONSF) were the mainstays of treatment for refractory IIH. In the last decade, venous sinus stenting (VSS) has emerged as a safe and effective option for treating refractory IIH patients with venous sinus stenosis. Through this study, we want to share our experience with venous stenting in refractory IIH patients with venous sinus stenosis associated with a significant pressure gradient (≥10 mm Hg). METHODS: Retrospective chart review of all the patients diagnosed with refractory IIH who underwent VSS or angioplasty at our comprehensive stroke center from November 2016 to March 2019. RESULTS: A total of seven refractory IIH patients underwent VSS or angioplasty within the specified period. The mean age was 39 years. Eighty-five percent of the patients were women (n = 6). The mean body mass index (BMI) was 37 kg/m2. Headache was the most common symptom (85%, n = 6) followed by transient visual obscurations (71%, n = 5) and pulsatile tinnitus (57%; n = 4). All patients had papilledema. Fifty-seven percent of patients (n = 4) had impaired visual field. Mean lumbar opening pressure was 40.6 cm H2O (SD = 9.66; 95% CI = 33.5-47.7). All patients were on maximum doses of acetazolamide ± furosemide. Six patients (85%) had dominant right transverse-sigmoid sinus. Fifty-seven percent of the patients had severe right transverse ± sigmoid sinus stenosis (n = 4) and the rest (43%) had bilateral TS stenosis (n = 3). Prestenting mean trans-stenosis pressure gradient was 18 mm Hg (SD = 6.16; 95% CI = 13.43-22.57). Six patients (85%) were treated with TS stenting and one (15%) with only angioplasty. Poststenting mean trans-stenosis pressure gradient was 4.8 mm Hg (SD = 6.6; 95% CI = -0.1-9.7). All patients were able to come off their medications with significant improvement in neurological and ophthalmological signs and symptoms. No procedure-related complications occurred. CONCLUSION: TS stenting ± angioplasty is a safe and effective means of treating refractory IIH with venous sinus stenosis associated with a significant pressure gradient (≥10 mm Hg).

Acute Ischemic Pediatric Stroke Management: An Extended Window for Mechanical Thrombectomy?

Ischemic stroke is a rare condition to afflict the pediatric population. Congenital cardiomyopathy represents one of several possible etiologies in children. We report a 9-year-old boy who developed right middle cerebral artery stroke secondary to primary restrictive cardiomyopathy. In the absence of pediatric guidelines, the child met adult criteria for mechanical thrombectomy given the small core infarct and large penumbra. The literature suggests children may benefit from mechanical thrombectomy in carefully selected cases. Our patient exemplifies specific circumstances in which acute stroke therapy with thrombolysis and thrombectomy may be safe.

Neuroscience step-down unit admission criteria for patients with intracerebral hemorrhage.

OBJECTIVES: The goal of our study is to determine optimal criteria which can be used to avoid admission to neuroscience intensive care units for patients with intracerebral hemorrhage (ICH). PATIENTS AND METHODS: This is a retrospective cohort study of 431 patients with primary ICH from January 2013 to the end of December 2015 and reviewed multiple admitting characteristics. Based on these needs, we tested the following step-down unit admission criteria: Supratentorial ICH, ICH volume <20 cc, no Intraventricular hemorrhage (IVH), systolic BP <200mmHg, no respiratory failure, GCS≥12. We classified 431 patients into two groups; 1-Patients who met step-down unit admission Criteria (71 patients). 2-Patients who didn't meet the criteria (360 patients). RESULTS: In our patients, 16.5% fulfilled the criteria. Length of stay in the ICU was 1.43days in step-down unit admission criteria patients. None of the patients who fulfilled the criteria were readmitted to the ICU, compared to 3 readmissions among the group of patients who did not fulfill the criteria (P=0.82). None of these patients required a neurosurgical procedure vs 47 patients (10.9%) in the other group (P=0.04). Among patients who met the criteria, 83.1% were discharged home or rehab RR 0.33 CI (0.19-0.55), (P<0.0001). CONCLUSION: We propose that patients who fulfill step-down unit admission criteria can be safely monitored in stroke unit and they have no need for ICU admission. Further studies are needed to validate these criteria in a prospective manner.

Impact of Insurance Precertification on Discharge of Stroke Patients to Acute Rehabilitation or Skilled Nursing Facility.

BACKGROUND AND PURPOSE: The purpose of this study is to determine if the common insurance practice of requiring precertification before a medically ready stroke patient can be discharged to a skilled nursing facility (SNF) or inpatient rehabilitation facility (IRF) causes a delay in discharge. Eliminating delays in discharge of stroke patients is important given the increasing demands for health-care efficiency after the passage of the Affordable Health Care Act. METHODS: A retrospective chart review of 1007 patients who were admitted to our comprehensive stroke center with the primary diagnosis of stroke over a 12-month period was performed. Out of the patient pool, 289 patients met the inclusion criterion of a primary diagnosis of stroke that required discharge to a SNF or IRF. All 289 patients were medically cleared for discharge to a SNF or IRF by a board-certified vascular neurologist. RESULTS: Of the 289 patients who met the inclusion criteria, 118 required insurance precertification and 171 did not require precertification before being discharged to a SNF or IRF. All 118 patients who required precertification had private health insurance. The patients who required insurance precertification had an average delay of discharge (DOD) of 1.5 days, and those patients who did not require precertification had an average DOD of .8 days (P value <.0001). After removing the outliers, the difference in the length of stay (LOS) between the 2 groups became statistically significant (P value < .04). CONCLUSION: The results of this study demonstrate that insurance precertification leads to delay in discharge, increased LOS, and increased hospital costs for stroke patients.

Ischemic Stroke After Wasp Sting.

BACKGROUND: Despite the common occurrence of hymenopteran stings worldwide, primary neurologic manifestations including stroke are rare. We report a case of a healthy male who developed a right middle cerebral artery (MCA) territory ischemic stroke after getting stung by a wasp. CASE REPORT: A 44-year-old man with hypertension presented to the hospital with sudden-onset left hemiparesis, left facial weakness, and dysarthria after being stung by a wasp. Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) scans of the brain revealed a right MCA territory infarct and a lack of flow in the distal right internal carotid artery and MCA. He was treated with intravenous tissue plasminogen activator. A computed tomography angiography scan of the brain performed 24 hours later revealed multiple regions of vasoconstriction in the territory of the bilateral MCA. Evaluations for causes of stroke, including echocardiography and telemetry, were not revealing. Immunologic testing showed significantly elevated levels of serum wasp immunoglobulin E. Therapy with aspirin and atorvastatin was started. At discharge, the patient had a mild left facial droop but normal strength in his left arm and leg. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians encounter large numbers of hymenopteran sting cases each year. These patients typically present with local reactions, such as itching, pain, and erythema. Systemic manifestations, such as anaphylaxis causing severe hypotension and bronchospasm, are less common but deadly. Neurologic complications, such as ischemic stroke, are extremely rare. This manuscript highlights the pathophysiology and management of stroke after a hymenopteran sting. There are no guidelines for the management of stroke after a hymenopteran sting, and therefore we intend to provide some guidance to physicians for treating stroke after a hymenopteran sting.

Auditory Hallucinosis as a Presenting Feature of Interpeduncular Lipoma with Proximal P1 Segment Fenestration: Report of a Rare Case and Review of Literature on Peduncular Hallucinosis.

The authors present a unique case of intracranial lipoma in the interpeduncular cistern associated with proximal P1 segment fenestration. This patient is a 20-year-old male with extensive psychiatric history and complaints of recent auditory hallucinations. Cranial magnetic resonance imaging (MRI) (T1, T2, and FLAIR) showed a hyperintense lesion in the left aspect of interpeduncular cistern with a prominent flow void within the hyperintense lesion suggestive of a combined vascular-lipomatous lesion. Computed tomography (CT) angiography showed a high-riding large tortuous P1 segment on the left side with proximal fenestration, the ectatic posteromedial limb harboring a fusiform dilated segment. Since there are anecdotal cases of cerebral aneurysms associated with intracranial lipomas, a conventional angiography was done, which confirmed a proximal left P1 fenestration and a fusiform-dilated segment, and no aneurysm. There are few cases of hallucinations associated with a vascular midbrain pathology reported in literature, but hallucinations associated with a combination of lipoma and arterial ectasia have never been reported. This article not only demonstrates the MRI and angiographic appearance of this rare lipomatous lesion but also highlights this unique association and significance of auditory hallucinations as a clinical presentation, akin to peduncular hallucinosis.

Lingual Artery-Retromandibular Vein Fistula Four Years after an Uncomplicated Carotid Endarterectomy: Case Report and Review of Possible Etiologies and Treatment Options.

The external carotid artery's lingual branch to retromandibular venous fistula following a carotid endarterectomy has not been reported earlier in literature. We report a unique case of an 87-year-old man who had a right-sided carotid endarterectomy in 2009 and presented four years later with complaints of fullness and discomfort in the area of right parotid gland with associated pulsatile tinnitus. A computed tomography (CT) scan of the neck revealed a deep portion of the right parotid gland having abnormal aneurysmal dilatation of a vascular structure, which appeared to be an arteriovenous fistula between branches of right external carotid artery and the retromandibular vein. Conventional catheter angiogram showed a complex arteriovenous fistula seen with the right retromandibular vein receiving multiple small arterial feeders from the right external carotid artery via its lingual artery branch. Slight reflux was noted into the right pterygoid plexus, right maxillary, and right submental veins as well. Surgical treatment was deferred due to high risk of inadvertent facial nerve injury from extensive parotid dissection involved in the procedure. Transarterial embolization of five discrete arterial branches from the right external carotid artery supplying the fistula was performed using particles with resultant remarkable slowing of the venous drainage into the retromandibular vein. After the procedure, his tinnitus and ear fullness resolved completely. The presence of arteriovenous fistula after carotid endarterectomy is a rare yet serious complication and therefore should be diagnosed early and treated promptly. The article highlights the relevant literature on arteriovenous fistula formation in the setting of arterial patch, intraoperative shunting, and surgical-site infections.

Noncompaction Cardiomyopathy and Stroke: Case Report and Literature Review.

BACKGROUND: To describe a rare case of isolated noncompaction cardiomyopathy and stroke and to review the medical literature on noncompaction cardiomyopathy. METHODS: Retrospective chart review of the case was performed. Extensive literature review on etiology, clinical presentation, diagnosis, and management of noncompaction cardiomyopathy was also performed. RESULTS: Our patient is a healthy 20-year-old woman who presented with sudden onset left face and arm weakness and hypesthesia. Magnetic resonance imaging (MRI) brain showed right middle cerebral artery (MCA) infarct. Magnetic resonance angiography head showed right MCA artery (M2) cutoff. MRI neck was nonsignificant. Echocardiogram was suggestive of noncompaction of left ventricle. Cardiac MRI confirmed the noncompaction of the left ventricle myocardium, which was thought to be the etiology of stroke. Patient was started on anticoagulation for secondary stroke prevention. CONCLUSIONS: Isolated left ventricular noncompaction cardiomyopathy (LVNC) is a rare form of primary genetic cardiomyopathy, which occurs because of the arrest of the process of compaction of ventricular myocardium during embryogenesis. Noncompaction cardiomyopathy is usually associated with other primary cardiac structural abnormalities like dysfunctional cardiac valves. In isolated noncompaction cardiomyopathy, there are no other primary cardiac structural abnormalities. The most common clinical features seen in LVNC include left ventricular systolic dysfunction, congestive heart failure, arrhythmias, and cardiac embolic events theorized to result from thrombus formation within the intertrabecular recesses. As it is a rare disease, evidence-based recommendations for preventing thromboembolic events in isolated left ventricular noncompaction have not been established.