Herpes Zoster Optic Neuritis: A Catastrophe of a Disease.

Isolated herpes zoster optic neuritis is a rare sequelae of herpes zoster ophthalmicus (HZO). It can occur in the acute phase of HZO, or as post-herpetic complications. We report a case of a young patient with poorly controlled diabetes who developed herpes zoster optic neuritis one month after the initial skin manifestation despite completing a two-week course of oral acyclovir 800 mg five times a day. He complained of a five-day history of sudden onset, painless left eye blurring of vision. His vision over the left eye was no light perception with the presence of a left relative afferent pupillary defect. Fundus examination of the left eye revealed a swollen optic disc. Magnetic resonance imaging showed minimal fat streakiness over the left orbit. He was treated with one week of intravenous methylprednisolone 1 g/day, followed by a tapering dose of oral prednisolone (1 mg/kg/day) together with oral acyclovir 800 mg five times a day for another week. His visual acuity remained poor with a slight improvement in vision to hand motion.

The Spectrum of Vessel Wall Imaging (VWI) Findings in COVID-19-Associated Neurological Syndromes: A Review.

Since the start of the pandemic, there have been extensive studies from all over the world reporting on coronavirus disease 2019 (COVID-19)-associated neurological syndromes. Although initially thought of as primarily a respiratory pathogen, it became increasingly clear that the virus does have other systemic manifestations, including on the neurological system. Since then, the discovery of the many neuroimaging features of COVID-19-associated neurological syndromes have puzzled researchers and physicians in terms of interpretation, and how best to manage these findings to benefit patients. We sought to review the neuroimaging findings of COVID-19-associated neurological syndromes, particularly the vessel wall imaging (VWI) features, in the hope of finding a common feature that would better guide physicians in terms of further management of this group of patients. We will also look into the potential pitfalls of interpreting the VWI findings in these patients.

Establishing a hyperacute stroke service during the COVID-19 pandemic: our institution's one year experience.

BACKGROUND AND AIMS: The corononavirus 2019 (COVID-19) pandemic resulted in modifications in the workflow and redistribution of human resources, causing challenges in setting up of an acute stroke service. We would like to share our preliminary outcome amid this pandemic, to determine if the implementation of COVID-19 standard operating procedures (SOPs) affected the delivery of our hyperacute stroke service. METHODS: We retrospectively analyzed one-year data from our stroke registry that began with the establishment of our hyperacute stroke service at Universiti Putra Malaysia Teaching Hospital from April 2020 until May 2021. RESULTS: Setting up acute stroke services during the pandemic with constrained manpower and implementation of COVID-19 SOPs, was challenging. There was a significant dip of stroke admission from April to June 2020 due to the Movement Control Order (MCO) implemented by the government to curb the spread of COVID-19. However, the numbers of stroke admission steadily rose approaching 2021, after the implementation of recovery MCO. We managed to treat 75 patients with hyperacute stroke interventions i.e. intravenous thrombolysis (IVT), mechanical thrombectomy (MT) or both. Despite implementing COVID-19 SOPs and using magnetic resonance imaging (MRI) as our first line acute stroke imaging modality, clinical outcomes in our cohort were encouraging; almost 40% of patients who underwent hyperacute stroke treatment had early neurological recovery (ENR), and only 33% of patients had early neurological stability (ENS). In addition, we were able to maintain our door-to-imaging (DTI) and door-to-needle (DTN) time in line with international recommendations. CONCLUSIONS: Our data reflects that COVID-19 SOPs did not deter successful delivery of hyperacute stroke services in our center. However, bigger and multi center studies are required to support our findings.

The prominent hypointense vessel sign on susceptibility-weighted imaging (SWI) as a potential imaging biomarker for poor clinical outcome in acute ischemic stroke (AIS).

Susceptibility-weighted imaging (SWI) is a relatively new magnetic resonance imaging (MRI) technique used in the workup and diagnosis of brain pathologies. In the context of acute ischemic stroke (AIS), it is increasingly becoming useful in the diagnosis, treatment, and further management of these patients. An elderly man with metabolic syndrome presented to us with an acute onset of right sided body weakness and aphasia. Urgent imaging via MRI noted a left middle cerebral artery (MCA) occlusion. Diffusion-weighted imaging (DWI)/fluid attenuated inversion recovery (FLAIR) mismatch was noted with an acute infarct involving the left MCA territory; hence, treatment with intravenous (IV) thrombolysis was administered. On SWI, the prominent hypointense vessel sign was noted. Recanalization of the occluded left MCA was seen on diagnostic cerebral angiography post IV thrombolysis, however, the patient was noted to have early neurological deterioration (END) and poor early stage clinical outcome, despite repeat MRI showing recanalization of the left MCA occlusion and reversal of the prominent hypointense vessel sign on SWI. Presence of the prominent hypointense vessel sign on SWI in AIS patients is associated with poor clinical outcome, unsuccessful recanalization rates, END, poor early stage clinical outcome, and infarct core progression. Some studies have shown an association between this imaging sign and poor collateral circulation status. Therefore, this imaging sign could potentially prove to be a useful imaging biomarker. However, more studies are needed to validate this theory.

The Utility of Vessel Wall Imaging in the Postulation of Acute Ischemic Stroke With Spontaneous Recanalization Pathophysiology.

ABSTRACT: Recent advances in technology, particularly in the field of magnetic resonance imaging, have brought forth new sequences, including vessel wall imaging (VWI). Traditionally, the workup for intracranial vascular pathology has always turned to luminal imaging using computed tomography angiography, magnetic resonance angiography, or digital subtraction angiography. Since its introduction, VWI has enabled researchers and practicing clinicians to better understand disease processes and manage patients to the best standard of care possible. Spontaneous recanalization in acute ischemic stroke (AIS) is a known but understudied phenomenon. Available literature has looked at this phenomenon and postulated the occurrence based on conventional cross-sectional imaging and angiography; however, objective evidence pointing to the occurrence of this phenomenon is scarce. We would like to share our experience using VWI in a patient who was clinically suspected to have a middle cerebral artery syndrome at onset, with resolution of the symptoms 3 hours after initial presentation. VWI showed vessel wall enhancement at the suspected vessel involved, with evidence of acute infarcts at the vascular territory supplied. A presumptive diagnosis of AIS with spontaneous recanalization was made. Our experience could potentially aid in the understanding of spontaneous recanalization in patients with AIS, particularly in the postulation of the pathophysiology.

Vessel wall imaging in COVID-19 associated carotid atherothrombosis and stroke: a case report and literature review.

COVID-19 associated neurological syndromes, including acute ischemic stroke, pose a challenge to treating physicians. The role of MRI in aiding diagnosis and further management is indispensable. The advent of new MRI sequences such as vessel wall imaging (VWI) allows an avenue in which these patients could be better investigated and treated. We describe our experience in managing a patient with COVID-19 associated atherothrombosis and stroke, focusing on the VWI imaging findings.

The middle cerebral artery (MCA) dot sign.

The middle cerebral artery (MCA) dot sign is an important radiological sign in patients presenting with acute ischemic stroke (AIS). If identified and intervened early, a good clinical outcome may be achieved.

Accidental Puncture of a Dialysis Catheter into the Brachiocephalic Trunk.

A 22-year-old male with underlying end-stage renal failure was referred to our center for a malpositioned dialysis catheter. Imaging showed the tip of the catheter to be placed in the brachiocephalic trunk; the patient was, however, asymptomatic. Surgical removal of the malpositioned catheter followed, with no postoperative complications.

Myelin oligodendrocyte glycoprotein-antibody (MOG-IgG) associated disease with centrally located long spinal cord lesion in a 14-month old child.

Myelin oligodendrocyte glycoprotein-antibodies (MOG-IgG) are associated with acquired inflammatory demyelinating syndromes, seen predominantly in children and young adults. The overlapping clinical and radiological features of the heterogenous spectrum of demyelinating central nervous system (CNS) diseases makes the detection of MOG-IgG antibodies important for prognosis and treatment decisions. Herein, we describe the occurrence of MOG-IgG associated disease presenting as acute disseminated encephalomyelitis (ADEM), with spinal MRI findings of centrally located long cord lesion in a 14-month old child.

Tuberculous Myelopathy Associated with Longitudinally Extensive Lesion: A Clinicoradiological Review of Reported Cases.

Acute transverse myelitis is an inflammatory disorder of the spinal cord in which there is no evidence of spinal cord compression. Longitudinally extensive transverse myelitis (LETM) is a specific subtype of acute transverse myelitis that usually affects three or more vertebral levels and produces marked neurological deficits. While the most-common cause of LETM is neuromyelitis optica or neuromyelitis optica spectrum disorder, there are rare cases of other causes mimicking this condition, including tuberculosis (TB). We sought to review the clinicoradiological features of TB myelopathy associated with longitudinally extensive lesion, which may mimic LETM, in the English literature. We searched the PubMed, Google Scholar, Web of Science, and Scopus databases for relevant articles using search terms including "longitudinally extensive transverse myelitis," "tuberculosis," "TB spinal cord," and various combinations of these expressions. Full-text papers were selected without limiting the publication year. We also examined the reference lists of key papers to identify further articles that are potentially relevant. We found 10 cases in 7 papers describing TB myelopathy associated with longitudinally extensive lesion. The demographics, clinical features, relevant cerebrospinal fluid findings, and radiological findings were compiled and summarized. TB myelopathy associated with longitudinally extensive lesion is very rare, with no documented prevalence. Early and accurate diagnosis is important since the condition is potentially treatable.

A case of anti-N-methyl-d-aspartate receptor encephalitis.

Anti-N-methyl-d-aspartate receptor encephalitis is characterized by the clinical manifestation of neuropsychiatric symptoms, predominantly affecting young adults, and frequently associated with neoplasms. It is the second most common cause of autoimmune and paraneoplastic encephalitis. Early diagnosis is often missed, as patients are commonly diagnosed with psychiatric illnesses and are treated with antipsychotics - which rarely gives complete resolution of symptoms. Herein, we discuss a patient with mixed clinical, imaging, electroencephalogram, and laboratory findings, with an eventual diagnosis of anti-N-methyl-d-aspartate receptor encephalitis requiring immunotherapy and operative intervention.

Development of pseudo-subarachnoid hemorrhage secondary to hypoxic-ischemic injury due to bleeding pulmonary arterio-venous malformation.

BACKGROUND: The computed tomography (CT) finding of a pseudo-subarachnoid hemorrhage (SAH) may lead the treating physician into a diagnostic dilemma. We present a case of a pseudo-SAH in a patient with post-resuscitative encephalopathy, secondary to a newly diagnosed bleeding pulmonary arterio-venous malformation (AVM). CASE PRESENTATION: A 19-year-old female presented acutely with massive hemoptysis. Cardiopulmonary resuscitation (CPR) followed, and the patient was subsequently intubated for airway protection with intensive care unit (ICU) admission. Urgent CT angiography of the thorax showed a bleeding pulmonary AVM, with evidence of hemothorax. Non-contrasted cranial CT initially revealed cerebral edema. Day 3 post admission, repeat cranial CT showed worsening cerebral edema, with evidence of pseudo-SAH. Patient passed away the next day. CONCLUSIONS: Pseudo-SAH, if present, carries a poor prognosis. It should be recognized as a potential CT finding in patients with severe cerebral edema, due to various causes. The diagnosis is vital, to avoid wrongful treatment institution, as well as determination of cause of death.

A case of metastatic adenocarcinoma from an unknown primary involving the aortic bifurcation.

Aortic malignant neoplasms are rare; these may be primary or secondary (metastatic). Increasing use of cross-sectional imaging has allowed better detection and diagnosis of these conditions. We encountered a young woman presenting with acute abdomen who was found on cross-sectional imaging to have a malignant tumor involving the aortic bifurcation. An en bloc excision of the tumor was performed, with distal aorta reconstruction using an aortoiliac Dacron graft; this was complicated with infection and graft occlusion, necessitating total removal and extra-anatomic bypass. A pathologic diagnosis of metastatic adenocarcinoma involving the aortic bifurcation, with an unknown primary, was made.

Dyke-Davidoff-Masson syndrome: a case report.

BACKGROUND: Dyke-Davidoff-Masson syndrome is a rare condition of unknown frequency resulting from brain injury due to a multitude of causes; especially in early life. Characteristics include cerebral hemiatrophy/hypoplasia, contralateral hemiparesis, seizures, and compensatory osseous hypertrophy. CASE PRESENTATION: We present a case of a 13-year-old girl who initially presented with headaches, followed by episodic complex-partial seizures; which was controlled via medication. She also had right sided hemiparesis. Computed tomography (CT) showed evidence of left parieto-temporal infarct with cerebral atrophy. Complementary magnetic resonance imaging (MRI) did not reveal additional information. Workup for young stroke was negative. Upon further evaluation by Neuroradiology, features suggesting Dyke-Davidoff-Masson syndrome were confirmed. Patient has been under Neurology follow up since. CONCLUSIONS: Due to its rarity, Dyke-Davidoff-Masson syndrome may easily be missed by the majority of treating clinicians. Knowledge of its features on imaging enables timely and accurate diagnosis - allowing appropriate management.

Supraclinoid direct carotid-cavernous sinus fistula.

Carotid-cavernous fistulas (CCFs) are vascular shunts between the carotid arterial system with direct drainage into the cerebral venous system, mainly to the cavernous sinus. Direct CCF is a well-recognised complication following head trauma. Classically in direct or traumatic CCF, vessel wall tear occurs at the cavernous segment of the internal carotid artery, between the fixed and free segment. Tears at the supraclinoid segment are rare. We report a case of an internal carotid artery supraclinoid segment pseudoaneurysm, with a direct communication with the cavernous sinus, draining into the superior ophthalmic vein.