Spontaneous limb movements and posturing secondary to acute basilar artery occlusion: a potentially devastating seizure mimic.

Basilar artery occlusion is a devastating but treatable form of ischaemic stroke with high morbidity and mortality rates. The diagnosis is often challenging due to considerable heterogeneity of clinical signs and symptoms. We report a case of an acute basilar artery occlusion presenting with decreased level of consciousness associated with rhythmic tonic movements of the four extremities, mimicking seizure activity. The patient was treated with intravenous thrombolysis and subsequently gained good recovery. Awareness of this entity is required to recognise this potentially treatable, but otherwise devastating seizure mimic.

Uveitis associated with Primary Angiitis of the Central Nervous System.

BACKGROUND: In Primary Angiitis of the Central Nervous System (PACNS), disease is typically limited to the brain and spinal cord although other organs may be affected. Uveitis is occasionally seen in systemic vasculitides but is not a recognized manifestation of PACNS. We describe two patients who developed PACNS following the onset of uveitis. CASE DESCRIPTIONS: Case 1--a 47-year-old male suffered multiple TIAs and left pontine stroke shortly after two episodes of diffuse uveitis. A cerbral angiogram demonstrated multiple caliber changes within several intracranial vessels. Cyclophosphamide was added after his stroke occurred during pulse methylprednisolone therapy. Case 2--a 35-year-old male suffered a spinal cord TIA followed by hemispheric and brainstem infarctions two months after an episode of uveitis and Bell's palsy treated with oral prednisone. A cerebral angiogram demonstrated multiple caliber changes within several intracranial vessels. He was successfully treated with oral prednisone and cyclophosphamide. CONCLUSIONS: Uveitis should be considered a recognized feature of PACNS. Combination immunosuppressive therapy with prednisone and cyclophosphamide may be necessary for successful treatment.

Reduction in IV t-PA door to needle times using an Acute Stroke Triage Pathway.

OBJECTIVE: To determine the effectiveness of an Acute Stroke Triage Pathway in reducing door to needle times in acute stroke treatment with IV t-PA. BACKGROUND: A previous study at our tertiary referral centre, examining IV t-PA door to needle times, was completed in 2000. The median door to needle time was beyond the recommended National Institute for Neurological Disorders and Stroke (NINDS) standard of 60 minutes. In November 2001, an Acute Stroke Triage Pathway was introduced in the emergency room (ER) to address this issue. The goal of this pathway was to rapidly identify patients eligible for treatment for IV t-PA, so that CT scans and lab studies could be arranged immediately upon ER arrival. Our hypothesis was that the Triage Pathway would shorten door to CT and door to needle times. DESIGN/METHODS: Using retrospective data, pre (n=87) and post (n=47) triage pathway times were compared. The door to CT time was reduced by 11 minutes (p=0.015) and door to needle time was reduced by 18 minutes (p=0.0036) in a subgroup of patients that presented directly to our hospital. CONCLUSIONS: These results indicate that the Acute Stroke Triage Pathway is effective in reducing Door to CT and Door to Needle Times in patients presenting directly to our ER. However, a majority of treatment times were still beyond NINDS recommendations. Stroke Centers require periodic review of their efficiency to ensure that target times are being obtained and may benefit from the use of an Acute Stroke Triage Pathway.

Resolution of spontaneous spinal epidural hematoma without surgery: report of two cases.

STUDY DESIGN: Case report. OBJECTIVE: To report two cases of spontaneous spinal epidural hematoma that completely resolved, clinically and radiographically, without surgical treatment. SUMMARY OF BACKGROUND DATA: The treatment of spinal epidural hematoma is usually surgical. Spontaneous spinal epidural hematoma is an uncommon phenomenon and may be of uncertain cause. METHODS: One patient with acute onset of complete quadriplegia and another with complete paraplegia caused by spontaneous spinal epidural hematoma were treated without surgery. RESULTS: Both patients recovered nearly completely with respect to their neurologic function at 3-month follow-up. No source of hematoma was ever identified. CONCLUSIONS: Spontaneous spinal epidural hematoma should be considered in the differential diagnosis of sudden onset of spinal cord compression in association with back pain. Patients initially presenting with severe neurologic dysfunction are potential candidates for conservative management if they demonstrate rapid and progressive improvement in neurologic function. Patients treated in this manner can have nearly complete restoration of function.

Yield of diffusion-weighted MRI for detection of potentially relevant findings in stroke patients.

OBJECTIVE: To determine whether diffusion-weighted imaging (DWI) could identify potentially clinically relevant findings in patients presenting more than 6 hours after stroke onset when compared with conventional MRI. METHODS: MRI with both conventional (T2 and proton density images) and echoplanar imaging (DWI and apparent diffusion coefficient maps) was performed 6 to 48 hours after symptom onset (mean, 27 hours) in 40 consecutive patients with acute stroke. All acute lesions were identified first on conventional images, then on DWI, by a neuroradiologist who was provided with the suspected lesion location, based on a neurologist's examination before imaging. Abnormalities were rated as potentially clinically relevant if they were detected only on DWI and 1) confirmed the acute symptomatic lesion to be in a different vascular territory than suspected clinically, 2) revealed multiple lesions in different vascular territories suggestive of a proximal source of embolism, or 3) clarified that a lesion, thought to be acute on conventional imaging, was not acute. RESULTS: The initial clinical impression of lesion localization was incorrect in 12 patients (30%). Clinically significant findings were detected by DWI alone in 19 patients (48%). DWI demonstrated the symptomatic lesion in a different vascular territory than suspected clinically or by conventional MRI in 7 patients (18%) and showed acute lesions in multiple vascular distributions in 5 patients (13%). In 8 patients (20%), DWI clarified that lesions thought to be acute on conventional MRI were actually old. CONCLUSION: In patients imaged 6 to 48 hours after stroke onset, DWI frequently provided potentially clinically relevant findings that were not apparent on conventional MRI.

Intravenous tissue plasminogen activator for acute ischemic stroke: A Canadian hospital's experience.

BACKGROUND AND PURPOSE: In the United States, tissue plasminogen activator (tPA) was approved for treatment of acute ischemic stroke in 1996. Its use has only recently been approved in Canada. We sought to evaluate the safety, feasibility, and efficacy of treatment in a Canadian hospital setting. METHODS: A combined retrospective and prospective review is presented of 46 consecutive patients treated with intravenous tPA at our hospital with a treatment protocol similar to that of the National Institute of Neurological Disorders and Stroke (NINDS) trial. RESULTS: Symptomatic intracranial hemorrhage at 36 hours occurred in 1 patient (2.2%). The median time to treat was 165 minutes, with a median "door-to-needle" time of 84 minutes. Compared with patients presenting initially at our hospital, patients transferred from another institution for tPA therapy were treated closer to the 3-hour time window (mean 173 versus 148 minutes, P:<0.001) but had a shorter door-to-needle time (43 versus 102 minutes, P:<0.001). For every 10 minutes closer to the 3-hour time window that any patient arrived at the hospital, 7 minutes was saved in the door-to-needle time (correlation coefficient 0.9, P:<0.001). Patient outcome did not differ from that in the NINDS trial (P:>0.75). CONCLUSIONS: Our safety and patient outcome data compare favorably with NINDS and Phase IV data. Although a 3-hour treatment window was feasible, the median door-to-needle time lengthened as more treatment time was available and the door-to-needle time was beyond recommended standards. This review has prompted changes in our community to improve treatment efficiency.

Basilar artery stenosis: clinical and neuroradiographic features.

INTRODUCTION: Although basilar artery stenosis (BAS) is an important cause of posterior circulation stroke, few reports detail the clinical and neuroradiological features of patients with BAS. METHODS: A retrospective review of symptomatic BAS patients who were evaluated by our Stroke Center. RESULTS: Twenty-eight patients were followed-up for a median of 16 months. Transient ischemic attacks (TIAs) specific for posterior circulation involvement were common (12/19 patients with TIA), were often multiple, and frequently preceded a posterior circulation stroke. The proximal (13/28) and mid (10/28) basilar arteries were the most common sites of stenosis. Brain infarction most often affected the pons, but also frequently involved the cerebellum and thalamus. Concomitant vertebral artery disease was prevalent (12/18 patients who underwent conventional cerebral angiography). Stroke mechanisms included artery to artery embolus, basilar branch disease, and hypoperfusion. The same-territory recurrent stroke rate was 8.2% per year. Most patients in the series were treated with warfarin. No patients suffered a recurrent stroke while on a therapeutic dose of warfarin (international normalized ratio [INR], 2.0 to 3.0). Angioplasty was performed in 6 patients. CONCLUSIONS: The same-territory stroke recurrence rate was 8.2% per year. Warfarin (INR, 2.0 to 3.0) appeared to be effective in preventing recurrent strokes. Angioplasty of the basilar artery was technically feasible. Symptomatic BAS typically affected the proximal and mid-basilar artery and most often caused infarction in the pons. The mechanisms for stroke were heterogeneous. TIAs frequently preceded a posterior circulation stroke.

Headache with neurological deficits and CSF lymphocytosis: A transient ischemic attack mimic.

Headache with neurological deficits and cerebrospinal fluid (CSF) lymphocytosis (HaNDL) is a benign condition with a transient ischemic attack (TIA)-like presentation. It is a disease of young adults that is characterized by headache, transient focal neurological symptoms, and lymphocytic pleocytosis. The onset of neurological symptoms after cerebral angiography in patients with this disease has occasionally been reported. The authors present the case of a 28-year-old man with episodes of left-sided numbness and weakness associated with headache. He underwent cerebral angiography as part of his evaluation, after which he experienced an episode of right hemiplegia and aphasia. A subsequent magnetic resonance image (MRI) revealed two small new infarcts in the left parietal cortex. A diagnosis of HaNDL was made based mainly on clinical symptoms and CSF analysis. The symptoms resolved with conservative therapy. HaNDL is a benign condition that can present with symptoms similar to a TIA. Although HaNDL remains a diagnosis of exclusion, caution is required when considering cerebral angiography in the evaluation of patients with a HaNDL-like syndrome, because these patients seem prone to developing neurological symptoms after angiography.

Angiographically defined primary angiitis of the CNS: is it really benign?

BACKGROUND: Primary angiitis of the CNS (PACNS) is a diagnostically challenging disorder. In patients whose diagnosis is ascertained solely by cerebral angiography without histologic verification, a benign monophasic clinical course with favorable response to a brief course of immunosuppressive therapy is often reported. METHODS: We performed a retrospective review of patients with PACNS seen at the Stanford Stroke Center. RESULTS: Patients were followed for a median of 27.5 months. Acute focal deficits (9 of 10) and headache (3 of 10) were the most frequent presenting symptoms. Significant recurrent neurologic symptoms occurred in 5 of 10 patients before the initiation of immunosuppressive treatment. Three of six patients had recurrent symptoms during prednisone therapy alone, whereas only one of seven patients had recurrent symptoms while receiving combination immunosuppressive therapy. None had recurrent stroke during immunosuppressive treatment. Dynamic arterial changes were seen in four of five patients who underwent follow-up angiography that often, but not always, correlated with disease activity. CONCLUSIONS: Patients with angiographically defined PACNS frequently did not have a benign outcome or monophasic course. Repeat angiography was useful in supporting the diagnosis of PACNS, but did not always correlate with disease activity. A prospective multicenter collaborative effort is required to better define the clinical course and optimal treatment of PACNS.

Encephalopathy complicating Henoch-Schönlein purpura: reversible MRI changes.

A 10-year-old boy with Henoch-Schönlein purpura complicated by encephalopathy, transient cortical blindness, and a secondary generalized seizure is reported. Reversible changes in the posterior white and gray matter were seen on magnetic resonance imaging. Our patient illustrates uncommon neurologic manifestations of Henoch-Schönlein purpura. The nature and location of the lesions and the normalization of the patient's magnetic resonance imaging is consistent with a posterior predominant parieto-occipital encephalopathy and suggests that cerebral edema from blood-brain barrier breakdown may play a central role in the pathophysiology of the central nervous system symptomatology in some patients.

Progressive facial hemiatrophy: abnormality of intracranial vasculature.

Progressive facial hemiatrophy (PFH) or Parry-Romberg syndrome is associated with ipsilateral brain lesions and neurologic symptoms. We describe a 35-year-old man with PFH and frequent hemiplegic migraine. On cerebral angiography, reversible vessel caliber changes were seen within the symptomatic hemisphere. An abnormality of the intracranial vasculature may be present in some patients with PFH and neurologic manifestations.

Diffusion-weighted MRI in transient global amnesia precipitated by cerebral angiography.

BACKGROUND: Transient global amnesia is a well-described complication of cerebral angiography. Speculation about the pathophysiology exists but is as yet unsubstantiated. Diffusion-weighted MRI is a new imaging technique that is very sensitive in detecting acute ischemia. Its use in the evaluation of transient amnesia precipitated by cerebral angiography has not previously been reported. CASE DESCRIPTION: A 44-year-old man underwent posterior circulation cerebral angiography for the investigation of episodic vertigo. Shortly after completion of the procedure, he was noted to have symptoms of transient global amnesia. Diffusion-weighted MRI at 6 and 44 hours after the procedure demonstrated increased signal in the right hippocampus and other areas within the posterior circulation bilaterally consistent with ischemia from emboli. Abnormalities on conventional MRI images performed at the same time points were noted only in retrospect. A follow-up MRI at 2 months was normal. CONCLUSIONS: Ischemia from cerebral emboli may cause transient global amnesia precipitated by cerebral angiography. Diffusion-weighted MRI may be useful in defining the pathophysiology.