Differences in clinical and biological factors between patients with PFO-related stroke and patients with PFO and no cerebral vascular events.

Background: While stroke is one of the most dissected topics in neurology, the primary prevention of PFO-related stroke in young patients is still an unaddressed subject. We present a study concerning clinical, demographic, and laboratory factors associated with stroke and transient ischemic attack in patients with patent foramen ovale (PFO), as well as comparing PFO-patients with and without cerebrovascular ischemic events (CVEs). Patients and methods: Consecutive patients with PFO-associated CVEs were included in the study; control group was selected from patients with a PFO and no history of stroke. All participants underwent peripheral routine blood analyses, as well as, on treating physician's recommendations, screening for thrombophilia. Results: Ninety-five patients with CVEs and 41 controls were included. Females had a significantly lower risk of CVEs than males (p = 0.04). PFO size was similar between patients and controls. Patients with CVEs had more often hypertension (n = 33, 34.7%), p = 0.007. No significant differences were found between the two groups with regard to routine laboratory tests and thrombophilia status. Hypertension and gender were identified in a binomial logistic regression model as independent predictors for CVEs, but with an area under the ROC curve of 0.531, suggesting a very poor level of discrimination between the two groups. Discussion and conclusions: There is little difference between patients with PFO with and without CVEs in terms of PFO size and routine laboratory analyses. While still a controversial topic in the specialty literature, classic first-level thrombophilic mutations are not a risk factor for stroke in patients with PFO. Hypertension and male gender were identified as factors associated with a higher risk of stroke in the setting of PFO.

Posterior reversible encephalopathy syndrome - A pathology that should not be overlooked in the era of COVID-19.

BACKGROUND AND OBJECTIVES: Severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) that causes Coronavirus Disease 2019 (COVID-19) may determine a series of neurological complications directly, by invasion of the nervous system or indirectly, secondary to systemic organ failure. Posterior reversible encephalopathy syndrome (PRES) represents a clinical and radiological neurological entity involving predominantly the occipital lobes. PRES was observed in patients receiving cytotoxic drugs, patients suffering from infectious diseases and sepsis, hypertensive emergencies and eclampsia, renal or autoimmune diseases. As more infectious SARS-COV-2 variants are now dominant in most of the Europe, an increasing number of patients is presenting to the Emergency Department. MATERIALS AND METHODS: Case report of a 38-year-old patient, with previous exposure to SARS-COV-2 presented to the Emergency Department (ED) with generalized tonic-clonic seizures, dyspnea, cortical blindness and aphasia. The patient had been exhibiting fever, cough and shortness of breath in the previous 10 days. He had no relevant medical history and was receiving antibiotics and corticosteroids as prescribed by his general practitioner. RESULTS: Laboratory findings together with the thoracic computed tomography scan were consistent with the diagnosis of severe SARS-COV-2 pneumonia. The cerebral MRI scans showed bilateral T2-weighted/FLAIR hyperintensities that were suggestive for PRES. The patient was diagnosed with COVID-19 complicated with PRES. He received adequate treatment and the symptoms resolved in 48 h. CONCLUSIONS: This is a rare and interesting case of a patient with PRES and COVID-19 as underlying pathology, in whom rapid diagnosis in the ED and early initiation of appropriate treatment led to full recovery. Immediate extensive work-up in patients with COVID-19 and neurological symptoms proves to be paramount for best outcome. To our knowledge this is the first case of PRES described in a patient with Delta variant of SARS-COV-2.

Low Fluctuation of Symptoms May Delay Diagnosis of Myasthenia Gravis: A Case Series.

INTRODUCTION: Myasthenia gravis is an autoimmune disorder affecting neuromuscular transmission, and its hallmark is fluctuating muscular weakness affecting the ocular, bulbar, respiratory, or limb muscles. Our objective is to highlight the difficulties encountered in diagnosing this disorder in patients lacking this characteristic phenomenon. METHODS: Three cases of patients presenting with progressive weakness of bulbar and ocular muscles, in whom a lack of fluctuation delayed the diagnosis of myasthenia gravis, are described. RESULTS: Amyotrophic lateral sclerosis was considered in two of the patients, while cavernous sinus thrombosis was initially diagnosed in the third. Electrodiagnostic, pharmacologic, and serologic testing ultimately established the diagnosis of myasthenia gravis. CONCLUSION: While the typical clinical pattern of myasthenia gravis is well known and easily recognizable, there are cases when the diagnosis, and thus the treatment, is delayed because of low or absent fluctuation of symptoms. The acknowledgment of this probably underestimated presentation is important for expeditious management.

Moyamoya-like vasculopathy associated to MYH9-related thrombocytopenia manifested by multiple cerebral ischemic lesions: a case report.

BACKGROUND: Moyamoya-like vasculopathy (MMV) and myosin heavy chain 9-related platelet disorders (MYH9-RPDs) or macrothrombocitopenias are rare syndromes. Their association is even more infrequent. CASE PRESENTATION: A 29-year-old female with history of MYH9-RPD, presented to our department for episodes suggesting transient ischemic attacks. Based on the imaging studies that revealed multiple ischemic lesions and stenoses of both distal internal carotid arteries and the arteries of the circle of Willis, the diagnosis of MMV was established. The treatment with Verapamil was initiated, leading to symptom remission. Two months later, the patient presented one episode of dysarthria, followed by involuntary movements of the right upper limb, few days later. Long-term electroencephalogram monitoring depicted epileptiform abnormalities. Resolution of symptoms was obtained after increasing the dose of Verapamil, and initiating Levetiracetam. CONCLUSIONS: This is an interesting case of a patient with two rare pathologies, who presented with cerebral ischemic strokes. To our knowledge there are few cases described in the literature presenting with cerebral hemorrhagic events but none of them with multiple cerebral ischemic lesions. As these cases are very rare, it is important to gather evidence regarding the best approach and treatment strategy.

Internal Carotid Artery Dissection - A Case for Antithrombotic Therapy in the Era of (Minimally) Invasive Procedures.

Objectives: Carotid artery dissection represents a common cause of stroke among people aged 30-45. We present two clinical cases and a review of the literature concerning the management of internal carotid artery dissections (ICADs). Materials and methods: The two patients are a 54-year-old male and a 40-year-old female. The first patient presented to our Neurology Department for one-week-old intense occipital headache. His clinical examination revealed left-sided miosis and upper eyelid ptosis. He underwent cerebral-cervical computed tomography (CT) and computed tomography angiography (CTA) scans and the latter revealed hemodynamically significant narrowing of both ICAs (right C1-C5 and left C1-C2 segments). Transcranial Doppler ultrasonography and Doppler ultrasonography (DUS) of the cervical-cerebral arteries showed right ICA occlusion at its origin (dissection fold and intraluminal thrombosis). Cervical magnetic resonance imaging (MRI) and time-of-flight magnetic resonance angiography (MRA) revealed a semilunar-shaped T2-weighted hypersignal present in the walls of the C1-C5 segments of the right ICA and of the C1-C2 segments of the left ICA, with bilaterally reduced intraluminal flow (right more than left). These findings indicated the presence of bilateral ICA intramural hematomas caused by subacute bilateral ICAD. The second patient presented to our Neurology Department for recurrent episodes of headache and lateral cervical pain on both sides. She underwent transcranial DUS and DUS of the cervicalcerebral arteries. They revealed right ICAD fold in its upper cervical segments. The CTA scan of the supra-aortic trunks showed hemodynamically significant narrowing with subsequent diminished blood flow in the upper cervical segments of right ICA. The patient was diagnosed with right ICAD. Results:Both patients were treated using antiplatelet therapy for primary prevention of ischaemic events. Follow-up at seven months and at six months, respectively, by means of CTA of the supra-aortic trunks or MRA of the cervical region, revealed the restoration of arterial patency with subsequent normal blood flow in both cases. Conclusions: The long-term outcomes of ICADs should be kept in mind when assigning medical or endovascular management on a case-by-case basis. Antiplatelet or anticoagulant therapy is a safe and effective first-line strategy in such patients, especially in cases that do not warrant particular management.