Prognostic Factors For Functional Outcome in Patients with Mesencephalic Hemorrhage.

Introduction: Mesencephalic hemorrhage (MH) is a rare presentation of spontaneous intraparenchymal hemorrhage. This study aims to evaluate prognostic parameters of the MH outcome. Methods: We conducted an extensive search in the literature for cases with spontaneous, isolated mesencephalic hemorrhage. The study was conducted according to the statement of Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). Sixty-two eligible cases have been reported in the literature as proven by CT or MRI, and to these, we added six cases confirmed by MRI. The modified Rankin Scale (mRS) was dichotomized into two groups as the favorable outcome (FO; score, 0-2) and unfavorable outcome (UO; score, 3-6). Results: Of the 68 patients studied, 26 (38%) presented with normal consciousness, 22 (32%) with lethargy , and 20 (29%) with stupor or coma. There was no cause of hemorrhage in 26 (65%) patients with FO and 12 (43%) with UO (p=0.059). In univariate analyses, neither arteriovenous malformations (p=0.33) nor cavernomas (p=0.19) were associated with outcome. Multiple logistic regression analysis revealed that hypertension (OR, 51.22; CI95%, 1.92-1370.24; P=0.019), consciousness (OR, 133.54; CI95%, 1.61-1113.3; P=0.03), NIHSS at admission (OR, 57.23; CI95%, 2.87-1141.2; p=0.008), and ventrodorsal hemorrhage size (≥1 cm) (OR, 61.83; CI95%, 2.15-1779.2; p=0.016) were significantly associated with UO. Three months after stroke, 40 patients (59%) had FO, 28 (41%) had UO, and 8 (12%) died. Conclusion: These results suggest that ventrodorsal size of hemorrhage and clinical severity at stroke onset are possible predictors of functional outcome after mesencephalic hemorrhage.

Cognitive and Behavioral Disorders in Patients with Precuneal Infarcts.

OBJECTIVE: Ischemic stroke of the precuneal cortex (PC) alone is extremely rare. This study aimed to evaluate the clinical, neurocognitive, and behavioral characteristics of isolated PC infarcts. METHODS: We assessed neuropsychological and behavioral findings in 12 patients with isolated PC infarct among 3,800 patients with ischemic stroke. To determine the most frequently affected brain locus in patients, we first overlapped the ischemic area of patients with specific cognitive disorders and patients without specific cognitive disorders. Second, we compared both overlap maps using the "subtraction plot" function of MRIcroGL. RESULTS: Patients showed various types of cognitive disorders. All patients experienced more than 1 category of cognitive disorder, except for 2 patients with only 1 cognitive disorder. Lesion topographical analysis showed that damage within the anterior precuneal region might lead to consciousness disorders (25%), self-processing impairment (42%), visuospatial disorders (58%), and lesions in the posterior precuneal region caused episodic and semantic memory impairment (33%). The whole precuneus is involved in at least one body awareness disorder. The cause of stroke was cardioembolism in 5 patients (42%), large artery disease in 3 (25%), and unknown in 4 (33%). CONCLUSIONS: This study showed a wide variety of neuropsychological and behavioral disorders in patients with precuneal infarct. Future studies are needed to achieve a proper definition of the function of the precuneus in relation to the extended cortical areas. PC region infarcts have been found to predict a source of embolism from the large arteries or heart.

Associations Between Neuroanatomic Patterns of Cerebral Infarctions and Vascular Dementia.

OBJECTIVE: A history of multiple cerebral infarctions is generally regarded as an important risk factor for vascular dementia. The authors examined the risk of vascular dementia in patients with multiple acute ischemic lesions. METHODS: The authors conducted a hospital-based prospective study of 11,200 patients with first-time stroke who underwent 1.5 or 3-T MRI and a global cognitive assessment. Univariate and multivariate logistic regression analyses estimated the risk of dementia associated with multiple lesions versus a single lesion. RESULTS: Having multiple lesions, compared with having a single lesion, was significantly associated with dementia in patients with stroke (odds ratio=5.83, 95% CI=5.08, 6.70; p<0.001). The apoliproprotein ε4 allele was more frequent in patients with multiple lesions than in those with a single lesion (odds ratio=1.70, 95% CI=1.39, 2.07; p<0.001). Severe leukoaraiosis (odds ratio=15.77, 95% CI=8.38, 29.68; p<0.001) and microbleedings (odds ratio=1.31, 95% CI=1.06, 1.63; p<0.01) were strong confounders for dementia in the multivariate analysis. Multiple logistic regression analysis showed that multiple lesions in one hemisphere versus a single lesion (odds ratio=2.14, 95% CI=1.83, 2.51; p<0.001), involvement of strategic regions (odds ratio=4.73, 95% CI=4.07, 5.49; p<0.001), and stroke lesion volume (odds ratio=1.31, 95% CI=1.03, 1.66; p=0.03) were significantly associated with dementia. There was a preponderance of lesions on the left side in patients with dementia (odds ratio=2.56, 95% CI=2.11, 3.11; p<0.001). CONCLUSIONS: Multiple spontaneous anterior or posterior circulation lesions after stroke increase a patient's risk of developing dementia. Recognition of multiple ischemic lesions after stroke may allow targeted rapid therapeutic interventions to prevent subsequent cognitive deterioration.

Predictors of Outcome in Patients with Medullary Hemorrhage.

BACKGROUND: Isolated medullary hemorrhage (MH) is an uncommon presentation of spontaneous intraparenchymal hemorrhage. The relationship between MH and neurological outcome is not well known. This study aims to assess predictive parameters for the outcome of medullary hemorrhage. METHODS: We conducted an extensive search of the literature for cases with spontaneous, isolated MH. The study was conducted according to the statement of Preferred Reporting Items for Systematic Reviews and Meta Analysis (PRISMA). Forty-three cases diagnosed by CT or MRI have been reported in the literature, to which we add three confirmed by MRI. The ventrodorsal size of hemorrhage was taken into account as a parameter of outcome. Early neurologic deterioration (END) was defined as an incremental increase in the National Institutes of Health Stroke Scale score by ≥1 point in motor power, or ≥2 points in the total score within the first week after admission. Modified Rankin Score (mRS) 0-2 was presumed as favorable outcome (FO) and mRS 3-6 score as unfavorable outcome (UO) at discharge and at 3 months after stroke. RESULTS: We enrolled 46 patients, and 17 (37%) patients were diagnosed with END. The cause of medullary hemorrhage was mostly vascular malformations, including cavernous malformation (33%) and arteriovenous malformation (11%). In univariate analyses, neither arteriovenous malformations (OR, 1.04; 95%CI, 0.10-10.53; P = 0.68) nor cavernomas (OR, 1.04; 95%CI, 0.22-4.89; P = 0.62) were associated with UO. Acute respiratory distress syndrome was higher in patients with UO group (44%) compared to those with FO group (16%), but this difference did not reach to a significant level (OR, 4.13; 95%CI, 0.85-20.04; P = 0.09). The diameter of hemorrhage was significantly larger (≥1 cm) in patients with UO compared to those with FO (OR, 16.67; 95%CI, 1.87-148.89; P = 0.003). Three months after stroke, 37 patients (80%) had FO and 9 (19.5%) had UO, and 5 (11%) died. Multiple logistic regression analysis using predetermined variables found to be significant in univariate analyses (END, consciousness disturbance at admission, hemorrhage size, and hypertension) showed that END at stroke onset was significantly associated with UO (OR, 4.97; CI95%, 1.13-21.94; P = 0.03). CONCLUSIONS: These results suggest that the END is a predictor for UO in patients with medullary hemorrhage. The extent of the medullary hemorrhage along the conduction tract may contribute to deterioration.

Cingulate infarction: A neuropsychological and neuroimaging study.

BACKGROUND AND PURPOSE: Ischemic lesions rarely affect the cingulate cortex (CC) in isolation, restricting human lesion/behavioural change correlational analysis. The aim of this study was to determine clinical, neuropsychological and neuroimaging features of isolated cingulate infarcts. METHODS: We studied, 3800 patients with first-ever ischemic stroke included in our Stroke Registry between 2012 and 2018. Among them we studied 7 patients with an acute isolated cingulate infarct confirmed by MRI. RESULTS: Among all patients, 7 patients (0.01%) showed ischemic lesions in the territory of cingulate cortex territory, allowing us to delineate 2 substantial distributions; (1) Anterior cingulate cortex (ACC) infarction (4 patients [57%]) was presented low vigilance level with apathy, mutism, deficits in executive function, attention, and disturbances of working, episodic and verbal memory; (2) Posterior cingulate cortex (PCC) infarction (3 patients [43%]) developed topographic disorientation, visual memory deficit and affective-emotional behavioural changes. CONCLUSIONS: According rarely seen CC infarction events, we suggest that anterior and posterior CC are functionally separated and differences in clinical presentation are explained by considering; ACC plays a role in executive functions, episodic and working memory, set maintenance, and PCC is focused on spatial and verbal attention, and memory system. We considered that different patterns of cingulate infarcts are the result of variation in cingulate arterial supply or suggest a source of embolism.

Testing Shoulder Pain Mapping.

OBJECTIVE: A previous study on shoulder pain mapping showed specific pain patterns for common shoulder disorders. This study aimed to test those patterns for accuracy, modify shoulder pain mapping as needed, and observe their reliability and validity. METHODS: This prospective study used a two-step process and was undertaken to determine its potential utility in daily practice. New shoulder pain patients marked their pain, its character and severity, on a custom-made mapping form. Then a researcher blinded to the diagnoses gave their estimations on the basis of previously established maps, and they were correlated with final diagnoses. Subsequently, a guide table was developed on how to read the maps, and intertester reliability was performed with three independent testers. RESULTS: The study included 194 patients, and the overall accuracy for estimations was between 45.4% and 49.5%. The sensitivity was high, especially for instability, followed by calcific tendinitis, acromio-calvicular joint pathology, and impingement. The intertester reliability showed clinically significant agreement between testers for both disease groups (κ = 0.70) and individual disorders (κ = 0.52). CONCLUSIONS: This was a unique and extensive study on shoulder pain mapping. The study concluded that pain mapping could be a useful adjunct to the clinical assessment of patients with shoulder pain and can be used in the primary care setting as well as secondary care and for research.

Myoclonic status epilepticus in six patients without epilepsy.

Myoclonic status epilepticus (MSE) is defined as prolonged period of myoclonic jerks that are correlated with epileptiform discharges on EEG. We here describe clinical features and video-EEG records of six adult patients with MSE who did not have a prior diagnosis of epilepsy. In four out of six patients, MSE was precipitated by drugs. Two out of four patients had chronic renal disease and received beta lactam group antibiotics. Two other patients, who described chronic pain, developed MSE while taking pregabalin. One patient who had dementia and family history of juvenile myoclonic epilepsy (JME) developed MSE one month after quetiapine was introduced. Another patient, who had a recent ischemic stroke, developed MSE due to an unknown reason. In these last two patients, an immediate triggering factor was not evident. Myoclonic status epilepticus ceased in five out of six patients after withdrawal of the drugs and/or intravenous antiepileptic treatment. Myoclonic status epilepticus is a rare event in patients without epilepsy. A correct diagnosis and prompt drug discontinuation may reverse this severe and life-threatening condition.