Three-Territory DWI Acute Infarcts: Diagnostic Value in Cancer-Associated Hypercoagulation Stroke (Trousseau Syndrome).

BACKGROUND AND PURPOSE: DWI infarcts involving the bilateral anterior and posterior circulation suggest an embolic etiology. In the absence of an identifiable embolic source, we analyzed DWI lesions involving these 3 cerebral territories to determine the diagnostic value for ischemic infarction caused by cancer-associated hypercoagulation. MATERIALS AND METHODS: A retrospective analysis of all brain MR imaging studies at our institution from July 2014 to June 2015 was conducted, yielding 4075 studies. Of those, 17% (n = 709) contained the terms "restricted-diffusion" plus either "numerous," "innumerable," "multiple," or "bilateral." Of these 709 reports, 6% (n = 41) of DWI lesions involving 3 or more vascular territories of the bilateral anterior and posterior circulation were analyzed. RESULTS: Of the 41 patients, 19 separate etiologies were identified, the most frequent being malignancy-related infarctions (22% [n = 9]) and hypoxic-ischemic injury (12% [n = 5]). Only 2 patients had an indeterminate etiology. The most frequent etiology of infarctions not suspected clinically or radiographically was malignancy (P < .001). Infarctions of malignancy had a characteristic appearance, being nonenhancing, nonring-appearing clusters or single areas of restricted diffusion of 0.5-2 cm with a peripheral location or larger vascular territories, uncommonly in a watershed distribution, and with absence of diffuse cortical ribbon or deep gray nuclei involvement. CONCLUSIONS: Approximately 1 in 5 ischemic infarcts in patients with DWI lesions involving 3 vessel territories are malignancy related. In the absence of an identifiable embolic source, ischemic infarction with cancer-associated hypercoagulation accounts for 75% of cases. Cancer-associated hypercoagulation infarction should be considered, particularly when no other cause is apparent.

Primary lymphoma of CNS, mycophenolate mofetil and lupus.

Lymphoproliferative disorders are known to complicate immunosuppressive therapy and two cases of primary lymphoma of CNS (PCNSL) have previously been described in association with mycophenolate mofetil (MMF) treatment. We report the third case of PCNSL in a patient with lupus nephropathy while on MMF treatment. PCNSL may be seen more frequently considering the increased use of MMF in immunosuppressant responsive conditions.

Magnetic resonance imaging abnormalities with septic encephalopathy.

A 48 year old woman, status post renal transplantation six years earlier, died after a two week illness characterised by fever, recurrent seizures, and coma. Widespread abnormalities were seen on neuroimaging. A diagnosis of septic encephalopathy was established on postmortem. We describe the magnetic resonance imaging findings of bilateral basal ganglia, thalamic, cerebellar, brainstem, and cerebral abnormalities in this patient, which correlate with the pathophysiology of septic encephalopathy.

Acute obstructive hydrocephalus heralding neurocysticercosis.

Delayed diagnosis occurred in a healthy young immigrant man who presented with symptoms and computed tomography (CT) findings of acute obstructive hydrocephalus as the heralding manifestation of neurocysticercosis. Recognizing that a patient is from an area endemic for this condition is paramount in considering the diagnosis as urgent surgical intervention may be required.

Cerebral venous thrombosis associated with epoetin alfa therapy.

BACKGROUND: Cerebral venous thrombosis is a rare complication of polycythemia. To our knowledge, epoetin alfa-induced polycythemia has not previously been reported in association with cerebral venous thrombosis. CASE DESCRIPTION: A 37-year-old patient who was receiving peritoneal dialysis and epoetin alfa (Epogen) therapy presented with a several-day history of worsening headache, and a neuroimaging scan demonstrated thrombosis of the sagittal and transverse sinus. Epoetin alfa therapy, which had been initiated 3 months earlier according to an institutional protocol, was associated with a problematic increase in hematocrit values. CONCLUSIONS: Headache should raise the suspicion of cerebral venous thrombosis in patients who are being treated with epoetin alfa, particularly in the presence of elevated hematocrit values. Monitoring hematocrit parameters in accordance with "standard guidelines" is recommended.

Myelodysplastic syndrome and sagittal sinus thrombosis.

After a 5-day illness beginning with severe headache, a 46-year-old man with myelodysplastic syndrome died of complications from cerebral venous thrombosis. Considering the underlying hematologic abnormality, multiple therapies, and potential for leukemic transformation, we suggest that patients with myelodysplastic syndrome may be at increased risk for developing cerebral venous thrombosis.

Idiopathic granulomatous angiitis of the CNS manifesting as diffuse white matter disease.

A 48-year-old man presented with progressive spastic paraparesis and diffuse white matter involvement on neuroimaging that suggested a primary demyelinating disease. Brain biopsy 3 years after onset of symptoms demonstrated idiopathic granulomatous angiitis. In patients with MRI features of diffuse white matter disease of uncertain etiology, open brain biopsy of leptomeninges and parenchyma should be considered to exclude idiopathic granulomatous angiitis of the CNS.

Alternating amaurosis fugax and temporal arteritis.

PURPOSE: To describe a patient with alternating amaurosis fugax and the importance of this condition in diagnosing temporal arteritis. METHODS: Case report of a 77-year-old man who had numerous episodes of transient alternating loss of vision for several days. RESULTS: Temporal artery biopsy showed vasculitis with a giant cell component. CONCLUSIONS: Alternating amaurosis fugax in an elderly patient suggests arteritis rather than atheromatous disease, and temporal artery biopsy should be considered.

Stroke and automobile accidents.

To define the causal relationship of ischemic cerebral infarction to automobile accidents in hospitalized patients a computerized hospital record search with ICD-9 diagnostic codes 433 and 434 for occlusive cerebrovascular disease, and E810 and E819 for motor vehicle traffic accidents was conducted over a three-year period. Inclusion criteria required patients be identified as the driver of the vehicle and demonstrate computed tomographic (CT) evidence of an evolving cerebral infarction on serial scans. Of 2,844 ischemic cerebral infarctions admitted to the hospital during the study period, four met the selection criteria. In three, stroke was the cause and in one, the result of the accident. When stroke preceded the accident, visual field defect impaired consciousness, and/or loss of motor control were major contributing factors. Head CT, detailed accident scene history, and vascular disease risk factors were most important in determining a cause-and-effect relationship of stroke to the accident.

Peripartum seizure and HIV infection.

Two patients with new-onset seizure within hours of parturition subsequently tested positive for human immunodeficiency virus (HIV). The peripartum period appears to predispose asymptomatic HIV-infected individuals to seizure. Such patients, especially with suggestive risk factors, should be screened for HIV-antibody.

Clinical and subclinical neurological involvement in children of conjugal multiple sclerosis patients.

We report the occurrence of clinically definite multiple sclerosis in an offspring of a couple with conjugal multiple sclerosis. Extensive investigation of all members of this family, which includes two additional asymptomatic children, eliminated the possibility of alternative neurological diagnoses. All family members were studied with magnetic resonance imaging (MRI), evoked potentials, and human leukocyte antigen (HLA) typing. An asymptomatic child had subtle white matter abnormalities on MRI, suggesting subclinical neurological involvement. This study documents the third case of multiple sclerosis in the child of conjugal multiple sclerosis patients and provides the first report of MRI lesions in an asymptomatic offspring of the same parents. Neurodiagnostic and immunogenetic investigations of such rare family clusters may contribute to the elucidation of the pathogenesis of multiple sclerosis.

Magnetic resonance angiography in the diagnosis of deep cerebral venous thrombosis.

Given the nonspecific and conflicting "indirect" signs and rare occurrence of the true "direct" signs on computed tomography (CT) and magnetic resonance imaging (MRI), conventional angiography has been the "gold standard" in the diagnosis of cerebral venous thrombosis. Visualization of the deep venous system by magnetic resonance angiography (MRA) suggests this modality may accurately demonstrate thrombosis at this level. We present a 34-year-old Down syndrome patient with deep cerebral venous thrombosis demonstrated by MRA who was initially misdiagnosed as a bithalamic glioma due to the similarity in the imaging characteristics of the two conditions. No direct evidence of venous thrombosis was present on CT or MRI. MRA was the sole noninvasive imaging modality to "directly" demonstrate venous thrombosis and is suggested in the evaluation of unexplained or atypical cerebral events that may represent deep cerebral venous thrombosis.

Coital cerebral hemorrhage.

Sudden headache, confusion, and hemiparesis followed within minutes of late-morning sexual intercourse in a 39-year-old man. Imaging studies revealed hemorrhage into a vascular malformation. Sexual intercourse and circadian rhythm independently elevate blood pressure, and their concurrence may predispose to cerebral hemorrhage in the presence of a vascular malformation.