Intracranial fungal Cladophialophora bantiana infection in a nonimmunocompromised patient: A case report and review of the literature.

Background: Cladophialophora bantiana is a dematiaceous fungus that rarely infects the central nervous system (CNS). It is associated with a mortality rate of over 70% despite treatment. Case Description: An 81-year-old female with a remote history of renal cell carcinoma presented with progressive headache and an expressive aphasia for 3 days. Computed tomography imaging revealed a left frontotemporal mass with surrounding vasogenic edema. A left frontotemporal craniotomy was performed and cultures revealed C. bantiana. The initial management with IV voriconazole was unsuccessful and the patient had a recurrence of the cranial infection and developed pulmonary abscesses. Following the addition of oral flucytosine, the patient showed a significant improvement with a complete radiographic resolution of both the cranial and pulmonary lesions. Conclusion: C. bantiana involving the CNS is a rare and often fatal disease. Surgical management along with standard antifungal treatment may not provide definitive therapy. The addition of flucytosine to IV voriconazole resulted in a positive outcome for this patient who is alive, living independently 1 year from the original diagnosis. In this rare fungal infection, standard antifungal treatment may not provide adequate coverage and the utilization of additional therapy may be required.

A Novel Use of Direct Platelet Application During Surgery for Clopidogrel-Associated Intracerebral Hemorrhage.

BACKGROUND: Dual antiplatelet therapy is associated with increased rates of intracerebral hemorrhage, especially in the context of subarachnoid hemorrhage. We present a case of a spontaneous hemorrhage in a patient treated with a Pipeline stent for a ruptured dissecting vertebrobasilar aneurysm and the novel use of direct application of platelets during surgery to control bleeding. CASE DESCRIPTION: A 54-year-old previously healthy woman presented with an intradural right vertebral artery dissection with a ruptured 6-mm pseudoaneurysm. The patient was started on aspirin and clopidogrel and the vessel was reconstructed with 2 Pipeline Embolization Devices. On postbleed day number 14, she became obtunded with a blown right pupil; computed tomography of the head demonstrated a large right temporal intracerebral hematoma. The patient was taken emergently to the operating room for evacuation of the clot. Intraoperatively, satisfactory control of bleeding was not achieved despite transfusing several units of platelets intravenously. Ultimately, a mixture of Floseal and platelets applied directly to the hematoma wall allowed prompt hemostasis. At 3 months the patient was doing extremely well clinically and angiography demonstrated occlusion of the aneurysm. CONCLUSIONS: This is the first reported description of direct application of platelets to achieve intraoperative hemostasis. Platelets are activated by thrombin and collagen and the use of Floseal (a bovine-derived, gelatin matrix and human-derived thrombin) further potentiated the effectiveness of this strategy. With the increased incidence of intracerebral hemorrhage associated with dual antiplatelet therapy, this technique may provide a useful tool in the neurosurgical armamentarium.

Clinical Characteristics and Outcomes of Patients with Intracerebral Hemorrhage after Interhospital Transfer to a Designated Stroke Center.

UNLABELLED: Patients with acute ischemic stroke have improved outcomes when cared for in designated stroke centers (SC), in part due to enhanced thrombolytic use. Whether patients with intracerebral hemorrhage (ICH) also benefit from SC care is unknown. In this study, we compared the clinical characteristics and outcomes of ICH patients who underwent interhospital transfer (IHT) to a Joint Commission (JC) designated SC, to ICH patients who presented directly to the SC's emergency department (ED). METHODS: Patients with ICH admitted between 2006 and 2013 were evaluated. The primary outcome measure was in-hospital death or hospice. RESULTS: Among 760 consecutive admissions for ICH, 321 (42.2%) were IHTs. There has been a 30% annual increase in IHT of ICH patients since 2006. The IHT group was younger (70.26 vs 72.28; P =.055), had lower ICH scores (P = .007), a higher Glasgow Coma Scale (GCS) (P = .037), and lower systolic blood pressure (SBP) (P = .003) than those arriving directly to the ED. Female sex was a predictor of in-hospital mortality (OR = 2.26). CONCLUSION: IHT is increasingly common for patients with ICH. The benefit of transfer remains unclear, as younger, healthier patients were the most likely to be transferred. Comprehensive stroke registries are needed to determine if outcomes differ for ICH patients based on transfer or SC care.

Clinical outcomes after neurogenic stress induced cardiomyopathy in aneurysmal sub-arachnoid hemorrhage: a prospective cohort study.

INTRODUCTION: Neurogenic stress cardiomyopathy (NCM) has been associated with poor outcomes in the setting of aneurysmal subarachnoid hemorrhage (aSAH). Much less is known regarding recovery of cardiac function. The aim of this prospective cohort study was to study the rate of early cardiac recovery after NCM and the potential effect of NCM on short term functional recovery. A secondary aim sought to determine whether certain biomarkers may be associated with the development of NCM. METHODS: Patients with confirmed aSAH between November 2012 and October 2013 were prospectively enrolled and received echocardiograms within 48 h of admission. Ejection fraction (%) and regional wall motion abnormality score index (RWMI) were noted. All patients with confirmed aSAH had a troponin and BNP level drawn on admission. Patients with confirmed NCM received a follow up echocardiogram 7-21 days after the initial echocardiogram. Clinical follow up at 3 months evaluated mortality, mRS and mBI scores. RESULTS: 63 patients with confirmed aSAH were enrolled. In this cohort 11 (17%) patients were confirmed to have NCM. The NCM group had higher in-hospital mortality [n = 4(36.4%)] compared to the non-NCM group [n = 5(9.6%)] (p = .021). At 3 months the development of NCM was associated with an unfavorable mRS (p = 0.042) and mBI (p = 0.005). Both an elevated BNP (> 100 pg/mL) and elevated troponin (>0.3 mg/dL) were associated with the development of NCM. Follow-up echocardiograms were performed within 21 days of admission on 8 patients with NCM. An abnormal RWMI of 1.5 or higher was present in 5(71%) patients. CONCLUSION: NCM is a frequent complication associated with aSAH. The onset of the disease occurs early in the course of aSAH and an elevated BNP and troponin may be associated with the onset of NCM. Cardiac function often remains impaired during the acute recovery phase potentially impeding resuscitation during this period. The routine use of short term follow-up echocardiography may be recommended.

Case report of a de novo brainstem arteriovenous malformation in an 18-year-old male and review of the literature.

De novo intracerebral arteriovenous malformations (AVMs) are exceedingly rare with only seven reported cases in the literature. Although generally considered congenital by nature, the lesions do not manifest themselves clinically until the third or fourth decades of life. However, with the advent of improved imaging modalities and more frequent surveillance, an increasing number of de novo cases are being found challenging the concept AVMs develop in the perinatal/antenatal period. Alternatively, this phenomenon could represent a distinct entity in which lesion development occurs after birth. A PubMed search of "de novo cerebral arteriovenous malformation" was performed in which seven reported cases were found. The mean age at diagnosis was 14.7 years with a mean follow-up imaging study of 5.8 years. Lesion location was supratentorial in all previously described cases. This case involves an 18-year-old male with congenital hydrocephalus and seizures diagnosed at 7 months of age. The patient underwent a ventriculoperitoneal shunt and was followed frequently by a neurologist. The last diagnostic imaging was an unremarkable MRI of the brain at age 12. Seven years later, the patient presented with an intracerebral hemorrhage. A CT angiogram demonstrated a large brainstem AVM with an intraparenchymal hemorrhage and intraventricular extension. This case is unique in that it is the first infratentorial de novo AVM. The congenital nature of AVMs is challenged with the increasingly described series of patients with previously documented normal radiographic imaging. This suggests there may be a subset of patients genetically predisposed to postnatal development of AVMs.

Isolated brain metastasis in cholangiocarcinoma: a case report and review of literature.

Cholangiocarcinoma is a rare malignancyinvolvingthe epithelium of the intrahepatic and extrahepatic bile ducts associated with high mortality usually from systemic recurrence. Isolated brain metastases occur rarely in this malignancy. We found three previous reports on this subject in our review of literature which had a varied presentation. We present the case report of a patient presenting with an isolated brain metastases and we present a review of the literature concerning this diagnosis.

Clinical characteristics and outcomes of neurogenic stress cadiomyopathy in aneurysmal subarachnoid hemorrhage.

BACKGROUND: Aneurysmal subarachnoid hemorrhage (aSAH) is an often devastating form of stroke. Aside from the initial hemorrhage, cardiac complications can occur resulting in neurogenic stress cardiomyopathy (NCM), leading to impaired cardiac function. We investigated whether aSAH patients with NCM had poorer long term functional outcomes than patients without NCM. Mortality, vasospasm, and delayed ischemic complications were also evaluated. METHODS: A retrospective study of all patients admitted for aneurysmal subarachnoid hemorrhage (aSAH) from January 2006 to June 2011 (n=299) was conducted. Those patients who underwent an echocardiogram were identified (n=120) and were assigned to the NCM (n=49) category based on echocardiographic findings defined by a depressed ejection fraction (EF%) along with a regional wall motion abnormality (RWMA) in a non-vascular pattern. Primary outcome measures included in-hospital mortality and functional outcomes as measured by the Modified Barthel Index (mBI) at 3 months and one year. Secondary analysis determined if there was an association between NCM, cerebral vasospasm and delayed cerebral ischemia. RESULTS: 16% of aSAH patients developed NCM. Mortality was higher (p<.001) in the NCM group (n=23[46.9%]) than in the non-CM group (n=28[11.2%]). Patients with NCM had poorer functional outcomes as measured by the mBI at both 3 months (p=.002) and 12 months (p=.014). The Hunt-Hess score was predictive of functional outcome as measured by the mBI at both 3 months (p=.002) as well as at 1 year (p=.014). NCM was associated with both death (p=.047 CI, 1.012-7.288) and vasospasm (p=.008 CI, 1.34-6.66) after correction for Hunt-Hess grade. Tobacco use (p<.001) and a history of diabetes mellitus (p<.009) were also associated with vasospasm. NCM was associated with higher in-hospital mortality (p=.047) in multivariate analysis. CONCLUSION: NCM is seen in a substantial number of aSAH patients and when present, it is associated with higher mortality and poorer long-term functional outcomes. This finding may guide further prospective studies in order to determine if early recognition of NCM as well as optimization of cardiac output would improve mortality.