Moyamoya Syndrome after Radiation Therapy: a Clinical Report

Moyamoya syndrome (MMS) is a rare, chronic and progressive vasculopathy with a characteristic angiographic pattern and well-recognized predisposing conditions, such as cranial therapeutic radiation. We report the case of a 36-year-old Caucasian female with a history of craniopharyngioma treated with whole-brain radiotherapy 20 years previously. She was admitted to the emergency department with disorientation and imperceptible speech lasting for 1 hour. Upon examination, she had slight motor aphasia, without sensory or motor deficits. However, the neurological deficits worsened on standing position. The computed tomography (CT) angiogram and transcranial Doppler ultrasonography revealed occlusion of the distal portion of the left internal carotid artery (ICA). Mechanical thrombectomy was attempted without success. Head CT was repeated, revealing left periventricular acute ischaemic stroke. The cerebral angiography showed total occlusion of the left ICA with an exuberant network of transdural collateral vessels, confirming MMS. The patient completed a functional rehabilitation program with progressive improvement of deficits and maintained a multidisciplinary follow-up. MMS is a serious late complication from cranial radiation therapy and a well-described risk factor for ischaemic stroke in younger patients. Therefore, early detection and prompt treatment are mandatory, as the consequences can be disastrous, such as cognitive and neurologic decline due to repeated strokes.

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COVID-19-associated ischaemic stroke due to underlying carotid artery thrombosis in a healthy young woman

BMJ Case Reports ◽

10.1136/bcr-2021-244396 ◽

2021 ◽

Vol 14 (8) ◽

pp. e244396

Author(s):

Kelly Lau ◽

Irwin White-Gittens ◽

Jonathan Schor ◽

Mina Guerges

Keyword(s):

Carotid Artery ◽

Ischaemic Stroke ◽

Heart Association ◽

Recombinant Tissue Plasminogen Activator ◽

Haemorrhagic Stroke ◽

Hypercoagulable State ◽

Left Internal Carotid Artery ◽

Ct Angiogram ◽

Contrast Ct ◽

Vessel Thrombosis

SARS-CoV-2 has proven its versatility in host presentations; one such presentation is a hypercoagulable state causing large-vessel thrombosis. We report a case on a previously asymptomatic COVID-19-positive patient presenting with an acute ischaemic stroke and an incidental left internal carotid artery thrombus. The patient’s medical, social and family history and hypercoagulability screening excluded any other explanation for the left carotid thrombus or stroke, except for testing positive for the COVID-19. This case explores the known hypercoagulable state associated with COVID-19 and the effect of the virus on the host’s immune response. It also questions whether administration of recombinant tissue plasminogen activator (t-PA), according to the American Heart Association guidelines, following a negative head CT for haemorrhagic stroke is safe without prior extended imaging in this patient population. We recommend, in addition to obtaining a non-contrast CT scan of the brain, a CT angiogram or carotid duplex of the neck be obtained routinely in patients with COVID-19 exhibiting stroke symptoms before t-PA administration as the effects may be detrimental. This recommendation will likely prevent fragmentation and embolisation of an undetected carotid thrombus.

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Management and outcomes of isolated interhemispheric subdural hematomas associated with falx syndrome

Journal of Neurosurgery ◽

10.3171/2018.8.jns181812 ◽

2019 ◽

Vol 131 (6) ◽

pp. 1920-1925

Author(s):

Daniel A. Tonetti ◽

William J. Ares ◽

David O. Okonkwo ◽

Paul A. Gardner

Keyword(s):

Neurological Deterioration ◽

Neurological Deficits ◽

Motor Deficits ◽

Study Cohort ◽

Venous Infarction ◽

Nonsurgical Management ◽

Subdural Hematomas ◽

Poor Outcomes ◽

Contemporary Management

OBJECTIVELarge interhemispheric subdural hematomas (iSDHs) causing falx syndrome are rare; therefore, a paucity of data exists regarding the outcomes of contemporary management of iSDH. There is a general consensus among neurosurgeons that large iSDHs with neurological deficits represent a particular treatment challenge with generally poor outcomes. Thus, radiological and clinical outcomes of surgical and nonsurgical management for iSDH bear further study, which is the aim of this report.METHODSA prospectively collected, single-institution trauma database was searched for patients with isolated traumatic iSDH causing falx syndrome in the period from January 2008 to January 2018. Information on demographic and radiological characteristics, serial neurological examinations, clinical and radiological outcomes, and posttreatment complications was collected and tallied. The authors subsequently dichotomized patients by management strategy to evaluate clinical outcome and 30-day survival.RESULTSTwenty-five patients (0.4% of those with intracranial injuries, 0.05% of those with trauma) with iSDH and falx syndrome represented the study cohort. The average age was 73.4 years, and most patients (23 [92%] of 25) were taking anticoagulants or antiplatelet medications. Six patients were managed nonoperatively, and 19 patients underwent craniotomy for iSDH evacuation; of the latter patients, 17 (89.5%) had improvement in or resolution of motor deficits postoperatively. There were no instances of venous infarction, reaccumulation, or infection after evacuation. In total, 9 (36%) of the 25 patients died within 30 days, including 6 (32%) of the 19 who had undergone craniotomy and 3 (50%) of the 6 who had been managed nonoperatively. Patients who died within 30 days were significantly more likely to experience in-hospital neurological deterioration prior to surgery (83% vs 15%, p = 0.0095) and to be comatose prior to surgery (100% vs 23%, p = 0.0031). The median modified Rankin Scale score of surgical patients who survived hospitalization (13 patients) was 1 at a mean follow-up of 22.1 months.CONCLUSIONSiSDHs associated with falx syndrome can be evacuated safely and effectively, and prompt surgical evacuation prior to neurological deterioration can improve outcomes. In this study, craniotomy for iSDH evacuation proved to be a low-risk strategy that was associated with generally good outcomes, though appropriately selected patients may fare well without evacuation.

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Management of an Uncommon Complication: Anterior Choroidal Artery Occlusion by Posterior Clinoid Process Detected Through Intraoperative Monitoring After Clipping of Paraclinoid Aneurysm: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opab113 ◽

2021 ◽

Author(s):

Walter Marani ◽

Francisco Mannará ◽

Kosumo Noda ◽

Tomomasa Kondo ◽

Nakao Ota ◽

...

Keyword(s):

Intraoperative Monitoring ◽

Motor Evoked Potential ◽

Japanese Woman ◽

Motor Deficits ◽

Anterior Choroidal Artery ◽

Diffusion Weighted Images ◽

Ct Angiogram ◽

Paraclinoid Aneurysms ◽

Anterior Choroidal ◽

Choroidal Artery

Abstract Despite technological advances in endovascular therapy, surgical clipping of paraclinoid aneurysms remains an indispensable treatment option and has an acceptable profile risk. Intraoperative monitoring of motor and somatosensory evoked potentials has proven to be an effective tool in predicting and preventing postoperative motor deficits during aneurysm clipping.1,2 We describe the case of a 61-yr-old Japanese woman with a history of hypertension and smoking. During follow-up for bilateral aneurysms of ophthalmic segment of the internal carotid artery (ICA), left-sided aneurysm growth was detected. A standard pterional approach with extradural clinoidectomy was used to approach the aneurysm. After clipping, a significant intraprocedural change in motor evoked potential (MEP) amplitude was observed despite native vessel patency was confirmed through micro-Doppler and indocyanine green video angiography.3-5 After extensive dissection of the sylvian fissure and exposure of the communicating segment of ICA, the anterior choroidal artery was found to be compressed and occluded by the posterior clinoid because of an inadvertent shift of the ICA after clip application and removal of brain retractors. Posterior clinoidectomy was performed intradurally with microrongeur and MEP amplitude returned readily to baseline values. Computed tomography (CT) angiogram demonstrated complete exclusion of the aneurysm, and magnetic resonance imaging (MRI) was negative for postoperative ischemic lesions on diffusion weighted images. The patient tolerated the procedure well and was discharged home on postoperative day 3 with modified Rankin Scale (mRS) 0. The patient signed the Institutional Consent Form to undergo the surgical procedure and to allow the use of her images and videos for any type of medical publications.

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Microalbuminuria in Ischaemic Stroke and its Relationship with Neurological Defects

Journal of Medical Science & Research ◽

10.47648/jmsr.2010.v1502.03 ◽

2010 ◽

Vol 15 (Number 2) ◽

pp. 15-18

Author(s):

S S Chowdhury ◽

T Mehdi ◽

F Alam ◽

R Ishrat ◽

S Parveen ◽

...

Keyword(s):

Risk Factors ◽

Ischaemic Stroke ◽

Developed Countries ◽

Cross Sectional Study ◽

Neurological Deficits ◽

Sectional Study ◽

Cross Sectional ◽

Common Cause ◽

Face To Face ◽

Structured Questionnaire

Stroke is Me third common cause of death in developed countries. Ischaernic stroke accounts for about 83 percent of all cases. For ischaemic stroke, besides modifiable and nononodifiable risk factors. there are some potential nosy risk factors which include mieroalbuminuria. Site objective of this study was to observe the association of microalbuminuria with isehaemic stroke and as well as consequent neurological deficits. This cross sectional study was done among 100 diagnosed patients of ischaeoric stroke of both sexes. A structured questionnaire and checklist was used to collect data through face to face interview. Urinary microalbuminuria was mesured in all study subjects and assessment of necrological defects was done by modified Ranakin scale. The study revealed that the frequency of presence of microallmminteria was significantly high in ischaernic stroke. Higher the level of mieroalburninuria higher was the necrological deficit. So, microalbunrinuria may be a marker for the process to develop the ischamnic stroke.

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Ahr and Cyp1a2 genotypes both affect susceptibility to motor deficits following gestational and lactational exposure to polychlorinated biphenyls

10.1101/184010 ◽

2017 ◽

Cited By ~ 1

Author(s):

Breann T. Colter ◽

Helen Frances Garber ◽

Sheila M. Fleming ◽

Jocelyn Phillips Fowler ◽

Gregory D. Harding ◽

...

Keyword(s):

Polychlorinated Biphenyls ◽

Learning And Memory ◽

Animal Studies ◽

Corn Oil ◽

Neurological Deficits ◽

Motor Deficits ◽

Wild Type ◽

Impaired Performance ◽

High Affinity ◽

Pcb Exposure

AbstractPolychlorinated biphenyls (PCBs) are persistent organic pollutants known to cause adverse health effects and linked to neurological deficits in both human and animal studies. Children born to exposed mothers are at highest risk of learning and memory and motor deficits. We developed a mouse model that mimics human variation in the aryl hydrocarbon receptor and cytochrome P450 1A2 (CYP1A2) to determine if genetic variation increases susceptibility to developmental PCB exposure. In our previous studies, we found that high-affinity AhrbCyp1a2(-/-) and poor-affinity AhrdCyp1a2(-/-) knockout mice were most susceptible to learning and memory deficits following developmental PCB exposure compared with AhrbCyp1a2(+/+) wild type mice (C57BL/6J strain). Our follow-up studies focused on motor deficits, because human studies have identified PCBs as a potential risk factor for Parkinson’s disease. Dams were treated with an environmentally relevant PCB mixture at gestational day 10 and postnatal day 5. We used a motor battery that included tests of nigrostriatal function as well as cerebellar function, because PCBs deplete thyroid hormone, which is essential to normal cerebellar development. There was a significant effect of PCB treatment in the rotarod test with impaired performance in all three genotypes, but decreased motor learning as well in the two Cyp1a2(-/-) knockout lines. Interestingly, we found a main effect of genotype with corn oil-treated control Cyp1a2(-/-) mice performing significantly worse than Cyp1a2(+/+) wild type mice. In contrast, we found that PCB-treated high-affinity Ahrb mice were most susceptible to disruption of nigrostriatal function with the greatest deficits in AhrbCyp1a2(-/-) mice. We conclude that differences in both genes affect susceptibility to motor deficits following developmental PCB exposure.

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Ischemic stroke with agraphestesia signal focus

10.5327/1516-3180.470 ◽

2021 ◽

Author(s):

Ana Luísa Lopes Espínola da Costa Reis ◽

Leonardo Henrique Gandolfi de Souza ◽

Vitor Roberto Pugliesi Marques

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Parietal Lobe ◽

Cerebral Arteries ◽

Sudden Onset ◽

Neurological Deficits ◽

Motor Deficits ◽

Ischemic Event ◽

The Right ◽

Sensory Ability

Introduction: The ischemic stroke is one of the main causes of death and disability in Brazil. Among the main risk factors are age, atrial fibrillation (AF), diabetes, dyslipidemia and physical inactivity. The main etiology of stroke is cardioembolic, resulting in obstruction of the cerebral arteries by a thrombus of cardiac origin. The artery most affected in ischemic strokes is the middle cerebral artery. The stroke has main characteristics, with emphasis on the sudden onset of symptoms, involvement of a focal area, ischemia caused by obstruction of a vessel and neurological deficits depending on the affected area. Graphesthesia is defined as a cutaneous sensory ability to recognize letters or numbers traced on the skin. The loss of this sensory ability is known as agraphesthesia. Case Report: M.A.F.O. female, 78a, arrived at the UPA complaining of mental confusion. Patient denies previous stroke. Personal history of systemic arterial hypertension. Upon physical examination, the patient was conscious, self and disoriented and inattentive. He was able to repeat and evoke words, without measurable motor déficits. Left upper limb with agraphestesia. Computed tomography was requested, which showed an extensive hypodense area in the right parietoccipital region, which leads to the erasure of the furrows between the adjacent gyres, which may correspond to a recent ischemic event. Magnetic resonance imaging, diffusion-restricted area with correspondence on the ADC map, located in the right temporoparietal region inferring an acute ischemic event. An electrocardiogram was also requested, which showed an irregular rhythm, characteristic of atrial fibrillation, resulting in a diagnostic hypothesis of cardioembolic ischemic stroke. Discussion: The involvement of post-central ischemic gyrus lesions may correspond to paresthesia, anesthesia, hypoesthesia; the involvement of secondary and terciary areas of sensitivity in the upper parietal lobe, especially in the active movements of the hand and in the modalities of integrated sensitivity, their lesions may be clinically affected by: apraxias, dysgraphias, hemineglect, agraphestesia, stereoagnosia and spacial disorientation.

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Analysis of Radiation Dose to the Shoulder by Treatment Technique and Correlation With Patient Reported Outcomes in Patients Receiving Regional Nodal Irradiation

Frontiers in Oncology ◽

10.3389/fonc.2021.617926 ◽

2021 ◽

Vol 11 ◽

Author(s):

Jose G. Bazan ◽

Dominic DiCostanzo ◽

Karen Hock ◽

Sachin Jhawar ◽

Karla Kuhn ◽

...

Keyword(s):

Breast Cancer ◽

Radiation Therapy ◽

Radiation Dose ◽

Patient Reported Outcomes ◽

Late Complication ◽

Treatment Technique ◽

Regional Nodal Irradiation ◽

Patient Reported ◽

The Impact ◽

Dash Questionnaire

Background/PurposeShoulder/arm morbidity is a late complication of breast cancer treatment with surgery and regional nodal irradiation (RNI). We set to analyze the impact of radiation technique [intensity modulated radiation therapy (IMRT) or 3D conformal radiation therapy (3DCRT)] on radiation dose to the shoulder with a hypothesis that IMRT use results in smaller volume of shoulder receiving radiation. We explored the relationship of treatment technique on long-term patient-reported outcomes using the quick disabilities of the arm, shoulder, and hand (q-DASH) questionnaire.Materials/MethodsWe identified patients treated with adjuvant RNI (50 Gy/25 fractions) from 2013 to 2018. We retrospectively contoured the shoulder organ-at-risk (OAR) from 2 cm above the ipsilateral supraclavicular (SCL) planning target volume (PTV) to the inferior SCL PTV slice and calculated the absolute volume of shoulder OAR receiving 5–50 Gy (V5–V50). We identified patients that completed a q-DASH questionnaire ≥6 months from the end of RNI.ResultsWe included 410 RNI patients: 54% stage III, 72% mastectomy, 35% treated with IMRT. IMRT resulted in significant reductions in the shoulder OAR volume receiving 20–50 Gy vs. 3DCRT. In total, 82 patients completed the q-DASH. The mean (SD) q-DASH=25.4 (19.1) and tended to be lower with IMRT vs. 3DCRT: 19.6 (16.4) vs. 27.8 (19.8), p=0.078.ConclusionWe found that IMRT reduces radiation dose to the shoulder and is associated with a trend toward reduced q-DASH scores ≥6 months post-RNI in a subset of our cohort. These results support prospective evaluation of IMRT as a technique to reduce shoulder morbidity in breast cancer patients receiving RNI.

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Abstract 162: Clinical and Neuroradiological Characteristics of Moyamoya Syndrome: UT Houston Experience

Stroke ◽

10.1161/str.43.suppl_1.a162 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Preeti sahota ◽

Peter Sedrak ◽

Paul S Lee ◽

Aditya P Lal ◽

William J Hicks ◽

...

Keyword(s):

Risk Factors ◽

Hospital Admissions ◽

Laboratory Data ◽

Neurological Deficits ◽

Disease Stage ◽

Moyamoya Syndrome ◽

Stroke Registry ◽

Single Center Experience ◽

Unilateral Disease ◽

Low Hdl

Background: Moyamoya (MM) is a rare progressive arteriopathy characterized by progressive stenosis and occlusion of the internal carotid arteries (ICA) and ultimately the arteries of the circle of Willis. It is called moyamoya disease (MMD) when idiopathic and involving bilateral ICA, and moyamoya syndrome (MMS) when associated with well-recognized risk factors, or when idiopathic but unilateral. Given the paucity of literature on MMS, we analyzed the clinical and radiological characteristics of MM patients presenting to our institute. Methods: We retrospectively identified patients admitted with acute neurological deficits and had ‘moyamoya-like’ physiology from our stroke registry (07/04 to 03/11). We collected demographics, clinical and laboratory data, and prior and subsequent hospital admissions. Two clinically blinded neuroradiologists collected radiological data including vessels involved, type of collateralization, and disease stage and progression. Patients were categorized into MMD or MMS based on risk factors and the side of disease. Results: We identified 36 MM patients (mean age 41.3 years), 13 (36.1%) with MMD and 23 (63.9%) with MMS. Both groups had female preponderance and multiracial involvement; hemiparesis was the leading clinical sign, and most patients had low HDL levels (83%). In MMS group, 4 (17.4%) patients had idiopathic unilateral disease, 4 (17.4%) had atherosclerotic disease, 3 (13%) each had vasculitis and intracranial dissection, 2 (8.7%) each had sickle cell disease and APLA syndrome, and 1 (4.3%) each had Down’s syndrome, Lupus, thyrotoxicosis, hypercoagulable disorder and chronic cocaine use. The MMS patients tended to be older, and higher proportion had ischemic stroke (87%) and neurological worsening after acute event (35%). On the other hand, higher proportion of MMD patients had hemorrhagic stroke (38.5%), multiple (>5) hospital admissions (23%) and EEG abnormality (80%) and were discharged home (62%). In MMS group, 2 (8.7%) patients underwent hemicraniectomy. In MMD group, 12.5% had disease progression radiographically. The clinical and radiological characteristics of these patients are summarized in tables 1 and 2 respectively. Conclusion: We present the single-center experience of clinical and neuroradiological characteristics of patients with MMS.

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Esthetic and Functional Rehabilitation of an Adolescent Patient with Severe Dental Fluorosis: A Clinical Report

Journal of Prosthodontics ◽

10.1111/jopr.13453 ◽

2021 ◽

Author(s):

Sherif Hosney ◽

Carlo Ercoli ◽

Deborah Dilbone ◽

Maria Gabriela Carranza ◽

Konstantinos Chochlidakis

Keyword(s):

Dental Fluorosis ◽

Clinical Report ◽

Adolescent Patient ◽

Functional Rehabilitation

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Acute ischaemic stroke in secondary polycythaemia due to complex congenital cyanotic heart disease

BMJ Case Reports ◽

10.1136/bcr-2019-231261 ◽

2019 ◽

Vol 12 (10) ◽

pp. e231261

Author(s):

Jeyaraj Durai Pandian ◽

Ivy Anne Sebastian ◽

Ashlee Sidhu

Keyword(s):

Congenital Heart Disease ◽

Heart Disease ◽

Ischaemic Stroke ◽

Congenital Heart ◽

Septal Defect ◽

Brain Mri ◽

Neurological Deficits ◽

Complex Congenital Heart Disease ◽

Haematocrit Level ◽

Polycythaemia Vera

A 65-year-old woman presented to the emergency department with an acute onset of left-sided hemiparesis and slurred speech for 6 hours. Physical examination was notable for clubbing and peripheral cyanosis. Brain MRI showed an acute infarct involving the right gangliocapsular region. Investigations showed an elevated haemoglobin level, a haematocrit level of >65% and thrombocytopaenia. Transthoracic echocardiography revealed tricuspid atresia, ventricular septal defect and atrial septal defect. A diagnosis of cyanotic congenital heart disease was made. Studies have indicated an association between raised haematocrit and vascular occlusive episodes in patients with polycythaemia vera. However, a relationship between raised haematocrit due to polycythaemia secondary to complex congenital heart disease and vascular thrombosis has not been reported. The improvement of neurological deficits in our patient coincided with a decline in haematocrit. The objective of this report was to highlight an association between elevated haematocrit and ischaemic stroke in patients with secondary polycythaemia due to complex congenital heart disease.

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