XVII. European Stroke Conference
Nice, France

Poster Session: Interesting cases
 

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
Focal CNS Angiitis with limited Wegener’s Granulomatosis
M.A.TAQI    H. AZIZ                                                           
 
UNIVERSITY OF TENNESSEE

USA

Case: A 20 year-old African-American male presented with bifrontal retro-orbital headache radiating posteriorly. Vital signs were T 36.7, P 63, BP 189/106 and R 18. General physical and neurological exam were normal. CT disclosed bilateral sphenoid sinusitis. IV antibiotics were started in preparation for surgery. On the following day, he became unresponsive. Exam demonstrated obtundation with intact brainstem reflexes. A spinal tap revealed 38 WBC (78% N), 0 RBC, protein 41 and glucose 63. Gram stain revealed gram positive cocci. Blood culture grew staphylococcus aureus. MRI revealed leptomeningeal contrast enhancement. He was started on IV dexamethasone; antibiotics were changed to vancomycin and ceftriaxone. He improved and started talking. On day 6, fever recurred (104 F), and he developed ventricular fibrillation and suffered a generalized seizure. He was converted pharmacologically to sinus rhythm and avoided chest compression. On awakening, he was aphasic and had a right hemiplegia. MRI disclosed infarction of the left caudate and left mid-parietal area. A catheter angiogram revealed severe narrowing of the left internal carotid, left middle cerebral and left anterior cerebral arteries with no vasodilatory response to local nitroglycerin. He received intravascular volume expansion therapy for vasospasm. Hemiparesis and mental status did not improve, repeat angiography(day 16) revealed no change in vasoconstriction. On day 18, CSF showed 8 WBC (85% L, 14% N), 0 RBC, protein 55, and glucose 61. Vasculitis seemed more likely a pathophysiology than vasospasm. Dexamethasone was changed to IV methylprednisolone. 3 days later, mental status and right side strength started improving. The sphenoid sinus was surgically drained. At no time did he exhibit systemic signs of vasculitis. Laboratory testing, however, found a positive p- ANCA 1.27 and equivocal c-ANCA 1.09. Conclusion: This patient had sinusitis complicated by meningitis. His stroke was attributed to vasoconstriction from meningeal inflammation. The positive ANCA and response to steroids, however, suggests Wegener's Granulomatosis may have contributed to ischemia.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
Acute bilateral thalamic infarction as a cause of acute dementia and hypophonia after occlusion of the artery of Percheron
E.S.Koutsouraki    G.D.Xiromerisiou    V.G.Costa     S.J.Baloyannis                                            
 
1st Dprt of Neurology, Aristotelian University, AHEPA Hospital

GREECE

The thalami of the human brain obtain their blood supply from many perforating arteries, which exhibit complex distribution and many variations. One rare variation is the artery of Percheron that supplies the paramedian thalami bilaterally. This artery arises from the first segment of the posterior cerebral artery and gives rise to bilateral medial thalamic perforants. Occlusion of the artery of Percheron non rarely results in bilateral thalamic and mesencephalic infarctions. Bilateral infarctions in the paramedian artery territory are very rare and may result in a variety of clinical presentations. Among the clinical manifestations disorientation, confusion, hypersomnolence, deep coma, akinetic mutism, amnestic syndrome and various neuropsychological phenomena have been described until now. Speech and language dysfunctions such as dysarthric and aphasic disturbances, hypophonia and dysprosody may also be detected. We attempted to describe the case of a patient with bilateral thalamic lesion due to ischemic stroke presenting with hypophonia, memory dysfunction, time disorientation and apathy. We describe the case of a 38 years old male patient, professor of Physics, with a presumed occlusion of this artery in whom MR imaging revealed characteristic symmetrical bilateral paramedian thalamic infarctions. The unique characteristics of this case are based on the young age of the patient, the absence of any risk factors or other diseases and even more on the rare clinical manifestations consisted of hypophonia, memory dysfunction, time disorientation and apathy.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
Subarachnoid hemorrhage due to distal basilar perforator artery aneurysm
J. SEDAT    Y.H.CHAU    L. SUISSA     S. LACHAUD     M.H.MAHAGNE                                    
 
HOPITAL ST ROCH CHU NICE

FRANCE

OBJECTIVES: Subarachnoid hemorrhage (SAH) due to distal basilar perforator artery aneurysm is very rare. Diagnosis and management of one case are reported and discussed. METHODS AND RESULTS: A 69-year-old man was hospitalized for SAH. The patient was classified grade I in the Hunt and Hess classification. Computed tomography of the head showed Fisher scale IV SAH with intraventricular blood. An initial four-vessel cerebral angiogram did not reveal a source for the hemorrhage. The patient was managed conservatively. Few days later a second angiogram was negative, and the patient was discharged. A third angiogram was carried out 3 months after the hemorrhage and a tiny aneurysm was observed behind the basilar artery on a perforator. An endovascular management was decided and planned one week later. The angiogram carried out before embolization, showed a significant decrease of the size of the lesion, and it was decided to manage it conservatively. The patient did not rebleed, and the follow-up cerebral angiogram one year later was unchanged. CONCLUSION: Diagnosis and management of distal perforator artery aneurysms are difficult. Knowledge of this entity is helpful for taking in charge patients with SAH.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
The inravenous rtPA therapy for acute ischaemic stroke and coexisting chronic lymphocytic leukemia. A case report.
M. Sledzinska    P. Sobolewski    R. Hatalska - Zerebiec                                                    
 
Neurology Department SPZZOZ Sandomierz

POLAND

Backgroumd. There has always been a problem of rtPA therapy of patients in acute phase of ischaemic stroke, with preexisting history of cancer.We present a long term efficiency of this treatment in case of coexisting ischaemic stroke and chronic lymphocytic leukemia. Case A 74 years old patient was admitted to our unit with left hemiparesis and left facial palsy. The patient was treated with CLL for 4 years. In the moment of admission there was no changes in CT scan, NIHSS was 10, and level of lymphocytes was 11900/ul, levelmof thrombocytes 97000/ul. We recognized an aute ischaemic stroke and qualified the patient for rtPA therapy. We achieved gradual withdrawal of symptoms and improvement of clinical status. The patient had 5 pointsin NIHSS in 7 days and 1 point in 30 days.In the control CT examination we stated an intracerebral haemorrhage, simultaneously with improvement of clinical status of the patient. Conclusion The decision in relation to treating patients with acute ischaemic stroke and history of cancer should be taken after careful estimation of clinical status of the patient and future prognosis. Each time it should be a very individual decision.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
HEMODINAMIC TIA IN A CASE WITH A MEDIUM STENOSIS OF THE CAROTID ARTERY
M. Sabau    A.M.Mos    A. Iova     I. Popa                                            
 
Clinical Hospital of Neurology and Psychiatry

ROMANIA

CASE DESCRIPTION The patient BI, 85 years old without any significant pathological history presents rhythmical involuntary movements on the left arm. He describes these movements as “tremor”. In the last 4-5 months the patient had these movements every week lasting 1-2 minutes and accompanied by dizziness, paresthesia on the left arm. After these movements also had a mild decease of the muscles strength of the left arm who lasts 10-15 minutes. The seizure appeared almost always in the morning, just after getting out of the bed or during the night when the patient went to the toilet. The consciousness was not affected ever. The neurological exam didn’t show any abnormalities. CT scan shows a discreet cerebral atrophy. Doppler exam shows atherosclerotic plaques on precerebral vessel. On the bifurcation of the carotid artery… with an extension on the right internal carotid artery we can notice an atherosclerotic plaque who determine stenosis 60-69%. MRI also shows the same aspect, cerebral atrophy and few lesion of lacunar infarcts in the white matter of the cerebral emispheres. MRA also shows the absence of the right posterior communicating artery. CONCLUSION The association of the stenosis of the internal carotid artery with the absence of the PcoA on the same side leads to the significant decrease of the flow in the territory of the MCA and to hemodinamic TIA who appears at small stenosis. KEY WORDS: abnormal circle of Willis, hemodinamic TIA, carotid artery stenosis, PcoA, involuntary movements

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
Reversed flow in the external carotid artery despite ipsilateral patent common carotid artery as diagnosed with color-coded duplex flow imaging
E. Savva    R. Sztajzel    T. Landis     F. Perren                                            
 
HUG, University Hospital and Medical School of Geneva

SWITZERLAND

Background: Occlusion of the common carotid artery (CCA) is generally associated to an occlusion of the ipsilateral internal carotid (ICA) or of the external carotid (ECA) arteries or of both. Sometimes, collateral circulation to the ECA may occasionally preserve patency of the ICA via retrograde perfusion through the bulb. We herewith report a case of reversed flow in the ECA in the presence of a patent but stenosed CCA as diagnosed with Color-coded duplex flow imaging (CDFI). Case report: 85-year-old right-handed man was admitted for rapidly regressive acute dysarthria associated to left hemiparesis. Diffusion-weighted MRI showed an acute ischemic lesion in the territory of the right middle cerebral artery. MR-angiography showed patency of the right ICA and ECA but an occlusion of the CCA was suspected. CDFI demonstrated patency of the right CCA with a high-resistance pattern due to a large, partially calcified, stenosing atheromatous plaque. Surprisingly, reversed flow was observed in the right ECA which signal was dampened. Discussion: Collateralisation with reversed flow in the ECA can occur in a patent but stenosed CCA associated to a high grade stenosis of the carotid bifurcation and that CDFI is a very useful tool to detect such hemodynamic conditions.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
Reduction of migraines after treatment of hereditary hemorrhagic telangiectasia (HHT)
J. Morier    V. Goncalves-Matoso    F. Doenz     X. Jeanrenaud     L. Hirt    P. Michel                             
 
Centre Hospitalier Universitaire Vaudois (CHUV)

SWITZERLAND

Background: Pulmonary arteriovenous malformations (PAVMs) due to hereditary hemorrhagic telangiectases (HHT) is associated with paradoxical strokes, brain abcesses, and increased prevalence of migraines. We report a patient in whom we found a relationship between PAMVs and a reduction in frequency of migraine with aura after the treatment of the first pulmonary malformation. Patient and Methods: A 67-year-old woman developed migraine with visual aura and major epistaxis during childhood. A PAVM is discovered and surgically removed in 1969. Migraines nearly disappeared during several years, after which they started to reappear progressively. A HHT syndrome is diagnosed based on recurrent epistaxis, the development of cutaneous telangiectases and a positive family history. She suffered a left subcortical stroke in 2008. Perfusion CT, chest radiography, thoracic CT-angiography, contrast echocardiography, contrast transcranial Doppler and cerebral MRI were performed. Results: Perfusion CT showed previous asymptomatic strokes in cerebellum and basal ganglia. 4 PAMVs were confirmed on the chest x-ray whose structural conformation is identified on thoracic CT. Contrast echocardiography and transcranial Doppler showed a massive right to left shunt. It is planned to embolize the 4 PAVMs, and migraine frequency will now be prospectively assessed. Conclusion: This patient with a pulmonary arteriovenous malformation showed a reduced migraine frequency after resection of her lung lesion. This suggests a causal relationship between a right to left shunt and migraine, as discussed in patients with patent foramen ovale.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
Infarction of the "hand knob" area mimicking radial nerve palsy: a case report
I. Vastagh    M. Pozsár    Á. Palásti     Zs. Arányi     P. Barsi    D. Bereczki                             
 
Semmelweis University Faculty of Medicine

HUNGARY

Background: Isolated hand weakness due to stroke is rare, and is often misdiagnosed as peripherial lesion. We report a 51-year-old man with isolated arm palsy, mainly affecting the extensors. Methods: We demonstrate the symptomes and the results of investigations of the patients, especially images of computer tomography (CT) and magnetic resonance imaging (MRI). Result: MRI confirmes acute infarction involving the hand knob area of the primary motor cortex. Discussion: Our case emphasises that small cortical infarction can cause radial type palsy. Precise evaluation of the clinical and radiological profiles helps us to make the correct diagnosis.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
Hypersomnia and neuropsychological deficits after acute bilateral paramedian thalamic stroke
K. Spengos    G. Paraskevas    E. Anagnostou     G. Tzimas     E.  Manios    S. Vassilopoulou     V.P.Zis                     
 
University of Athens

GREECE

Background: Paramedian thalamic stroke is characterized by a classic triad of symptoms: acute decrease of consciousness, neuropsychological disturbances and abnormalities of vertical gaze. Bilateral thalamic infarction due to the occlusion of the artery of Percheron is associated with more severe strokes with persisting deficits. We present a case of bilateral paramedian thalamic stroke that was identified as cause of newly observed hypersmonia and neuropsychological deficits in an otherwise healthy 75-year old man. Case presentation: Suspecting dementia the patient’s relatives searched for neurological advice almost one week after having observed severe hypersomnia (>17h/d) and rapid cognitive decline. An initial episode of lethargy followed by a state of confusion for 15 hours was reported. The patient had no memory of this incident. On admission only slight dysarthria was found. No oculomotor alterations were seen. Primitive reflexes were bilaterally present. Neuropsychological evaluation revealed a severe cognitive deficit (MMSE19/30; Clock-test 2) affecting mainly temporal and spatial orientation, memory recall, complex attention and visual recognition. No similar features were previously observed. A subacute bilateral paramedian thalamic infarction was identified as cause of this syndrome by means of diffusion weighted MRI. With the exception of hyperhomocysteinemia no other vascular risk factors were described. Detailed diagnostic evaluation including holter-ECG and transesophageal echocardiography failed to identify a source of embolism, finally leaving stroke etiology undetermined in the present case. At follow-up three months later no significant improvement was documented. Conclusion: We present in detail the neuropsychological features and sleep changes in a case of subacute bithalamic stroke.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
Pathogenesis of stroke caused by osteophytic compression of a vertebral artery
S. Lanthier    F. Guilbert                                                           
 
Université de Montréal and Centre hospitalier de l'Université de Montréal

CANADA

Background: Compression of a vertebral artery (VA) by osteophytic spurs is a rare cause of ischemic stroke (IS), attributed to hemodynamic compromise due to insufficient contralateral supply. Goal: To challenge this hypothesis. Methods: Case report. Results: A 53 year-old man with controlled hypertension and dyslipidemia had several transient ischemic attacks (TIA) lasting <1 minute and four IS between 2002-09 and 2006-12 despite antiplatelet, antihypertensive, and statin therapy. His TIA/IS consisted of vertigo, left sensory-motor deficit and unstable gait. He had isolated transient binocular blindness (ITBB) in 2006-11. He reports no cardiac symptoms or craniocervical trauma or pain. He quited smoking in 2005-02. Physical exam shows dysathria, left sensory-motor and cerebellar deficit, unstable gait, and normal vital signs, heart and neck arteries. Serial brain MRI between 2002-11 and 2007-04 revealed consecutive infarcts in the inferior part of both cerebellar hemispheres. Contrast angiography revealed two 40-60% excentric stenoses in the second segment of the right VA, occluded left posterior inferior cerebellar artery (PICA), small but patent left VA, patent carotid, basilar and intracranial arteries, and no atherosclerosis. CT angiography (CTA) showed right VA compression by osteophytes at C5-C6 and C6-C7 spinal levels, causing stenoses. Results of three 24-hour Holter monitorings, transthoracic and transesophageal echocardiography, blood glucose, lipids on statin treatment (LDL=1.79 mmol/l, total/HDL=2.51), and prothrombotic and vasculitic work-up were normal. He underwent right VA surgical decompression on 2007-06-07. He had no additional TIA or IS as of 2008-01-11. Discussion: Although ITBB in the case we report suggests right VA dissection with top of basilar embolism, absence of neck pain, multiple TIA/IS over several years, absence of infarcts in territories distal to the right VA, and left PICA occlusion are more consistent with hemodynamic compromise. Surgical VA decompression resolves the cause in both mechanisms.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
Two cases of spontaneous intracranial vertebrobasilar artery dissection with different clinical outcome
D.I.Shin    H.S.Han    S.H.Lee     S.S.Lee                                            
 
Chungbuk National University Hospital

SOUTH KOREA

Background & Significance:Spontaneous intracranial vertebrobasilar artery dissection is a rare clinical entity. Though anticoagulation has been recommended for patients with acute dissection of vertebrobasilar artery, the validity of such treatment has never been proved. We experienced two patients with anticoagulant therapy who had no consistent results. Cases:Case 1. A 41-year-old man suddenly developed headache, dizziness and dysphagia 1 day before admission. Neurologic examination showed minimal dysarthria, left facial hypesthesia and left limb ataxia. Brain MRI showed left cerebellar infarction and left medullar was compressed by left vertebral artery dissection. Transfemoral cerebral angiography showed a tapered, flame-like occlusion of an acute vertebral artery dissection. After anticoagulant therapy, he complained chest pain and dyspnea six days after admission. Chest CT showed moderate amounts of pleural effusion and hematoma in right lung field. Case 2. 51-year-old healthy man was admitted to Chungbuk national university hospital complaining of dizziness, dysarthria and right side weakness. These symptoms lasted for two hours, being mild and transient. There was no abnormality on the neurologic examination. Brain MRI showed no acute lesion. MR angiography and transfemoral cerebral angiography findings were consistent with basilar artery dissection. After anticoagulant therapy, he had no more attacks of these symptoms. Conclusion or comments:The therapeutic approach for spontaneous intracranial vertebrobasilar artery dissection has not yet been full established. The risk/benefit rate of anticoagulation must be carefully weighed in patients with intracranial vertebrobasilar artery dissection. As many of them have serious underlying disorders, anticoagulation may carry increased risk.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
Visual extinction and dominant hemisphere strokes
M. Rodrigues    R. Maré    C. Ferreira     J. Fontes                                            
 
Hospital S. Marcos, Braga

PORTUGAL

Background: Visual extinction is the inability to detect stimulus opposite the brain lesion, in the presence of bilateral stimuli, but preserving it when unilaterally applied. It is frequently associated with stroke, especially in the non-dominant hemisphere Case reports: The first is the case of a 41-y-old male, admitted with aphasia and right hemiparesis, that gradually improved, who presented right visual extinction until day 4. CT scan showed left frontal ischemic stroke. The second is a 58-y-old male, also admitted with aphasia and right hemiparesis, scoring 10 in the National Institute of Health Stroke Scale (NIHSS), who underwent thrombolysis with rtPA. During the 1 hour rtPA perfusion, he presented right visual extinction. He was discharged scoring 1 in the NIHSS (disarthria) and follow-up CT scan showed left striatal ischemic stroke. Discussion: Visual extinction is present in about 24,3% of the strokes in the non-dominant hemisphere and in 4,9% in the dominant. In the later it is usually transient. Most frequent locations are cortical, especially frontal, and there also some descriptions of basal ganglia strokes, as were our cases. They presented transient visual extinction with no other types of neglect. Routine use of the NIHSS allows the detection of less frequent findings as is the case of right visual extinction.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
Posterior circulation stroke, vertebral artery dissection and pheochromocytoma
J. Damásio    M. Cardoso    J. Chaves     A. Tuna     M. Correia                                    
 
Hospital de Santo António, Centro Hospitalar do Porto

PORTUGAL

Background: Cervicocerebral arterial dissection is a recognized cause of stroke among young individuals, with extracranial arterial dissections more frequent and intracranial dissections, although rare, a well documented entity. Its pathogenesis is partially understood, with trauma and arteriopathy being considered important causes. Case report: A 50-years-old male with history of dyslipidemia, smoking and alcoholic habits presented sudden left-sided weakness during exercise. On first examination he had slight left-sided hemiparesis which deteriorated minutes later – score 6 on National Institute of Health Stroke Scale. Cranial computed tomography (CT) was normal. Treatment with alteplase was started 90 minutes after symptoms onset. During thrombolytic treatment he developed: ophthalmoplegia (left oculomotor palsy with pupillary sparing); left-sided hyperhidrosis and coldness; right peripheral facial palsy; decreased right palatal excursion; dysphonia and liquids dysphagia; left-sided hypesthesia and left Babinski sign. For two hours clinical status fluctuated, and then presented normal neurological examination. Brain magnetic resonance (MR) was normal; angio-MR and angiography disclosed intracranial right vertebral artery dissection. During hospital stay he had, previously unknown, high blood pressure (HBP). Investigation revealed high levels of catecholamines and metanephrines on 24-hour urinary collection and right adrenal mass on abdominal CT. He was submitted to surgery and histopathology revealed pheochromocytoma. Comments: We find this case interesting on account of the clinical fluctuation during alteplase perfusion and the much probable relation of arterial dissection with exercise-associated HBP peaks, as first manifestation of pheochromocytoma.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
Progressive unilateral cerebral lesions and early atrophy in late onset Mitochondrial myopathy, Encephalopathy, Lactic acidosis and Stroke-like episodes (MELAS)
A.E.KOUAME-ASSOUAN    T.H.CHO    B. MOUSSON DE CAMARET     F. TAHON     L. DEREX    P. TROUILLAS     N. NIGHOGHOSSIAN                     
 
Hôpital neurologique Pierre Wertheimer. unité 201, Centre d'urgences cérébrovasculaires. CHU Lyon

FRANCE

Background Late onset MELAS is seldom reported. Unusual clinical and radiological features may further confound diagnosis. We report a late onset case of MELAS with serial magnetic resonance imaging (MRI) monitoring. Case description A 38-year-old woman presented with sudden onset of confusion, psychotic behavior, mild aphasia and 3 partial epileptic seizures. Medical history was unremarkable. Short stature and previous migrainous headaches were noted. Acute cerebral MRI revealed a left temporal lesion with non-vascular distribution. Diffusion-weighted imaging disclosed a mixed apparent diffusion coefficient (ADC) lesion pattern, with reduced ADC values in the cortex and elevated ADC in adjacent subcortical white matter. Follow-up MRI on day 5 and 17 showed progressive unilateral parieto-occipital extension and severe atrophy. Genetic analysis confirmed the A3243G mutation of mitochondrial DNA on peripheral blood. Clinical evolution was unfavorable with persistent cognitive impairment. Conclusion MELAS should be considered in cases of unilateral, rapidly progressive lesions with heterogeneous ADC and early atrophy on MRI.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
Oral contraceptive pill use prior to first presentation in Moyamoya Disease. Is abnormal thrombogenesis an aetilogical factor?
C.E.Machili    S.L.Dawson                                                           
 
Leicester General Hospital, Gwendolen Road, Leicester, LE5 4PW

UNITED KINGDOM

Introduction Moyamoya is a cerebrovascular disease characterised by progressive occlusion of the major arteries feeding into the Circle of Willis. Its aetiology remains elusive but histological examinations observing fibrin thrombi in close association to areas of intimal thickening, and the demonstration of smooth muscle growth promotion by fibrin-fibrinogen in vitro suggest a candidate role for abnormal thrombogenesis. Case Report We report an 18 year old woman who presented with a right total anterior circulation stroke, National Institute of Health Stroke Scale (NIHSS) 14. A month prior to presentation she started taking the oral contraceptive pill (OCP). She otherwise had no other notable stroke risk factors. Three weeks prior to her stroke she experienced recurrent headaches. Her head CT and MRI scans confirmed right middle cerebral artery (MCA) territory infarction. Magnetic resonance angiography showed occlusion with absence of flow in both internal carotid arteries at and above the skull base. Carotid angiography showed obliteration of the carotid siphons bilaterally with the intra-petrous portions terminating in moderately sized collaterals and capillary blushes, radiological features compatible with Moyamoya disease. Discussion OCP use is associated with increased risk of ischaemic stroke and the observed two fold rise in stroke incidence relative to controls is yet higher in the context of traditional stroke risk factors and thrombophilia. Oestrogens have complex and multifaceted effects on the neurovascular unit and although some e.g. vasodilatation and anti-oxidation are neuroprotective, others e.g. increased inflammation, platelet and thrombin activation and synergism with factor V Leiden contribute to an increased stroke risk. Although the aetiology of Moyamoya remains elusive, abnormal thrombogenesis may cause the emergence of Moyamoya vessels. Continuing thrombogenesis (as promoted here by OCP) in a critically narrowed vessel, further expedited by slow flow, could be the final event precipitating vessel occlusion and clinical stroke.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
A rare case of bilateral complete Third nerve palsy and mid-sized pupils
R. Sivakumar    S. Rao    L. Fan     S. McCracken                                            
 
Ipswich Hospital, Ipswich, Suffolk

UNITED KINGDOM

Background: Top of Basilar artery syndrome (TBAS) typically causes a combination of visual, oculomotor and behavioural manifestation. Unilateral Third nerve palsy is common but bilateral complete Third nerve palsy with fixed midsized pupils is very rare. Case report: A 74-year-old lady was admitted with unresponsiveness. She had a past medical history of myocardial infarction and was an ex-smoker. Glasgow Coma Scale fluctuated between 5 and 13. Examination revealed bilateral complete ptosis with bilateral complete IIIrd nerve palsy. Pupils were mid-sized and unresponsive. There was mild left sided weakness and ataxia. Deep tendon reflexes were normal with bilateral extensor responses. Unenhanced CT scan was unhelpful. She also experienced many episodes of extreme sleepiness during which she was barely arousable. MRI with diffusion weighted imaging revealed an acute infarct involving the midbrain/mesencephalon and infarcts in both the thalami. Holter monitor and Echocardiogram did not reveal any potential cardiac substrate. A diagnosis of TBAS was made. Hypersomnolence episodes gradually reduced in frequency but other deficits persisted. Discussion: The presentation of TBAS can be a mesencephalon-diencephalon or posterior hemispheric picture or both. Midsized fixed pupils can be explained by involvement of both parasympathetics and sympathetics. In a large series, only one out of 61 patients had bilateral complete IIIrd nerve palsy.1 It is likely that this sort of symmetrical bilateral medial thalamic and rostral mesencephalic infarctions result from the involvement of a single blood vessel (artery of Percheron) arising from either of the posterior cerebral arteries. 2 Ref: 1.Arch Neurol. 1988;45:966 -971 2.Am J Neuroradiol 24:2005-08

http://www.eurostroke.org/ni_graphics/g_aid3054.htm
 

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
Ischemic stroke due to post partum angiopathy following preeclampsia
R. Werner    R. Berger    J. Middelanis     J.C.Woehrle                                            
 
Katholisches Klinikum, Koblenz

GERMANY

Background: Pregnancy can be complicated by cerebrovascular disease. While endothelial dysfunction in preeclampsia (PE) may lead to posterior reversible encephalopathy syndrome, post partum angiopathy (PPA), featuring vasoconstriction of large cerebral arteries, is a rare cause of ischemic stroke. Case report: Two days after delivery of a healthy girl, the 25-year old primigravida with no past medical history or family history of thromboembolic events noticed sudden difficulties in concentration, verbal and written expression and reading together with a bifrontal dull headache. Pregnancy had been complicated by PE with elevated blood pressure and proteinuria. The neurological examination revealed a gyrus angularis syndrome with alexia, dyscalculia, left-right confusion and finger agnosia. Colour-coded duplex sonography showed bilateral stenoses in the M1-segments of the middle cerebral arteries (MCA). Magnetic resonance imaging displayed restricted temporoparietal diffusion on the left side, consistent with acute stroke in the MCA-territory. Cardiac or aortic sources of embolism, carotid dissection, cerebral venous sinus thrombosis, encephalitis or vasculitis were excluded. We diagnosed PPA with intracranial vasospasms as the cause of stroke. An additional causative factor was assumed for the mild antiphospholid syndrome with positive lupus anticoagulant and slightly elevated partial thromboplastin time. The antiphospholid syndrome is known to increase the likelihood of PE. We treated with acetylsalicylic acid, low-dose nadroparin, isovolemic hemodilution, and reduced the antihypertensive medication (alpha-methyl dopa, dihydralazine). The vasospasms gradually subsided. The neuropsychological deficits improved with speech therapy and occupational therapy. Discussion: In case of sudden central nervous deficits around childbirth one has to consider PPA, in particular if the patient had previously suffered from PE. PPA and PE may share common pathophysiological features, of which one could be the antiphospholipid syndrome.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
OCULAR ISCHEMIC SYNDROME, IS NEWER TREATMENT HELPFUL?
M. Haq    S. Hussain      Rajesh       Ummer       Swadiq                                    
 
Ems Memorial Hospital,Perinthalmanna

INDIA

Back ground:-Ocular Ischemic Syndrome(OIS) is rare diseaese,awareness about this is less among ophthalmologists.If suspected and proper neurological evaluation is done and treated accordingly - carotid artery stenting-it prevent future neurological complications and may improve visual out come CASE REPORT Middle aged diabetic male presnted to an Ophthalmologist with sudden dimness of vision on right eye.After clinical examination a fluorescein angiography was advised and due to strong clinical suspesion a neurology evaluation was asked.Patient was neurologically stable except for dimness of vison on right side.He was taken up for 4 vessel cerebral DSA and this showed 93% stenosis of right internal carotid artery proximally and distal right ACA was filled by ACOM through left side Patient was taken up for CAS(Carotid artery Stenting)under local anaesthesia after explaining the need for revascularisation to prevent future risk of stroke which is very high.Procedure was uneventful and the patient was discharged on third day.He developed secondary glaucoma one week later which was treated and the vision is gradually inproving after that. CONCLUSIONS 1 Awareness of Ophthalmologist about Ocular Ischemic Syndrome is necessary for early diagnosis and treatment 2 Early treatment will prevent future neurological complicatuion 3 Intrventional Neurology offers safe and effective treatment for OIS 4 vISUAL OUTCOME MAY BE BETTER IF TRETED EARLY AS IN THIS CASE

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
Intracranial stenting for rapid revascularization in acute carotid artery “T” and/or complete middle cerebral artery “M1” segment occlusions
Z. Kulcsar    C. Bonvin    B. Gory     H. Yilmaz     R. Sztajzel    D.A.Rufenacht                             
 
Geneva University Hospital

SWITZERLAND

Background and purpose: Carotid-T and complete middle cerebral artery M1 segment occlusions are most resistant to recanalization attempts with a high failure rate. We present our initial experience with intracranial stenting in the treatment of such occlusions. Materials and methods: Five acute stroke patients with a mean age of 56 years, presenting acute carotid-T and/or complete M1 segment occlusion (4/1) with severe neurologic symptoms were treated with self expandable intracranial stenting for revascularization. In the retrospect analysis the success rate of stent deployment, the recanalization rate and the outcome of patients was assessed. Results: At presentation one patient was unconscious and intubated, the other 4 patients had a mean NIHS-score of 15. Prior to the endovascular intervention systemic thrombolysis was not performed in neither of cases. Stent deployment was preceded by ineffective thrombaspiration and thrombectomy manoeuvres in two cases. Successful stent deployment and immediate recanalization was achieved in all of the cases with a TICI score of 2a, 2b and 3 in two, two and one cases respectively. The mean time needed to stent deployment after the first contrast injection was 57 minutes (range 42–101 minutes), time including the diagnostic runs and thrombectomy/thrombaspiration manipulations. No procedure-related complications were noticed. Two patients developed intracerebral hematoma, one patient died. The mean NIHS-score of the 4 surviving patients at 10 days was 10, but only one patient (with the TICI 3-recanalization) showed a complete recovery. Conclusions: Acute treatment with self expandable stents proved to be feasible, efficient and fast in the recanalization of the occluded vessels with a 100% angiographic success. The results suggest that stenting may be an option for recalcitrant cerebral arterial occlusions, however the need of use of antiplatelet drugs might constitute a problem in the further management of patients who become candidates for neurosurgical interventions.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
Acute organic psychosis – a rare, severe complication of rostral brainstem stroke
J.C.Wöhrle    R. Werner                                                           
 
Katholisches Klinikum Koblenz

GERMANY

Background: Peduncular hallucinosis is one complication of the top of the basilar syndrome. Further features like somnolence, apathy, insomnia and agitation are described by Caplan in 1980. Case report: A healthy 44 year-old smoker was admitted with acute asymmetric tetraparesis (R>L), left-sided hemiataxia, dysarthria, and a complex eye movement disorder (bilateral paresis of adduction, ptosis, vertical gaze palsy, disturbed convergence). Ultrasonography and magnetic resonance angiography revealed a high-grade top of the basilar artery obstruction that was subsequently recanalized by endovascular thrombolysis and thrombectomy. After intervention, the patient was awake, oriented and mobilized to standing, but the eye movement disorder persisted. After 4 days, he developed psychotic symptoms with agitation and aggression, as well as sweating and tachycardia, requiring neuroleptic medication and physical restraint. Exploration of relatives and laboratory investigations excluded a substance withdrawal syndrome or metabolic disturbance. Repeated cerebrospinal fluid and autoantibody studies were normal. Repeated brain imaging documented left and central mesencephalic and left superior cerebellar artery infarctions. We assumed that the rostral brainstem infarction was responsible for the acute psychosis. The psychomotor agitation with reaching and fighting against intruders was typical for persons hallucinating; however the patient was now mute. Psychotic symptoms improved over two weeks and he started to show depressive emotional expressions, when referred to a rehabilitation unit. Discussion: Severe visual deprivation can be the cause for visual hallucinations in patients with ocular disease (Charles-Bonnet-syndrome). Moreover, visual hallucinations occur in top of the basilar artery infarctions as peduncular hallucinosis, possibly arising from lesions of the reticular formation and dopaminergic nuclei. In our case, both etiologies may have led to the observed severe organic psychosis with delayed onset after rostral brainstem infarction.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
An Uncomoun sensitive impairment in a Lateral Medullar infarction
J. Fernández Domínguez    J. Medina Báez    A.  Tallón Barranco     L.  Gabaldón Torres     B. Fuentes Gimeno    A. Frank García     E. Díez Tejedor                     
 
Hospital Universitario La Paz. Madrid

SPAIN

INTRODUCTION: Lateral Medullar Infarction, known as well as Wallenberg`s syndrome, was completely describe in 1895. Among the different typical symptoms, it has a common sensitive loss patron characterized by decrease or loose of tactil and algesic sensitiveness in the ipsilateral hemiface and in the contralateral hemibody (both referred to the lesion). In fact, there are multiple sensitive expressions in Wallenberg´s syndrome. Stopford´s classification, developed in nineties is one of the multiple classifications done for the sensitive impairment in this syndrome. MATERIAL AND METHODS: We present a 55-year-old patient with clinical history of Familiar Hypercholesterolemia, unknown hypertension and great tobacco smoker, who complained of sudden numbness, dizziness and gait ataxia. Neurological examen showed left IX and X cranial nerves impairment, Left Horner`s syndrome, left hemiface algesic and tactil sensitive decreased as well as right hemibody tactil and algesic loss, and vibratory decreased sensation in left hemibody. Cranial RMI and RM Angiography were done. RESULTS: Left lateral medullar infarction as well as left PICA stroke were shown, both of them due to left vertebral arterial thrombosis. CONCLUSION: Vibratory loss is uncommon in lateral medullar infarction, but possible. It could be due to an anatomic variant of the spinocerebellar tract or to a damage of both cuneatus and gracilis nuclei in cervical medulla, before their decussation. More research should be done in order to stablish the different possible patrons of sensitive expression.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
Intravenous thrombolysis in a first trimester pregnant woman with acute ischemic stroke
V. Palumbo    P.  Nencini    I. Romani     M.  Nesi     D. Inzitari                                    
for The Careggi Stroke Team
University of Florence

ITALY

Background: The use of thrombolysis in ischemic stroke during pregnancy is considered relatively contraindicated, although not specifically addressed in European guidelines, due to concern over the risk of bleeding mainly at placenta level. Pregnant women remain excluded in ongoing randomized controlled trials. Summary of case: We report the case of a 32 year old woman who presented to Emergency Department with left hemiplegia, hemianestesia, and hemineglect within 97 minutes from onset (NIHSS 18). CT scan showed hyperdense middle cerebral artery and early hypodensity on right temporal lobe and lenticular nucleus. An ultrasound showed the presence of right internal carotid and middle cerebral artery occlusion. The patient had a history of polycystic ovary syndrome, with insulin resistance, hyperandrogenemia, and anovulation. Monthly followed by a fertility clinic, the patient had been recently put on progestin drug for presumed persistent anovulation. Due to the presence of severely disabling deficit, the patient was treated with intravenous tPA at 170 minutes from symptoms onset after obtaining informed consent; a partial recanalization of both vessels was achieved. The pregnancy test, performed routinely on admission in Stroke Unit, resulted positive. The patient turned out to be 9 weeks pregnant. There were no hemorrhagic complications. At 90-day follow up the patient showed moderate/severe disability due to residual left hemiparesis (mRankin Scale 3). The patient delivered a healthy infant at term. Conclusions: This case shows that intravenous tPA may be safe in ischemic stroke within 3 hours, even in the first-trimester of gestation. Pregnant women are treated occasionally and mainly inadvertently. Further exploration on this topic is warranted.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
HEMORRHAGIC AND ISCHEMIC STROKE IN SNEDDON'S SYNDROME: A CASE REPORT
L. Fumagalli    M. Brioschi    P. Santoro     M. Piatti     C. Ferrarese                                    
 
University of Milano-Bicocca, S. Gerardo Hospital, Monza

ITALY

We describe a case of a 32-years-old woman who presented sudden cephalalgia and loss of consciousness. She had an history of Raynaud’s phenomenon and diffuse purplish mottled discoloration of legs, arms and trunk such as livedo reticularis since the infancy. She had a familiar history of juvenile ischemic stroke. At the Emergency Department she presented unconscious. A cerebral TC scan revealed a left cerebellar haemorrhage and subdural occipital haematoma. Neurosurgical evacuation was made and cerebral pressure was monitored with external derivation of cerebrospinal fluid. She was studied with cerebral angiography showing disseminated vasculitic alterations with left carotid siphon, bilateral pericallosal arteries and right vertebral artery stenosis. A subsequent angiographic study achieved one week later didn’t show any modifications. Cerebral NMR performed showed residual cerebellar haematoma, diffuse ischemic lacune and ventricular and cortical sulci atrophy. Trombophilic and immunological studies, including antiphospholipid antibodies, were negative. After 2 weeks, owing to neurological worsening, brain CT scan and NMR showed a left cerebellar ischemic lesion and a treatment with aspirin was introduced. During recovery patient’s consciousness gradually improved: at dimission she presented disartria, nistagmus, gaze palsy, flaccid tetraparesis and ataxia. The association between livedo reticularis, stroke and the angiographic findings led us to the diagnosis of Sneddon's syndrome (SS). SS is checaracterized by livedo reticularis and multiple ischemic cerebrovascular events with cognitive impairment. Intracerebral, subarachnoid or intraventricular haemorrhage have rarely been reported, maybe due to ischemia-related angiogenesis. Neuroradiological findings include stenosis and occlusion of the major cerebral vessel, transdural anastomosis, large networks of fine collateral vessels and granulomatous leptomeningeal infiltration at cerebral angiogram and small white matter infarcts, leptomeningeal enhancement, diffuse atrophy at MRI.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
"Brown-Sequard Syndrome as a Complication of Anticoagulation Therapy"
A. Sharma    S.E.Brook    D.J. R.Morgan                                                    
 
Chelsea and Westminster Hospital NHS Foundation Trust, London

UNITED KINGDOM

Introduction Brown-Séquard syndrome is uncommon, constituted of ipsilateral hemiplegia with contralateral pain and temperature sensation deficits. Causes include spinal cord trauma, tumour, degenerative spine disease, ischaemia, spinal infections or inflammation and spinal haematoma. Spinal haematomas occurring spontaneously are rare. They are often neurosurgical emergencies requiring prompt diagnosis and treatment. Haematoma causing Brown-Séquard syndrome is usually due to trauma but can form spontaneously, often as a result of anticoagulation therapy. All types of haematoma have been reported in literature to present as Brown-Séquard syndrome, but the majority are epidural and subdural in nature. There are very few reports of subarachnoid haematoma presenting in such a manner, especially if due to anticoagulation therapy. Methodology This report illustrates the case of a 75-year old male on antigoagulation therapy with warfarin for atrial fibrillation. He was admitted to the hospital with an acute onset left leg weakness that mimicked a cerebrovascular event. It was later confirmed to be Brown-Séquard syndrome. Magnetic resonance imaging showed cord compression at T2 level due to a subarachnoid lesion within the thoracic spinal canal. The patient underwent T1-T3 laminectomy with subsequent histopathology confirming the lesion removed to be a haematoma. Due to the delay in diagnosis and the subsequent evacuation of haematoma he did not regain any strength in his left leg despite intensive physiotherapy and was transferred to a neuro-rehabilitation centre. Discussion As the use of anticoagulation therapy is increasing in the clinical practice, the report proposes a critical review of the pertinent literature of spinal haematoma as a result of warfarin use. Additionally, recognising ist relatively atypical clinical presentation in a timely manner will allow correct diagnostic and therapeutic measures to be taken to maximise the patient's chance of complete recovery.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
Bilateral cerebellar ataxia due to an unilateral brainstem infarction
S.W.Han    S.J.Yim    J.H. Park     J.S.Baik     J.H.Park                                    
 
Sanggye Paik Hospital, Inje University College of Medicine

SOUTH KOREA

Background & Significance: Cerebellofugal fibers from dentate nucleus of cerebellum proceed to superior cerebellar peduncle and cross at tegmentum of caudal mesencephalon. These fibers, via contralateral red nucleus, go to the thalamus or olivary nucleus. Although the functions of these fibers are well known, the precise anatomic pathways are not documented. Moreover, bilateral cerebellar ataxia due to an unilateral brainstem infarction is rare. Case1: A 70-year-old man with a history of diabetes mellitus and hypertension presented with an abrupt gait disturbance. On neurologic examination, there was severe dysmetria on finger-to-nose and heel-to-shin testing on both sides. He did not fall in any directions upon sitting or standing. He could stand but not walk due to gait ataxia as well. There was no motor weakness, sensory changes, or ocular signs. Brain magnetic resonance imaging (MRI) showed a right paramedian infarct in the tegmentum of the caudal mesencephalon. Magnetic resonance angiography revealed a multifocal stenosis of right posterior cerebral artery. Transthoracic echocardiographic study was normal. Over the several days, his gait and limb coordination were improved gradually. After 14 days of symptom onset, he could walk independently but remained mild dysmetria on heel-to-shin and finger-to-nose tests. Case2. A 74-year-old woman with a history of diabetes mellitus presented with an abrupt gait disturbance. On neurologic examination, there was severe dysmetria on finger-to-nose and heel-to-shin testing on both sides. She could stand but not walk due to gait ataxia. There was no motor weakness, sensory changes, or ocular signs. Brain MRI showed a left paramedian infarct in the rostral pons. Conclusion: We report two patients with bilateral limb ataxia after unilateral brainstem infarction. The ipsilateral involvement of both cerebellofugal fibers in the rostral pons and caudal mesencephalon, before and after decussation, was responsible for the bilateral cerebellar ataxia.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
Bilateral spontaneous carotid cavernous fistula treated by transfemoral embolization
M.S.Park    J.T.Kim    S.H.Lee     S.M.Choi     M.K.Kim    K.H.Cho     I.G.Kim                     
 
Chonnam National University Hospital

SOUTH KOREA

The carotid cavernous fistula (CCF) is an abnormal communication between the carotid system and the venous cavernous sinus. Bilateral spontaneous carotid cavernous fistula is extremely rare. In the previous literature, the occurrence rate of bilateral traumatic CCF ranged from 0.17-1.01%. However, the incidence of bilateral spontaneous CCF might be lower than that of traumatic CCF. We present a 63-year-old woman with bilateral spontaneous CCF. The patient had had severe stenosis of cavernous portion of left ICA for 2 years which determined by conventional angiogram and treated with aspirin medication. One month ago, she developed bilateral exophthalmos and conjunctival injection. Angiography revealed a Barrow type C CCF. The patient was treated with transarterial embolization by detachable balloon. We report a case of bilateral spontaneous CCF and also reviewed the previous literatures.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
Clinical features and comorbidity in Greek Moyamoya patients
K. Spengos    S. Vassilopoulou    E. Anagnostou     G. Paraskevas     P. Zis    E. Manios     E. Koroboki     V.P.Zis             
 
University of Athens

GREECE

Background: Moyamoya (MM) is a rare arteriopathy of unknown etiology affecting typically the intracranial portion of the anterior circulation and sometimes also the vessels of the posterior circulation. Especially in cases of Caucasian adults with other associated conditions the diagnosis of MM-syndrome rather than MM-disease is suggested. We present the imaging findings, clinical features, history of the disease and comorbidity in a series of 5 Greek patients diagnosed with MM in our institution in the period 2002-2007. Case presentations: In four women and one man aged 25-47 years the diagnosis of MM syndrome was set. Time between symptom presentation and diagnosis ranged from a few days (2 cases) up to 11 years. Two cases with delayed diagnosis were initially treated as multiple sclerosis. Acute ischemic stroke (47y-W) and first epileptic seizure (39y-M) were the initial symptoms leading to a rapid diagnosis, whereas progressive gait disorder was the main feature in both cases that were first misdiagnosed as multiple sclerosis (40y-W, 25y-W). A visual field defect was the initial symptom of the last case (34y-W) that was correctly diagnosed 5 years later while evaluating hyperventilation enhanced choreatic movements. Involvement of both anterior and posterior circulation was visualized by means of DSA in 3 of 5 cases. Multiple ischemic lesions, clinically silent or prominent, were seen in all cases on MRI. Arterial hypertension was documented in two women, whereas the man suffered also from coronary heart disease. Mental retardation and an optic nerve coloboma were found in one woman, whereas Turner syndrome, glaucoma, arterial hypertension and mild cognitive impairment were present in another. Glaucoma and arterial hypertension were also found in a female, whereas the male patient suffered also from coronary heart disease. One woman underwent-interna-externa bypass-surgery and another gave birth to healthy girl after section caesaria. Conclusion: MM is a rare cause of stroke among young adults and is associated with various other conditions and diseases.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
Unilateral superficial siderosis revealing a cerebral amyloid angiopathy
I. Bonnaud    N. Limousin    S. Debiais     D. Saudeau     B. De Toffol    J.P.Cottier                             
 
CHRU Bretonneau

FRANCE

Background Superficial siderosis (SS) is a rare entity, characterized by chronic hemosiderin deposition in the subpial layers of the brain and spinal cord. Main symptoms are classically gait disturbances and hearing loss. It usually results from a chronic subarachnoid hemorrhage in patients with tumors or vascular malformations. The causal lesion remains undiscovered in 50 % of cases. We report a case of an atypical unilateral SS revealing a CAA. Methods Case report. A 84 y.o. man was admitted because of recurrent confusional states. Three months before, he had presented with a transient aphasia evoking a TIA, and aspirin had been instituted. At admission, he was confused and reported visual hallucinations, the MMS was 26/30. In the following days appeared cognitive disorders, visual troubles, delirium, gait disturbances and falls. Biological examinations (vitamins, thyroid, bacterial and viral serologies) were normal. Analysis of the CSF showed a normal protein and glucose rate, 2 leukocytes and 250 red cells/ mm 3. The CT scan showed only isolated leukoaraiosis. An MRI examination demonstrated several right hypo-intensities in T2 -weighted sequences, specific of hemosiderin deposition. There was a subacute subarachnoid hemorrhage on the right side, and small spontaneous frontal hematomas in T2* weighted sequences. Diagnosis of unilateral SS complicating a CAA was evoked. The clinical status worsened and the patient died two weeks later. Conclusion This is an atypical case of right hemisphere dysfunction, due to unilateral SS associated with a probable CAA, in an old demented patient with spontaneous lobar hemorrhages. Aspirin could have worsen the chronic hemorrhage. This association is difficult to demonstrate. Extensive examinations are necessary to confirm the diagnosis.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
A case of a young woman with Multiple Cerebral Infarctions Following Viral Myocarditis
I.M.Jang    K.B.Lee    J.H.Kim     K.I.Yang                                            
 
College of Medicine, Soonchunhyang University

SOUTH KOREA

Although non-ischemic diseases of the myocardium are commonly complicated by cerebral embolism, those are mostly associated with chronic dilated cardiomyopathy or combined with endocardiopathy. Viral myocarditis is usually benign, most patients improved significantly or recovered fully. But unfortunately, patients with myocardial infarct-like signs can develop ischemic strokes. A 36-year-old woman was admitted for sudden dyspnea. She had no medical problem except hypertension. Serum cardiac biomarkers are elevated and Echocardiography revealed multiple territory severe hypokinesia and reduced ejection fraction. On the second hospital day, she presented sudden right hemiplegia and global aphasia. Brain magnetic resonance image showed multiple cerebral infarctions in the left temporoparietal lobe and bilateral cerebellum. There is no stenosis in the intracranial or extracranial arteries on brain magnetic resonance angiography. One week later, She discharged with right hemiplegia and global aphasia in spite of completely normalization of Echocardiography findings. We suggest that anticoagulant therapy should be considered in viral myocarditis when the cardiac wall motion is severely decreased.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
Brainstem ischemia due to dissection of the vertebral artery presenting as a “Fou rire prodromique”. Case report.
S. Martínez-Ramírez    I. Barroeta    A. Vidal     M. Sáinz     E. Martínez-Hernández    J.L.Martí-Vilalta     J. Martí-Fàbregas                     
 
Hospital de la Santa Creu i Sant Pau

SPAIN

Background “Fou rire prodromique” (FRP) is a very rare form of pathological laughter that may appear as the first symptom of cerebral ischaemia. Charles Féré coined the term in 1903. Methods We report a 52-year-old man with unmotivated, inappropiate and unemotional laughter lasting for about 10 minutes followed by anarthria, diplopia , bilateral facial paresis and right brachial-crural hemiplegia. Results The pathological laughter reported by this patient showed the clinical traits of FRP. Magnetic Resonance Imaging showed acute and subacute ischaemic lesions in the vertebro-basilar territory, affecting the brainstem (right medulla, left hemiprotuberance and the left midbrain), the right temporo-occipital cortex, and both thalami as well as the cerebellar hemispheres. The Magnetic Resonance Angiography showed dissection of the right extracranial vertebral artery. The patient was treated with anticoagulation and severe neurological sequela persisted during follow-up. No further episodes of pathological laughter were observed. Discussion The Fou rire prodromique, may be a warning symptom of severe vertebro-basilar ischaemia. To our knowledge, this is the first case of Fou rire prodromique as the presenting symptom of a vertebral dissection. Although the pathophysiology of this symptom is uncertain, it is thought to be a consequence of a lesion in the descending corticopontine and corticobulbar pathways.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
Lateral medullary syndrome and ipsilateral hemiplegia (Opalski´s syndrome) due to left vertebral artery dissection.
J. Garcia-Garcia    O. Ayo-Martín    S. Garcia-Muñozguren     J. Gracia     T. Segura                                    
 
Complejo Hospitalario Universitario de Albacete

SPAIN

Background. First described in 1946, Opalski´s syndrome (OS) is considered a variant of dorsolateral medulla oblongata (Wallenberg´s) syndrome with ipsilateral hemiplegia. This association is rarely seen in clinical practice. Until now only few neuropathological and neuroradiological cases have shown that in OS the lesion is located lower the medulla, involving corticospinal fibers caudal to pyramidal decussation . Case report. After a neck trauma, a 26 year old woman developed left headache and vomiting followed by left hemiparesis. On admission she displayed left Horner´s syndrome with ipsilateral reduced facial sensation to pain and temperature. She complained of dysesthesia in the left body, but there was decreased pain and temperature sensation in her right limbs. In addition she had dense left limbs hemiparesis and slight right leg weakness. All laboratory tests were normal including the chest X-ray and the electrocardiogram. Diffusion-weighted imaging on MRI showed an acute infarction affecting the left dorsolateral medulla and upper cervical cord. MRI angiography showed abrupt luminal stenosis and a vessel wall haematoma in the left vertebral artery (VA) suggesting arterial dissection. The basilar artery was normal. Intravenously heparin was administered followed by oral anticoagulation with acenocumarol. Discussion. This case adds information regarding the anatomic basis for ipsilateral hemiparesis in dorsolateral medullary infarctions and confirms that occlusion of the vertebral artery is a frequent cause of OS that explains the simultaneous compromise of several medullary and submedullary penetrating arteries. To the best of our knowledge, this is the first report of Opalski's syndrome due to a VA dissection .

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
Progressive vertebro-basilar infarction in patients with giant cell arteritis – two case reports
H. Cangür    G. Seidel                                                           
 
University Hospital of Schleswig-Holstein, Campus Lübeck

GERMANY

Background: Giant cell arteritis (GCA) is a systemic vasculitis and a common cause of occipital headache in patients over 50 years of age. The affinity to vertebral arteries (VA) is less common but can cause progressive vertebro-basilar infarction. Similar to dissection of VA it can be accompanied with occipital headache or neck pain. Color-coded duplexsonography (CDS) of the temporal artery may help to differentiate both entities. Method: Two patients suffering from acute onset of ischemic stroke in the vertebro-basilar circulation and GCA proved by biopsy were submitted to our stroke unit within almost one year: a 71 year old female suffered from acute bilateral posterior cerebral artery (PCA) and bilateral cerebellar ischemic stroke (NIHSS 15) and a 72 year old male suffered from brain stem infarcts (bilateral inferior colliculi and right peduncle of cerebrum, NIHSS 6) . Results: GCA was proven in both patients by temporal artery biopsy and elevated erythrocyte sedimentation rate (ESR) (in the first hour 80mm (male patient) and 100mm (female patient)). On CDS (Sonos 5500, Philips) of the superficial temporal arteries (STA) a concentric hypoechogenic mural thickening (a so called halo) appeared. Vascular brain imaging showed in both an occluded right-sided VA and a narrowed left-sided VA in the segment V4. The female patient died two days after symptom onset due to space occupying infarction. A high score of NIHSS on admission indicated that malignant course. The male patient developed a progressive brainstem infarct syndrome with an increasing of NIHSS up to 16. Discussion: This case report presents two patients with GCA as an uncommon cause of vertebro-basilar infarction. The clinical course of our patients suggests a bad prognosis after onset of ischemic stroke, so early diagnosis and therapy of GCA are crucial. CDS and ESR are simple tests to differentiate GCA from VA dissection.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
Near total improvement of isolated cortical deficit in acute infarctions with loading Clopidogrel after 3 days from stroke onset: Case reports
M.M.Awadh    R.R.Moustafa                                                           
 
Ain Shams University, Cairo, Egypt

UNITED KINGDOM

Background: Neurological disabilities secondary to cortical infarctions are underestimated by various stroke severity scales. Patients with such “low score” deficits are ineligible for thrombolysis and residual dependency is the result. Few cases were reported to show near total improvement, which is either very early or quite late after the event. The pathophysiological mechanisms for such improvement are still uncertain. Methods: Three acute stroke patients with isolated cortical deficits are presented. All were candidates for our ongoing trial with single loading dose of 900 mg Clopidogrel, followed by daily 75mg and low dose anticoagulation from the next day. NIH-SS is the standard for clinical assessment and MRI, MRA or CT for follow up. Results: Three patients with isolated cortical blindness, expressive and receptive aphasia were admitted within 7, 4, 6 hours from onset of stroke, and their initial NIH-SS were 9, 4, 5 respectively. Both aphasic patients were stable in the first 48 hours without marked improvement. The patient with cortical blindness actually deteriorated with sleepiness and left hemiparesis on the second day, NIH-SS 15. All patients showed marked non-gradual improvement on the third day. Both aphasic patients were near normal except for mild dysarthria in the expressive one. The third patient improved to be with only residual mild weakness, hemihyposthesia and dysarthria. His NIHSS was then 5 and 2 on discharge after a week. All 3 could read and write easily. Discussion: These cases provide more questions than answers about the differences between “specialized” cortical and “generalized” subcortical neurones in their vulnerability to and/or recovery from an ischemic insult. An anti-inflammatory action of Clopidogrel might suggest such a mechanism.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
Pseudotumoral demyelination and the stroke physician
S.H.Wong    C Woodhall    D Crookes     K. Das     T.P.Enevoldson    R. Durairaj     R.P.White                     
 
The Walton Centre NHS Trust and The Stroke Unit, University Hospital Aintree, Liverpool.

UNITED KINGDOM

Background Stroke physicians encounter diseases mimicking stroke. We report 3 patients with vascular risk factors presenting to stroke services with pseudotumoral demyelination, illustrating clinical and imaging features. Method A case series of 3 patients. Results All patients were male (48, 57, 67 years) with stroke risk factors; 2 referred directly to the stroke unit. One presented with abrupt onset of left arm monoplegia, facial weakness and dysarthria improving within 10 minutes. Review revealed a 4 week history of left hand clumsiness. The other 2 presented with a one week history of progressive left hemiparesis and right hand apraxia respectively. Review of the latter revealed 3 months of right hand clumsiness. Patients had serial imaging. 2 had cerebral biopsies; one had serial biopsies due to inconclusive imaging and biopsies (infarct on 1st biopsy). CSF non-specific; negative oligoclonal bands in one and type 4 in two patients. Corticosteroids contributed to improvement. Discussion Stroke physicians need to manage stroke mimics. Our patients have similar demographics to stroke patients, although pseudotumoral demyelination typically occurs in women (average age 37 years). It is a protean disorder. The pathogenesis is not understood. MRI changes include little mass-effect, centrally dilated veins within the lesion, an open-ring enhancement decreased perfusion and MR spectroscopy may show elevated choline and suppressed N-acetylaspartate relative to creatine. Careful review of history frequently gives a gradual progression of symptoms, although an abrupt worsening can occur, as seen in our 1st patient. Cerebral biopsy may help, but can be inconclusive or misleading. We highlight pseudotumoral demyelination as an unusual cause of presentation to the stroke services.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
INTRACEREBRAL HEMORRHAGE AFTER NAPHAZOLINE
M. Sabau    A.M.Mos    A. Iova     I. Popa                                            
 
Clinical Hospital of Neurology and Psychiatry

ROMANIA

INTRODUCTION: Naphazoline is known as a cause of intracerebral hemorrhage. We present the case of a young man hospitalized with IH after a few days treatment with Naphazoline. CASE PRESENTATION: The patient SC 16 years old without any significant pathological history comes with large involuntary movements an the right hemibody started a few days before. 10-14 days before the patient has an infection of the superior respiratory tract and he was treated with antibiotics and Naphazoline drops. Neurological exam: right hemibalism. CT scan, MRI showed left subthalamic hemorrhage. MRA and angiography trough direct carotidian puncture are normal. CONCLUSION: Notice the fact that using this medicine who seems no harmful and who can be bought without any medical prescription in any pharmacy could determine an important cerebral complication KEY WORDS: Naphazoline, cerebral hemorrhage

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
A Case of Transient Bilateral Gustatory Change following Subacute Infarction in Right Parieto-temporal Area.
K.O.Lee    S.J.Na    J.E.Kim     K.S.Yum     Y.D.Kim                                    
 
Konyang University College of Medicine, Daejeon

SOUTH KOREA

Background & significance : Gustatory change after cerebral ischemia is an uncommon event. Some previous literature reported that primary taste cortex in human is located on the rostrodorsal insular cortex, mainly in left side. We report the case of transient bilateral gustatory change following subacute infarction in right parieto-temporal area. Case : A 74-year-old right-handed woman presented with gustatory change which was developed one month ago. She had medical history of hypertension, diabetes mellitus, angina pectoris, hyperlipidemia. And, since about ten years ago, she had suffered due to essential tremor. In neurological examination, he could not discriminate all modalities of taste perception on bilateral tongue. She felt as altered to only “sweet” perception for all stimulus of taste modalities. Dysarthria, swallowing and olfactory disturbance were not shown. No other neurological signs were observed. The fluid-attenuated inversion recovery(FLAIR) and T2-weighted images of magnetic resonance imaging(MRI) showed a high signal intensity and T1-weighted images showed hypo-intensity on white matter in right parieto-temporal area, suggested subacute to chronic ischemic stroke. The following all laboratory studies were normal or nonspecific. Her gustatory change gradually improved after two weeks later and completely subsided after one month later. Conclusions or commentes : It is well known that predominance of the left cortical hemisphere including insular cortex for taste perception in right-handed person. We documented here an uncommon case of transient bilateral gustatory change following subacute infarction in right parieto-temporal area. This case maybe suggests that other possible mechanism for perception pathway of taste. .

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
Ocular ischemia treated with external carotid endarterectomy: A brief discussion
A.C.Bhatt    M.U.Farooq    A. Majid     M. Kassab     R. Gupta                                    
 
Michigan State University

USA

Background Occlusion of CCA (common carotid artery) and ipsilateral ocular ischemia is a known entity. Collateral circulation via ipsilateral ECA (external carotid artery) may maintain patency of the distal ICA (internal carotid artery) in a retrograde fashion. These patients may still suffer transient ischemic attacks from “carotid steal phenomenon” . Recognition of this unique pathophysiological entity may allow us to effectively intervene in appropriate patients. Case presentation We describe a 67-year old male presents with a 3-year history of recurrent Amaurosis fugax right eye. He has a known history of common carotid artery occlusion. He had frequent episodes transient right eye for the 4 months. Cerebral angiogram confirmed right CCA and ICA occlusion, with collaterals between ECA and vertebral artery. Patient underwent right CCA/ECA carotid endarterectomy. A post-operative CT angiogram revealed communication right CCA and ECA with persistence of right ICA occlusion. Patient remains assymptomatic on 3-month follow-up. Conclusion We report a case of patient with left common carotid artery occlusion and ischemic ophthalmopathy, was successfully treated with endarterectomy. This may help preventing ischemic opthalmopathy due to recurrent “carotid steal”.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
Acute aphasia without initial DWI-lesion – are there DWI-negative infarctions?
C.M.Rueckert    A. Bernhard    T. Staudacher     D. Bengel                                            
 
Department of Neurology, Oberschwabenklinik St. Elisabeth Hospital

GERMANY

Background: Diffusion-weighted imaging (DWI) has been shown to be superior to conventional magnetic resonance imaging (MRI), both in early phases and also up to 48 hours after the onset of stroke. DWI is very sensitive and relatively specific in detecting acute ischemic stroke, and DWI findings have shown high levels of diagnostic accuracy. Studies have demonstrated that changes in DWI and corresponding apparent diffusion coefficient values (ADC) occur as early as 10 minutes following the onset of ischemia. Therefore DWI is recommended for patient selection with respect to thrombolysis. Case: A 83-year old woman presented with an acute onset of global aphasia. An MRI of the brain conducted 4,5 hours after the beginning of symptoms revealed no abnormality in DWI- nor ADC-sequences. So we suspected that an underlying ischemia could be excluded, and fibrinolysis was not performed. However, the symptoms persisted, and another MRI conducted 24 hours after admission showed DWI-lesions in the middle cerebral artery territory proving acute infarction. Conclusion: In clinical settings it is the assumption that brain ischemia leads to cytotoxic edema and corresponding abnormalities in DWI, whereas tissue at risk is reflected by abnormal findings in perfusion imaging, the so called mismatch concept. Our observation may indicate that negative DWI does not exclude acute brain ischemia nor indicate good prognosis, and should therefore not be considered as a definite criterion against thrombolysis.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
Diastoilc flow reversal in cerebral arteries in severe aortic regurgitation
V.K.Sharma    H.L.Teoh    B.PLChan                                                    
 
National University Hospital

SINGAPORE

Background: Spectral flow pattern in the cervical segments of carotid arteries may be influenced by various cardiac valvular abnormalties. Depending on its severity, aortic regurgitation (AR) may cause diastolic flow reversal in aorta and its branches up to variable distance. The most severe case of flow spectral changes due to AR previously described in the literature showed diastolic flow reversal of varying degree in the extracranial arteries but the flow during the diastole remained antegrade in the intracranial arteries. Methods: We describe the findings of cerebrovascular ultrasound in a 72-years old woman, referrred to our tertiary care neurovascular laboratory following a transient left-sided weakness. Results: Doppler spectra obtained from the cervical ultrasound of both common and internal carotid arteries as well as vertebral arteries demonstrated an early-diastolic flow reversal with no discernible flow during rest of the diastole. Similar unusual spectral flow patterns with a holo-diastolic flow reversal were noted in middle anterior and posterior cerebral arteries, bilaterally. The Doppler spectra obtained from the basilar and the vertebral arteries showed only systolic spikes with no demonstrable diastolic flow signals. A transthoracic echocardiography performed later, confirmed severe AR. Conclusion: A holodiastolic flow reversal is an extremely abnormal finding in the intracranial arteries since the cerebrovascular system tends to ‘smooth-out’ the backflow effect of cardiac lesions by altering the peripheral resistance. To the best of our knowledge this is the first case of a severe AR with no diastolic flow in the vertebro-basilar arteries and holo-diastolic flow reversal in the remaining branches of the circle of Willis. Similar findings in multiple cerebral arteries are usually seen in patients with cerebro-circulatory arrest and may lead to an erroneous diagnosis and potentially serious prognostic and ethical considerations in critically ill patients with unknown intracranial pressure and previous history of valvular heart disease.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
ACUTE POSTERIOR MULTIFOCAL PLACOID PIGMENTARY EPITHELIOPATHY (APMPPE) – AN UNUSUAL CAUSE OF ISCHEMIC STROKE.
F.F.Poncha    A. Aggarwal    H. Samant     P. Samant                                            
 
Jaslok Hospital & Research Centre

INDIA

Case:A 25 year man presented with insidious onset blurring of vision in the right eye. Ophthalmologic examination showed best corrected vision of 6/24 in right and 6/6 in left eye. Pupillary responses and anterior segments were normal bilaterally. Multiple yellowish-white placoid lesions involving the retinal pigment epithelium were seen at the posterior pole of both eyes. Macula was spared bilaterally. Fluorescein angiography showed early hypofluorescence and late hyperfluorescence in the abnormal regions. After 6 weeks of oral steroids vision improved and fundus examination showed early atrophy in areas of previously active lesions. One week after stopping steroids he presented with acute right hemiparesis. MR showed a large left pontine hyperintensity on DW MR, with restricted ADC. There was no contrast enhancement. Cerebral MR angiography, echocardiogram and cerebrospinal fluid examination were normal. Tests for tuberculosis, HIV, syphilis, systemic vasculitis, collagen vascular diseases and sarcoidosis were negative. APMPPE with associated cerebral vasculitis was diagnosed and a pulse of high dose intravenous methylprednisolone administered. Neurologic deficit improved within 3 days. The patient was discharged on oral steroids and azathioprine and remains well 18 months later Discussion:APMPPE is a rare chorioretinal vasculitis and increasingly recognized cause of strokes (less than 50 reported cases), which can be catastrophic. APMPPE with cerebral vasculitis should be considered in patients with unexplained strokes and visual symptoms. Ophthalmologic features are diagnostic. Conclusion:This case report emphasizes the role of long term immunosupression in APMPPE. Withdrawal of steriods in our patient precipitated a brainstem infarct which resolved with prompt administeration of high dose steroids. He has remained asymptomatic on immunosuppresion since 18 months. Strokes associated with AMPPE need to be reported and followed up to increase awareness of the disease, study its natural history and develop guidelines for long term treatment.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
Cor triatriatum with intra-atrial thrombus formation: An uncommon cause of stroke
K. Spengos    S. Vassilopoulou    E. Gialafos     E. Anagnostou     P. Zis    E. Manios     G. Paraskevas     V.P.Zis             
 
University of Athens

GREECE

Background: Cor triatriatum (CT) is a rare congenital heart defect characterized by a membrane in the left atrium, which separates it into two chambers. Most cases become symptomatic during infancy. Adult manifestation is rare and usually imitates the clinical features of mitral stenosis. Cardioembolic stroke is considered as a highly uncommon presenting manifestation of CT. Up to date only five similar cases have been reported. Case presentation: A 55-year old man presented with impaired level of consciousness, motor aphasia, severe right-side hemiparesis and left-side gaze deviation (NIHSS-score:20; mRS-score:5) due to an acute territorial MCA infarction, as visualized on DWI. Carotid ultrasound suggested thrombotic occlusion of the left internal carotid artery, which was also confirmed on MRA. Although transthoracic echocardiography revealed only a dilatation of the left atrium, further evaluation with a transesophageal study demonstrated typical CT findings. The left atrium was separated into two communicating chambers by an echo-dense membrane with no pressure gradient. Moreover, this anomaly was accompanied by an ostium secundum defect of 15mm diameter with left-right shunt. In addition a smoking like appearance of the left atrium was described suggesting thrombus formation. Finally, a 3.5x2.5cm thrombus, attached on the basis of the anterior cusp of the mitral valve and the free atrial wall was visualized. Forced anticoagulation led to thrombus resolution within three months. Elective surgery was then performed and successfully corrected both congenital anomalies. Six months after stroke the patient presents a remarkable recovery with only residual motor aphasia (mRS-score:2) Conclusion: We present the uncommon case of ischemic stroke due to a confirmed intra-atrial thrombus formation in an otherwise asymptomatic adult with CT, as diagnosed by means of transesophageal echocardiography and MRI.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
Do microbleeds cause clinical symptoms? Evidence from a lacunar stroke syndrome
S.M.Gregoire    M.M.Brown    D.J.Werring                                                    
 
National Hospital for Neurology and Neurosurgery, UCL, Queen Square

UNITED KINGDOM

Background: Microbleeds are tiny haemorrhages that can be detected on Gradient-Echo T2* MRI. Although generally considered clinically silent, their prevalence reaches up to 30% of ischaemic stroke patients and their presence may be associated with an increased risk of further ischaemic and haemorrhagic stroke. However, it is not clear whether the development of new microbleeds can cause acute clinical events. We report a 62 year old man in whom clinical and radiological features support this idea. Case report: A 62 year old man presented with sudden weakness of his left face, arm and leg which improved almost fully over a few days. There was no history of hypertension, diabetes, hyperlipidemia and no family history of stroke. He was a non smoker and did not drink alcohol. A CT Scan of the head was unremarkable. Neurological examination two months later showed pyramidal slowness of the left hand and mild proximal weakness of the left arm. Light touch and pinprick sensation were subjectively reduced over the left arm and leg. Gradient-echo MRI scan revealed a microbleed in the right thalamus and mild cerebral small vessel disease. No significant abnormality was found after full cardiovascular investigation. He was started on aspirin. Discussion: This patient presented with a sensorimotor lacunar syndrome. The only significant imaging abnormality was a microhaemorrhage in the right thalamus at a typical site for this syndrome, which suggested that it was the cause of his symptoms. Conclusion: This case provides further evidence that microbleeds may cause clinical symptoms. There is currently no guidance for the treatment of such patients. Further prospective studies on cerebral microbleeds are crucial to guide treatment, as the prescription of antithrombotic agents could exacerbate further microbleeding, and potentially cause fatal intracranial haemorrhage.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
Reversible subtotal basilar artery occlusion in temporal arteritis
R. Topakian    K. Stieglbauer    K. Nussbaumer     F.T.Aichner                                            
 
Academic Teaching Hospital Wagner-Jauregg, Linz

AUSTRIA

Background: Temporal arteritis (TA) is a systemic vasculitis predominantly affecting extracranial medium-sized and large vessels. Literature suggests that arteritic involvement of intracranial arteries in TA is very rare and associated with a fatal course that fails to respond to corticosteroids. We report a patient with TA and subtotal basilar artery (BA) occlusion. Timely diagnosis and immediate treatment were followed by an excellent clinical response and marked improvement on vascular imaging. Case Report: An 80-year-old man presented with acute left-sided blurred vision. History taking revealed increasing malaise in the last couple of weeks, fever, loss of weight, new-onset headache, jaw claudication, polymyalgia-like symptoms, and transient episodes with vertigo, ataxia, and dysarthria. He was unable to tell the number of fingers stretched out in front of his left eye at a distance of 30 cm. Both temporal arteries appeared tender. Erythrocyte sedimentation rate (ESR) was 87 mm/h. Ophthalmologic evaluation suggested occlusion of the left central retinal artery. Emergent magnetic resonance imaging (MRI) revealed bilateral subacute cerebellar infarcts and contrast enhancement of both optic nerve sheaths. Magnetic resonance angiography (MRA) showed extensive involvement of both extracranial vertebral arteries and a subtotal occlusion of the BA in the middle portion. The diagnosis of TA was made on the basis of the criteria of the American College of Rheumatology, and immediate therapy was started with high-dose IV methylprednisolone and heparin. The response to corticosteroids was dramatic, with stabilisation of vision and resolution of all other symptoms within days. ESR normalized within 3 weeks. Control MRA and transcranial Doppler studies were compatible with marked improvement of flow in the BA. Conclusion: In TA with intracranial arteritic involvement, immediate treatment can result in excellent clinical outcome and resolution of severe vascular changes. MRI and MRA may offer important information in the emergent work-up and monitoring of the disease.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
'PULMONARY VENOUS THROMBO-EMBOLIC' POSTERIOR CIRCULATION INFARCTION
J.A.Kinsella    A.J.MacCarthy    T. Kiernan     D.P.Moore     D. Mulcahy    D.J.H.McCabe                             
 
The Adelaide and Meath Hospital, Dublin, Incorporating the National Childrens Hospital

IRELAND

Background: Cerebral infarction secondary to pulmonary vein thrombo-embolism has only been identified in patients with a pulmonary AVM, lung neoplasia, hypercoagulable state, or pulmonary transplantation. Case Description: A 59 year old man developed bilateral pontine and left occipital ischaemia-infarction on warfarin, aspirin, and dipyridamole. He had mild hyperlipidaemia, migraine equivalents, and posterior circulation TIAs 7 years earlier following metal mitral valve replacement. Investigations: INR was 2.1 six days before presentation and 3.0 on admission. Factor VIII activity 2.07 IU/ml (normal range: 0.5-2.0) with normal haematological, biochemical, thrombophilia and autoantibody screening otherwise. Brain MRI revealed acute right pontine infarction, prior cerebellar infarction and moderate-severe small vessel disease. TOE revealed a patent foramen ovale without definite interatrial shunting, and thrombus in the proximal right superior pulmonary vein. The patient was initially anticoagulated with intravenous heparin. Warfarin was recommenced (target INR 3.5), and aspirin subsequently added because of difficulty achieving anticoagulation targets. Thoracic CT angiography did not reveal a pulmonary AVM or AV fistula. Repeat TOE at 12 weeks showed complete resolution of the pulmonary vein thrombus. Discussion: 'Pulmonary venous thrombo-embolic cerebral infarction' may occur in the absence of established risk factors, emphasising the importance of TOE in the investigation of similar patients.

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
Bilateral Orolingual Angioedema associated with tPA use in a case of Brainstem Ischemic Stroke
J.E.Silva    L.G.Gould    R. Whiteman                                                    
 
McMaster University, Hamilton Health Sciences

CANADA

Background and Purpose Orolingual Angioedema (OA) is an uncommon, not fully understood and potentially life threatening complication of Thrombolysis in the setting of acute ischemic stroke. OA usually manifests contralateral to the hemisphere involved in the infarct. We describe a rare case of bilateral OA in a patient with brainstem stroke post thrombolysis treatment. Case Report 75 year old female presented with a one hour history of dysarthria, left sided weakness , left gaze preference, drowsiness, right sided decortication signs, bilateral hyperreflexia and Babinski sign. Previous medications include acebutolol , lisinopril plus hydrochlorothiazide, atorvastatin, glyburide. Admision BP = 165/83, NIHSS =16. CT head showed no acute ischemia, but high density in the distal basilar artery (BA) trunk. CT Angiogram confirmed a clot in the distal BA. IV Thrombolysis was performed at 3hrs post symptom onset. One half hour post completion of IV tPA the patient developed bilateral orolingual angioedema requiring immediate intubation and ventilatory support. IV steroids and antihistamines were given. Patient recovered partially with residual left sided weakness and dysphasia requiring percutaneous endoscopic gastrostomy. Discussion The presence of acute cerebral ischemia in patients using ACE inhibitors and receiving tPA seem to be precipitating factors of OA. Central pathways involvement could play a role in triggering this phenomenon. In this case, the bilateral brainstem involvement could have accounted for the diffuse rather than unilateral presentation of OA. Similar findings are very rarely reported in the Acute Myocardial Ischemia cases

Session: Poster Session I
Date: Wednesday 14 May 2008  
Time: 12:30 - 14:00
Room: Agora 2

  
Migrainous incomplete infarction: adult onset hemiplegic migraine with cerebral vasospasm leading to selective cortical neuronal death
A. Kunizawa    M. Fujioka    S. Suzuki     R. Iwata     A. Asai    K. Kawamoto     Y. Kitazawa