Case Report: Brain Metastasis Confined to the Infarcted Area Following Stroke

Background: Ischemic stroke and cancer are frequent in the elderly and are the two common causes of death and disability. They are related to each other, and cancer may lead to ischemic stroke and vice versa. If patients with cancer exhibited recurrent acute neurological deficits after index stroke, a cancer-related stroke could be considered. However, a brain metastasis is another common cause of neurological complications and has a poor prognosis in patients with ischemic stroke and comorbid cancer. Here, we report a rare case of metastatic cancer that occurred after index stroke in a patient with renal cell carcinoma (RCC) and unusual imaging findings. Through the case, we discuss the pathophysiology and probable predisposing factors for metastatic disease in areas of infarction.Case Presentation: A 48-year-old man presented with sudden onset of left facial palsy and hemiparesis. He had a history of hypertension and RCC with pulmonary metastases treated with radical nephrectomy and chemotherapy. Brain magnetic resonance imaging (MRI) revealed multiple scattered acute infarctions in the right insular, frontal, parietal, and left occipital cortices. There were no definite sources of embolism. Eight months after the index stroke, he presented with subacute onset of progressive left hemiparesis. He had no focal neurological deficits except left-sided weakness and left nasolabial fold blunting. MRI scan demonstrated partial diffusion restriction on the right frontotemporal cortices without decline of apparent diffusion coefficient values on the corresponding lesions and T1 hypointensities and T2 hyperintensities with perilesional vasogenic edema on the right insular, frontal, parietal, and left occipital cortices, indicative of brain metastases confined to the area of previous infarctions.Conclusions: Cerebral infarctions can cause neovascularization and disruption of the blood–brain barrier. Moreover, the compartmentalized cavity formed by the ischemic injury may accept a large volume of metastatic tumor cells. Such an altered microenvironment of infarcted tissue would be suitable for the colonization and proliferation of metastatic seed. Further, brain metastases should be considered, in addition to recurrence, when new focal neurological deficits develop in patients with ischemic stroke and comorbid cancer.

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Cerebral hemispheres – cerebellum – kidney interaction in patients with acute cerebral ischemia

Medicni perspektivi (Medical perspectives) ◽

10.26641/2307-0404.2021.1.227941 ◽

2021 ◽

Vol 26 (1) ◽

pp. 90-98

Author(s):

O.M. Kononets ◽

O.V. Tkachenko ◽

O.O. Kamenetska

Keyword(s):

Nervous System ◽

Ischemic Stroke ◽

Brain Magnetic Resonance Imaging ◽

Environmental Parameters ◽

The Body ◽

Electrolyte Balance ◽

Vector Correlation ◽

Vertebrobasilar System ◽

Acute Cerebral Ischemia ◽

The Right

The nervous system, in particular the autonomic one, is well known to constantly regulate the internal functioning of the body, adapting it to changeable external and internal environmental parameters. In particular, there is a close multiple-vector correlation between the nervous system and the kidneys. The aim of this study was to specify the mechanisms, clinical and paraclinical characteristics of the concomitant lesions of the nervous system and the kidneys in patients with acute stroke. This paper presents the case report of 215 patients, aged 70 ± 8.44, who suffered from ischemic stroke. Among them, we examined 144 women and 71 men. The patients underwent a comprehensive examination, including a detailed clinical and neurological check-up (evaluating the patients’ condition severity with the National Institutes of Health Stroke Scale (NIHSS) and the Barthel index on admission and on the 21st day of the disease), laboratory analysis (electrolyte balance, nitrogen metabolism (on admission and on the 21st day of the disease) and instrumental examination (CT scan of the brain, the follow-up brain magnetic resonance imaging). The statistical methods were used to analyze the data. In the 1st day of the disease, all the surveyed patients with right hemispheric carotid stroke and the overwhelming majority of the patients with left hemispheric carotid stroke and ischemic stroke in the vertebrobasilar system had cerebral renal syndrome, represented by renal concentration-filtration dysfunction, accompanied by the reduced glomerular filtration rate. A reliable relationship was found between the renal concentration and filtration function and the right hemispheric ischemic focus in patients with ischemic stroke, the characteristics are to be specified.

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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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Postoperative ischemic changes following brain metastasis resection as measured by diffusion-weighted magnetic resonance imaging

Journal of Neurosurgery ◽

10.3171/2013.9.jns13596 ◽

2013 ◽

Vol 119 (6) ◽

pp. 1395-1400 ◽

Cited By ~ 17

Author(s):

Jens Gempt ◽

Julia Gerhardt ◽

Vivien Toth ◽

Stefanie Hüttinger ◽

Yu-Mi Ryang ◽

...

Keyword(s):

Brain Metastasis ◽

Brain Metastases ◽

Neurological Deficit ◽

Karnofsky Performance Status ◽

Performance Status ◽

Neurological Status ◽

Neurological Deficits ◽

Brain Irradiation ◽

Diffusion Weighted ◽

The Mean

Object Brain metastases occur in 10% to 40% of patients harboring cancer. In cases of neurosurgical metastasis resection, all postoperative neurological deterioration should be avoided. Reasons for postoperative deficits can be direct tissue damage due to resection, hemorrhage, venous congestive infarcts, or arterial ischemic events leading to tissue infarction. The aim of this study was to evaluate whether postoperative ischemic infarctions occur in surgery for brain metastasis and to determine their influence on new postoperative neurological deficits. Methods Patients who underwent resection of brain metastases and had preoperative and early postoperative (within 48 hours) MRI scans, including diffusion-weighted imaging sequences and apparent diffusion coefficient maps, between January 2009 and May 2012 were included in this study. Clinical and histopathological data (histopathological results, pre- and postoperative neurological status, and previous tumor-specific therapy) were recorded. Results One hundred twenty-two patients (56 male, 66 female) who underwent resection of brain metastases were included. The patients' mean age was 60 years (range 21–89 years). The mean time span from initial tumor diagnosis to resection of brain metastasis was 44 months (range 0–338 months). The mean preoperative Karnofsky Performance Status was 80% (exact mean 76% ± 17% [SD]), and the mean postoperative value was 80% (exact mean 78% ± 17%). Twelve (9.8%) of the 122 patients had postoperative permanent worsening of a neurological deficit or a new permanent neurological deficit; 44 (36.1%) of the 122 patients had postoperative ischemic lesions. When comparing patients with and without previous brain irradiation, 53.8% of patients with previous brain irradiation had ischemic lesions on postoperative imaging compared with 31.3% of patients without previous brain irradiation (p = 0.033). There was a significant association between ischemia and postoperative neurological status deterioration (transient or permanent); 13 (29.5%) of 44 patients with ischemic lesions had deterioration of their neurological status compared with 7 (9%) of the 78 patients who did not have ischemic lesions (p = 0.003). Conclusions This study demonstrates a high prevalence of vascular incidents in patients undergoing resection for metastatic brain disease. Patients harboring postoperative ischemic lesions detected by MRI have a higher rate of neurological deficits (transient or permanent). Patients who had previous irradiation therapy are at higher risk of developing postoperative ischemic lesions. A large number of postoperative neurological deficits are caused by ischemic incidents.

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Molecular and cellular mechanisms underlying brain metastasis of breast cancer

Cancer and Metastasis Reviews ◽

10.1007/s10555-020-09881-y ◽

2020 ◽

Vol 39 (3) ◽

pp. 711-720 ◽

Cited By ~ 2

Author(s):

Mari Hosonaga ◽

Hideyuki Saya ◽

Yoshimi Arima

Keyword(s):

Breast Cancer ◽

Brain Metastasis ◽

Brain Metastases ◽

Cancer Cells ◽

Metastatic Cancer ◽

Breast Cancer Patients ◽

Cellular Mechanisms ◽

Her2 Positive ◽

Cells Of The Microenvironment ◽

The Brain

Abstract Metastasis of cancer cells to the brain occurs frequently in patients with certain subtypes of breast cancer. In particular, patients with HER2-positive or triple-negative breast cancer are at high risk for the development of brain metastases. Despite recent advances in the treatment of primary breast tumors, the prognosis of breast cancer patients with brain metastases remains poor. A better understanding of the molecular and cellular mechanisms underlying brain metastasis might be expected to lead to improvements in the overall survival rate for these patients. Recent studies have revealed complex interactions between metastatic cancer cells and their microenvironment in the brain. Such interactions result in the activation of various signaling pathways related to metastasis in both cancer cells and cells of the microenvironment including astrocytes and microglia. In this review, we focus on such interactions and on their role both in the metastatic process and as potential targets for therapeutic intervention.

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Overview of The Head CT-Scan in Stroke Patients who was Treated at Muhammadiyah Hospital Palembang

Muhammadiyah Medical Journal ◽

10.24853/mmj.2.1.24-34 ◽

2021 ◽

Vol 2 (1) ◽

pp. 24

Author(s):

Pratrisna Yusastra ◽

Indriyani Indriyani ◽

Budi Utama

Keyword(s):

Ischemic Stroke ◽

Ct Scan ◽

Hemorrhagic Stroke ◽

Right Hemisphere ◽

Clinical Symptoms ◽

Neurological Deficits ◽

Thalamic Lesion ◽

Stroke Patients ◽

Head Ct ◽

The Right

Background: Stroke is a collection of symptoms of neurological deficits due to sudden acute disturbance of brain function, both focal and global, caused by blockage or rupture of arteries and veins and proven by imaging and/or reflex pathology. Using CT-Scan, the description of acute phase stroke can be easier and can determine the appropriate treatment criteria for stroke. Purposes: To determine characteristic Head CT-Scan image of stroke patients hospitalized in Muhammadiyah Palembang Hospital. Methods: This study was conducted in a retrospective descriptive manner and obtained a sample of 41 stroke patients according to the inclusion and exclusion criteria using total sampling. Result: In this study, there were 28 patients (68.2%) with ischemic stroke and 13 patients (31.7%) with hemorrhagic stroke. Head CT-Scan image of ischemic stroke shows basal ganglia lesion (28.5%) and the right hemisphere lesions (57.1%) as the most predominant area. Head CT-Scan image of hemorrhagic stroke (58.3%) had intracerebral hemorrhage with the dominant thalamic lesion area (66.6%) and the right hemisphere (58.3%) had the most lesions with 8 patients (66, 6%) had a midline shift. Stroke patients were treated as experienced by the elderly (90.2%) and were dominated by the female sex (63.4%) and are dominated by clinical symptoms of hemiparesis (29.2%). Conclusion: Stroke patients at Muhammadiyah Palembang hospital dominated by ischemic stroke and on head CT Scan image predominantly shows lesions on the right cerebral hemisphere.

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OTHR-05. THE ABILITY TO MAKE INFORMED TREATMENT DECISIONS IS COMPROMISED IN ADULTS WITH ADVANCED STAGE CANCER

Neuro-Oncology Advances ◽

10.1093/noajnl/vdz014.082 ◽

2019 ◽

Vol 1 (Supplement_1) ◽

pp. i19-i19

Author(s):

Kristen Triebel ◽

Kyler Mulhauser ◽

Meredith Gammon ◽

Adam Gerstenecker ◽

L Burt Nabors ◽

...

Keyword(s):

Brain Metastasis ◽

Brain Metastases ◽

Medical Center ◽

Metastatic Cancer ◽

Academic Medical Center ◽

Treatment Decisions ◽

Medical Decision ◽

Control Group ◽

Advanced Stage ◽

Advanced Stage Cancer

Abstract OBJECTIVE: To investigate medical decision-making capacity (MDC) in patients with advanced stage cancer. METHODS: Participants were 113 newly diagnosed adults with brain metastases and 41 adults with metastatic cancer without brain metastases who were recruited from an academic medical center and 40 demographically-matched healthy controls recruited from the community. We evaluated MDC using the Capacity to Consent to Treatment Instrument (CCTI) Vignette B and its four clinically relevant consent standards (expressing a treatment choice, appreciation, reasoning, and understanding). Capacity impairment ratings (no impairment, mild/moderate impairment, and severe impairment) on the consent standards were also assigned to each participant using cutoff scores derived statistically from the performance of the control group. RESULTS: Both of the metastatic cancer groups (with and without brain metastasis) performed significantly below controls on consent standards of understanding and reasoning. The brain metastasis group performed below the non-metastatic cancer group on understanding. Capacity compromise was defined as performance ≤1.5 standard deviations (SD) below the control group mean. Using this definition, approximately 65% of the participants with brain metastases and 51% of participants with metastatic cancer without brain metastases were impaired on at least one MDC standard. CONCLUSION: Over half of participants with metastatic cancer regardless of whether they have brain disease have reduced capacity to make treatment decisions. The finding of impaired MDC in patients without brain metastases is surprising and suggests this group likely exhibits cognitive deficits that impact their ability to understand and reason about different treatment options. The reasons underlying this impairment will be investigated. This highlights the importance of routine clinical assessment of MDC in all patients with metastatic cancer when important treatment decisions are being discussed. These results also indicate a need for the development and investigation of interventions to support or improve MDC in this patient population.

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NCOG-09. TREATMENT DECISION MAKING IN THE SETTING OF ADVANCED CANCER

Neuro-Oncology ◽

10.1093/neuonc/noz175.670 ◽

2019 ◽

Vol 21 (Supplement_6) ◽

pp. vi160-vi160

Author(s):

Kristen Triebel ◽

Kyler Maulhauser ◽

John Fiveash ◽

Dario Marrotta ◽

Meredith Gammon ◽

...

Keyword(s):

Decision Making ◽

Brain Metastasis ◽

Brain Metastases ◽

Metastatic Cancer ◽

Treatment Options ◽

Academic Medical Center ◽

Treatment Decision ◽

Medical Decision ◽

Control Group ◽

Treatment Decision Making

Abstract OBJECTIVE To investigate medical decision-making capacity (MDC) in patients with advanced stage cancer. METHODS Participants were 113 newly diagnosed adults with brain metastases and 41 adults with metastatic cancer without brain metastases who were recruited from an academic medical center and 40 demographically-matched healthy controls recruited from the community. We evaluated MDC using the Capacity to Consent to Treatment Instrument (CCTI) Vignette B and its four clinically relevant consent standards (expressing a treatment choice, appreciation, reasoning, and understanding). Capacity impairment ratings (no impairment, mild/moderate impairment, and severe impairment) on the consent standards were also assigned to each participant using cutoff scores derived statistically from the performance of the control group. RESULTS Both of the metastatic cancer groups (with and without brain metastasis) performed significantly below controls on consent standards of understanding and reasoning. The brain metastasis group performed below the non-metastatic cancer group on understanding. Capacity compromise was defined as performance ≤1.5 standard deviations (SD) below the control group mean. Using this definition, approximately 65% of the participants with brain metastases and 51% of participants with metastatic cancer without brain metastases were impaired on at least one MDC standard. CONCLUSION Over half of participants with metastatic cancer regardless of whether they have brain disease have reduced capacity to make treatment decisions. The finding of impaired MDC in patients without brain metastases is surprising and suggests this group likely exhibits cognitive deficits that impact their ability to understand and reason about different treatment options. This finding suggests that clinicians need to carefully consider the patient’s ability to engage in treatment decision making when they are discussing treatment options for metastatic cancer. These results also indicate a need for the development and investigation of interventions to support MDC in this patient population.

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Management of brain metastasis in a patient with advanced epithelial ovarian carcinoma by gamma-knife radiosurgery

Srpski arhiv za celokupno lekarstvo ◽

10.2298/sarh1504205n ◽

2015 ◽

Vol 143 (3-4) ◽

pp. 205-209 ◽

Cited By ~ 4

Author(s):

Marinos Nikolaou ◽

Srdjan Stamenkovic ◽

Christos Stergiou ◽

Christos Skarleas ◽

Michael Torrens

Keyword(s):

Ovarian Cancer ◽

Brain Metastasis ◽

Brain Metastases ◽

Gamma Knife ◽

Cancer Metastasis ◽

Gamma Knife Radiosurgery ◽

Brain Magnetic Resonance Imaging ◽

Mri Scan ◽

Abdominal Disease ◽

The Brain

Introduction. Brain metastases from epithelial ovarian cancer (EOC) are rare events. We present a rare case of single ovarian cancer metastasis to the brain treated with gamma-knife radiosurgery (GKRS). Case Outline. A 65-year-old woman with advanced EOC presented with severe neurologic symptoms. A single brain metastasis of 3.2 cm with surrounding edema in the left parietal lobe was detected by brain magnetic resonance imaging (MRI) scan during the work-up. The decision to perform GKRS was due to a surgical inaccessibility of intracranial lesion. Twelve weeks after the procedure, the MRI scan showed reduction in the diameter of brain metastasis and surrounding edema and the patient returned to good mental and motor performance. The patient survived for 22 months following treatment and died from a progressive intra-abdominal disease. Prognosis of ovarian cancer patients with brain metastases is generally poor regardless of treatment. Conclusion. Our case shows that GKRS as primary treatment modality for the control of ovarian cancer metastases to the brain was effective and can be considered as a treatment of choice if international selection criteria are followed.

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New Endovascular Approach for Hypothermia With Intrajugular Cooling and Neuroprotective Effect in Ischemic Stroke

Stroke ◽

10.1161/strokeaha.119.026523 ◽

2020 ◽

Vol 51 (2) ◽

pp. 628-636 ◽

Cited By ~ 5

Author(s):

Yunxia Duan ◽

Di Wu ◽

Mitchell Huber ◽

Jingfei Shi ◽

Hong An ◽

...

Keyword(s):

Ischemic Stroke ◽

Blood Brain Barrier ◽

Caspase 3 ◽

Isotonic Saline ◽

Brain Barrier ◽

Neurological Deficits ◽

Brain Cooling ◽

Blood Brain ◽

Neuroprotective Efficacy ◽

The Right

Background and Purpose— Induction of hypothermia as a stroke therapy has been limited by logistical challenges. This study was designed to determine the hypothermic and neuroprotective efficacy of infusing cold saline directly into the internal jugular (IJ) vein and compare the effects of IJ hypothermia to those achieved by intracarotid artery hypothermia in an ischemic stroke model. Methods— The right middle cerebral artery was occluded in rats using an intraluminal filament. Immediately following reperfusion, hypothermia was achieved by infusing isotonic saline through microcatheter into the right IJ or right intracarotid over 30 minutes. Infarct sizes, neurological deficits, blood-brain barrier damage, edema volume, blood-brain barrier associated molecules (MMP-9 [matrix metallopeptidase 9] and AQP-4 [aquaporin 4]), and apoptosis-associated proteins (Bcl-2 and cleaved Caspase-3) were measured. Results— We found that both IJ- and intracarotid-based infusion cooled the brain robustly with a minimal effect on rectal temperatures. This brain cooling led to significantly reduced infarct volumes at 24 hours after reperfusion, as well as decreased expression of the proapoptotic protein cleaved Caspase-3 and increased expression of the antiapoptotic protein Bcl-2. Intracarotid and IJ cooling also aided in blood-brain barrier maintenance, as shown by decreased edema volumes, reduced Evans Blue leakage, and decreased expression of edema-facilitating proteins (MMP-9 and AQP-4). Both cooling methods then translated to preserved neurological function as determined by multiple functional tests over a 28-day observation period. Most importantly, the cooling and neuroprotective efficacy of IJ cooling was comparable to intracarotid cooling by almost every metric evaluated. Conclusions— Compared with intracarotid infusion, IJ infusion conferred a similar degree of hypothermia and neuroprotection following ischemic stroke. Given the ease of establishing vascular access via the internal jugular vein and the powerful neuroprotection that hypothermia provides, IJ brain cooling could be used as a promising hypothermia-induction modality going forward.

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Unusual Presentation and Imaging Findings of a Rare Supratentorial Neurenteric Cyst

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2019.295 ◽

2019 ◽

Vol 47 (1) ◽

pp. 121-123

Author(s):

Eduardo Portela de Oliveira ◽

John Woulfe ◽

Carlos Torres ◽

Nader Zakhari

Keyword(s):

Vision Loss ◽

Peripheral Vision ◽

Brain Magnetic Resonance Imaging ◽

Lesion Size ◽

Neurological Deficits ◽

Neurenteric Cyst ◽

Magnetic Resonance Imaging Mri ◽

The Right ◽

Head Computed Tomography

This is a case of a 30-year-old right-handed male patient who presented to the hospital in 2014 after hitting his head on the mat during a wrestling match followed by headache and temporary peripheral vision limitation. The patient’s past medical history was unremarkable. On physical examination, Glasgow Coma Scale was 15 with no focal neurological deficits. Unenhanced head computed tomography (CT) and enhanced brain magnetic resonance imaging (MRI) were performed (Figure 1). The patient was managed conservatively, and follow-up CT and MRI in 2015 (Figure 2) demonstrated significant decrease in size of the previously seen right frontoparietal lesion with also changes in its radiological features. The patient remained asymptomatic for about 3 years when in 2018 he presented to the Emergency Department with increasing headaches and peripheral vision loss. MRI demonstrated an increase in the right frontal lesion size (Figure 3). He underwent surgical resection of the lesion.

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