Funny turns in Young badminton player: A case of cerebellar infarction secondary to vertebral artery dissection

Spontaneous vertebral artery dissection is a rare cause of cerebellar infarction. Common presentations of cerebellar artery infarction are dizziness and ataxia. We are reporting a case of a 31-year-old male who presented with acute onset dizziness while playing badminton, who was diagnosed as cerebellar vermis infarction secondary to vertebral artery dissection.

Rate of Infarct–Edema Growth on CT Predicts Need for Surgical Intervention and Clinical Outcome in Patients with Cerebellar Infarction

Background Up to 20% of patients with cerebellar infarcts will develop malignant edema and deteriorate clinically. Radiologic measures, such as initial infarct size, aid in identifying individuals at risk. Studies of anterior circulation stroke suggest that mapping early edema formation improves the ability to predict deterioration; however, the kinetics of edema in the posterior fossa have not been well characterized. We hypothesized that faster edema growth within the first hours after acute cerebellar stroke would be an indicator for individuals requiring surgical intervention and those with worse neurological outcomes. Methods Consecutive patients admitted to the neurological intensive care unit with acute cerebellar infarction were retrospectively identified. Hypodense regions of infarct and associated edema, “infarct–edema”, were delineated by using ABC/2 for all computed tomography (CT) scans up to 14 days from last known well. To examine how rate of infarct–edema growth varied across clinical variables and surgical intervention status, nonlinear and linear mixed-effect models were performed over 2 weeks and 2 days, respectively. In patients with at least two CT scans, multivariable logistic regression examined clinical and radiological predictors of surgical intervention (defined as extraventricular drainage and/or posterior fossa decompression) and poor clinical outcome (discharge to skilled nursing facility, long-term acute care facility, hospice, or morgue). Results Of 150 patients with acute cerebellar infarction, 38 (25%) received surgical intervention and 45 (30%) had poor clinical outcome. Age, admission National Institutes of Health Stroke Scale (NIHSS) score, and baseline infarct–edema volume did not differ, but bilateral/multiple vascular territory involvement was more frequent (87% vs. 50%, p < 0.001) in the surgical group than that in the medical intervention group. On 410 serial CTs, infarct–edema volume progressed rapidly over the first 2 days, followed by a subsequent plateau. Of 112 patients who presented within two days, infarct–edema growth rate was greater in the surgical group (20.1 ml/day vs. 8.01 ml/day, p = 0.002). Of 67 patients with at least two scans, after adjusting for baseline infarct–edema volume, vascular territory, and NIHSS, infarct–edema growth rate over the first 2 days (odds ratio 2.55; 95% confidence interval 1.40–4.65) was an independent, and the strongest, predictor of surgical intervention. Further, early infarct–edema growth rate predicted poor clinical outcome (odds ratio 2.20; 95% confidence interval 1.30–3.71), independent of baseline infarct–edema volume, brainstem infarct, and NIHSS. Conclusions Early infarct–edema growth rate, measured via ABC/2, is a promising biomarker for identifying the need for surgical intervention in patients with acute cerebellar infarction. Additionally, it may be used to facilitate discussions regarding patient prognosis.

A Review of Remote Intracerebral Hemorrhage after Chronic Subdural Hematoma Evacuation

Background Remote intracerebral hemorrhage (RICH) is a severe complication following chronic subdural hematoma (cSDH) drainage, and only case reports and small case series have been reported to date. The authors present an emblematic patient affected by RICH following cSDH drainage. A systematic review of the literature on diagnosis and management of patients affected by RICH following cSDH evacuation has also been performed. Methods A literature search according to the PRISMA statement was conducted using PubMed and Scopus databases with the following Mesh terms: [(remote) AND (intracerebral hemorrhage or cerebral hematoma or cerebral infarction or cerebellar hemorrhage or cerebellar hematoma or cerebellar infarction) AND (chronic subdural hematoma)]. Results The literature search yielded 35 results, and 25 articles met our inclusion criteria: 22 articles were case reports and 3 were case series including three to six patients. Overall, 37 patients were included in the study. Age was reported in all 37 patients, 26 males (70.3%) and 11 females (29.7%), with a male-to-female ratio of 2.4:1. The mean age at diagnosis was 64.6 years (range: 0.25–86 years). Only in 5 cases (13.5%) did the ICH occur contralaterally to the previously drained cSDH. The rapidity of drainage can lead to several types of intracranial hemorrhages, caused by a too rapid change in the cerebral blood flow (CBF) and/or tears of bridging veins. The average time interval between cSDH drainage and neurologic deterioration was 71.05 hours (range: 0–192 hours). Conclusions RICH following cSDH represents a rare occurrence and a serious complication, associated with elevated morbidity. Careful monitoring of drain speed after cSDH evacuation surgery is recommended, and minimally invasive techniques such as twist drill craniostomy are suggested, especially for massive cSDHs.

Abstract 1122‐000088: Vertebral Origin Stenting Appears Safe and is Associated with Improved Functional Outcome at 3 Months

Introduction : Stenosis of the vertebral artery origin (VAOS), while under‐diagnosed, is common and may cause up to 25% of posterior circulation infarctions. Stenting is widely employed as a secondary prevention strategy, but clinical studies of safety and efficacy are limited compared to carotid interventions. Methods : This is a retrospective observational cohort study of subjects who underwent vertebral origin stenting at two large academic centers. The demographic profile of the subjects, medical comorbidities, and radiological parameters were all collected. Primary safety outcome was defined as 30‐day post‐procedure complications. Secondary safety outcomes included periprocedural complications and change in the pre‐procedure Modified Rankin score (mRS) at 3 months of follow‐up. Results : There were 80 subjects who underwent vertebral artery stenting in this cohort. Mean age was 66.6 +10.2 years, 72.5% (n = 58) were male, 70% (n = 56) were Caucasian. 53.8% (n = 43) were treated for the right VA, 72.5% (n = 58) received second‐generation drug‐eluting stents (DES). Hypertension 67.5% (n = 54) and hyperlipidemia 65% (n = 52) were the most prevalent vascular risk factors. 76.3% (m = 61) of subjects were symptomatic at presentation. There were 8 adverse events identified at 30 days (10%): 3 strokes in the same vascular territory (2 minor and without permanent disability), 1 stroke in a different vascular territory, 2 subjects with worsening of symptoms attributable to the posterior circulation, 1 GI bleed, and 1 femoral thrombosis. 3 of these subjects were found to have ipsilateral tandem stenosis and 1 patient died due to distal occlusion and large cerebellar infarction. There were 4 (5%) adverse events identified in the immediate periprocedural period: 1 vertebral dissection, 1 in‐stent thrombosis, 1 SCA embolism, and 1 stent migration. mRS of these patients remained the same at 30 days and 3 months of follow‐up. Overall, the Modified Rankin score was significantly lower at 3 months versus the pre‐procedure (Z = ‐2.45, p = 0.01). Conclusions : This large cohort of subjects undergoing vertebral origin stenting demonstrates a low incidence of procedural complications and adverse outcomes at 30 days. mRS was significantly lower at 3 months. While disability seemed to decrease in this population, longer prospective efficacy endpoints are needed to better evaluate this therapy.

Acute Cerebellar Stroke in a Military Active-Duty Pilot

BACKGROUND: Cryptogenic stroke leading to cerebellar infarction is a rare but serious cause of acute nausea and vomiting. This has the potential of devastating consequences if this occurs in aviators during flight. We present a case of cryptogenic stroke causing incapacitating nausea and vomiting in a U.S. Air Force pilot.CASE REPORT: A 36-yr-old active-duty U.S. Air Force male pilot developed acute onset severe vertigo, nausea, and vomiting during initial descent. Initial computed tomography imaging was normal and his initial assessment yielded a diagnosis of benign paroxysmal positional vertigo. MRI-Brain at 1 mo revealed a small right inferomedial cerebellar infarct. Echocardiography revealed a patent foramen ovale and bilateral atrial enlargement. He made a full neurological recovery and was eventually returned to active flight status with Flying Class IIC waiver.DISCUSSION: Cryptogenic stroke caused by patent foramen ovale (PFO) is uncommon. However, this is increased in patients younger than 50 yr of age. This can lead to an acute incapacitation with varying degrees of dysfunction. There is controversial discussion of treatment options for secondary stroke prevention with PFO. However, there is no significant literature on primary prevention in these patients. A small subset of patients benefit from closure of PFO and most patients benefit from antiplatelet therapy after a stroke occurs. There may also be a significant subset of patients with PFO that may benefit from antiplatelet therapy as a primary prevention of stroke.Lytle ME, Martin BR. Acute cerebellar stroke in a military active-duty pilot. Aerosp Med Hum Perform. 2021; 92(11): 919-923.

Rapid closure technique in suboccipital decompression

Objective Suboccipital decompression has been established as standard therapeutic procedure for raised intracranial pressure caused by mass-effect associated pathologies in posterior fossa. Several different surgical techniques of dural closure have been postulated to achieve safe decompression. The aim of this study was to examine the differences between fibrin sealant patch (FSP) and dural reconstruction (DR) in suboccipital decompression for acute mass-effect lesions. Methods We retrospectively analyzed our institutional data of patients who underwent suboccipital decompression due to spontaneous intracerebellar hemorrhage, cerebellar infarction and acute traumatic subdural hematoma between 2010 and 2019. Two different dural reconstruction techniques were performed according to the attending neurosurgeon: (1) fibrin sealant patch (FSP), and (2) dural reconstruction (DR) including the use of dural patch. Complications, operative time, functional outcome and the necessity of a ventriculoperitoneal shunt (VP Shunt) were assessed and further analyzed. Results Overall, 87 patients were treated at the authors’ institution (44 in FSP group, 43 in DR group). Glasgow coma scale on admission and preoperative coagulation state did not differ between the groups. Postoperatively, we found no difference in cerebrospinal fluid leakage or chronic hydrocephalus between the groups (p = 0.47). Revision rates were 2.27% (1/44 patients) in the FSP group, compared to 16.27% (7/43) in the DR group (p < 0.023). Operative time was significantly shorter in the FSP group (90.3 ± 31.0 min vs. 199.0 ± 48.8 min, p < 0.0001). Conclusion Rapid closure technique in suboccipital decompression is feasible and safe. Operative time is hereby reduced, without increasing complication rates.