Left hemispheric cortical watershed infarcts triggered by carotid sinus self-massage

A 69-year-old man was presented to our emergency department with acute onset of hemianopsia, aphasia and dizziness. He reported that while he was sitting in front of his computer at home, he had performed a bilateral self-massage of his carotid arteries when suddenly the symptoms occurred. A neurological examination revealed a hemianopsia with a visual field loss on the right side. In addition, a mild aphasic syndrome with agraphia and a word-finding disorder (National Institutes of Health Stroke Scale (NIHSS): 3 points) was diagnosed. The initial brain CT scan with CT angiography showed neither an intracerebral haemorrhage nor a cerebral infarction. Also, no occlusion or any signs of artery dissection or a flow relevant stenosis of the brain supplying arteries were found. After excluding other contraindications, an intravenous thrombolysis with weight-adapted alteplase was performed. The symptoms of the patient significantly improved in the short-term follow-up. Three days after admission no neurological deficits remained. The MRI of the brain revealed multifocal, small, left hemispherical strokes in the middle cerebral artery territory. In general, watershed infarcts after carotid sinus self-massage follow a rare ischaemic stroke mechanism. This case emphasises the importance of a detailed anamnestic evaluation to determine the aetiological classification of ischaemic stroke as well as educating patients’ (poststroke) behaviour.

Hypoplastic internal carotid artery ending as an ophthalmic artery with multiple cerebral aneurysms, fenestrated Acom and triple A2

A rare case of a hypoplastic internal carotid artery (ICA) terminating in the ophthalmic artery with multiple intracranial saccular aneurysms in the contralateral ICA, anterior communicating artery fenestration and triple A2 was identified. The aetiology and pathogenesis of ICA hypoplasia are subjected to certain hypotheses. Developing several collaterals to preserve the blood supply of the ipsilateral cerebral hemisphere could result in aneurysm formation due to flow overload on the contralateral vasculature, but it could also result in hemicranial hypoplasia, cerebral atrophy and deep watershed infarcts, as in our case.

SCORPION STING CAUSING MULTIPLE WATERSHED INFARCTS

Scorpion sting presents with several neurotoxic local effects, cranial nerve effects (roving eye movements, blurring of vision, tongue fasiculations, dysphagia), central nervous system effects (encephalopathy, convulsions, CVA, central respiratory failure). We report a case of a 53 year old female who sustained a scorpion sting at her residence and initially presented with local site symptoms only. During the course of hospital stay, after 2 days she had a episode of hypotension followed by an episode of generalised tonic clonic seizures and right hemiplegia. MRI brain was suggestive of bilateral acute ischemic watershed infarcts, carotid Doppler was suggestive of low ow bilaterally. Patient was started on dual antiplatelets, anti edema and anti epileptic measures. The patient recovered spontaneously over a period of 2 weeks.

Abstract P383: AI-Guided Detection and Volumetric Analysis of Embolic and Watershed Infarcts on Diffusion-Weighted MRI Enables Measurement of the Absolute and Relative Ischemic Infarct Burden

Acute ischemic strokes frequently present with multiple restricted diffusion lesions scattered throughout the brain parenchyma, particularly embolic and watershed infarcts. The morphological variety and complexity of such infarcts are high in terms of their potential number, shape, volume, and spatial distribution. In current clinical practice, there is a limited description of the burden and variability of such infarcts. Here, we demonstrate an artificial-intelligence guided approach using high-performance computing, for the fast (minutes) and precise (sub-milliliter) detection and quantification of each infarcted brain volume regardless of size and morphology. Our methodology is based on processing and analyzing the original DICOM data by filtering, segmentation, and morphological neighborhood operations to identify and triage 3D-connected volumes of interest that represent ischemic stroke. Figure Panel A shows the analysis of a watershed stroke with the identification of 5 ischemic subvolumes with an overall infarct volume of 23.6 ml and a relative infarct volume of 2.0 % of the total brain volume of 1152 ml. In contrast, Figure Panel B shows the analysis of an embolic stroke with the identification of 20 ischemic subvolumes with an overall infarct volume of 51.6 ml and a relative infarct volume of 4.4 % of the total brain volume of 1178 ml. What is novel here is that our approach allows for the immediate measurement of the absolute (in ml) and relative (in terms of % of total brain volume) infarct burdens of complex strokes on initial MRI imaging. Volumetric analysis of stroke may represent a critical future biomarker. We suggest that such an approach might be easily implemented into clinical and research settings to guide clinical diagnoses, therapeutic decisions, and outcome prediction.

A Rare Case of Stroke Following Manual Strangulation

Stroke following manual strangulation is a rare presentation. We report a case of 61-year-old man with no known comorbidities presenting with right hemiplegia following manual strangulation. Neuroimaging showed left middle cerebral artery territory infarct along with left posterior watershed infarct. Although isolated cases of thromboembolic stroke and watershed infarcts have been reported, combined watershed infarct and thromboembolic stroke in a person has not been reported till date to the best of our knowledge. The probable mechanism is discussed based on literature review. The need for anticipation of delayed cerebrovascular injuries and appropriate investigations in all strangulation victims who arrive at emergency department is also stressed upon based on this case report.

Moyamoya vasculopathy in a young Caucasian woman with significant methamphetamine use

BackgroundMoyamoya is a rare cerebrovascular disorder seen predominantly in Asian populations. Methamphetamine use is a recognised cause of stroke in young people, but its pathophysiology is not fully understood. The incidence of moyamoya vasculopathy in methamphetamine-associated stroke is unknown due to a lack of sufficient data. We present a rare case of moyamoya syndrome in a young Caucasian woman with methamphetamine-associated stroke.CaseA 31-year-old Caucasian woman presented with progressive right arm weakness, speech disturbance and seizures on a background of escalating methamphetamine use in the 9 months prior to admission. She did not have a personal or family history of stroke. MRI revealed both embolic and watershed infarcts in bilateral frontal regions and CT angiography showed development of new lenticulostriate collateral vessels. Digital subtraction angiography confirmed steno-occlusive disease of the bilateral anterior circulations and a ‘puff of smoke’ appearance.ConclusionIn young patients who present with stroke with unclear aetiology, it is important to obtain a thorough substance use history. Moyamoya vasculopathy should be considered when evaluating the pathophysiology of stroke in young people.

Chronic Lymphocytic Leukemia Presenting as a Subcortical Watershed Infarct

Internal watershed infarcts (WI) involve white matter between deep and superficial arterial systems of middle cerebral artery. These infarcts are considered to be either from low blood flow or microembolism. Anemia is an extremely rare cause of watershed infarcts. Very few cases of hemolytic anemia causing watershed cerebral infarcts have been reported. Chronic lymphocytic leukemia (CLL) is frequently complicated with secondary autoimmune cytopenia such as autoimmune hemolytic anemia (AIHA), immune thrombocytopenia (ITP), and pure red cell aplasia. AIHA is present in about 7–10% of patients with CLL. AIHA from CLL presenting as WI is an extremely rare phenomenon with no previously published case reports to the best of our knowledge.