Fatal disseminated paradoxical embolism in inferior sinus venosus atrial septal defect

Inferior sinus venosus arterial septal defect (ASD) is a rare congenital cardiac anomaly. As with other types of ASDs and patent foramen ovale (PFO), this defect results in arteri-venous shunting with the risk of developing paradoxical embolism (PDE) to the systemic circulation from venous emboli. We report a case of a 67-year-old lady presented to emergency department (ED) with massive pulmonary embolism (PE) and recurrent acute limb ischaemia. On CT pulmonary angiography (CTPA), an incidental finding of inferior sinus venosus ASD was discovered that has caused the PDE. Thrombolysis was administered followed by open mechanical thrombectomy. The patient developed massive lower gastrointestinal bleed post thrombolysis then passed away despite embolization. This case report describes the catastrophic effect of PDE to cause disseminated multisystem thromboembolism. It also emphasizes the importance of early detection of a possible right-to-left shunt in patients presented with recurrent acute limb ischaemia. Transthoracic echocardiography has reduced sensitivity for inferior sinus venosus ASD requiring further assessment with transoesophageal echocardiography in selected cases.

Putra Acute Stroke protocol

Putra Acute Stroke protocol

Fetal posterior communicating artery as a conduit for concurrent anterior and posterior circulation infarct: A case report

Fetal type posterior cerebral artery (FTPCA) is a variant of posterior circulation of brain, in which the distal part of posterior cerebral artery (PCA) is perfused by a branch of internal carotid artery (ICA) via fetal posterior communicating artery (fetal PCOM). In the presence of fetal PCOM, a paradoxical concurrent infarction of anterior and posterior circulation may happen. We report a 67-year-old man who presented with sudden onset right sided weakness and aphasia, with National Institutes of Health Stroke Scale (NIHSS) score of 22 and clinically diagnosed to have left total anterior circulation infarct (TACI). Subsequently, he received IV Alteplase as a standard hyperacute ischemic stroke treatment. Computed tomography angiography (CTA) of brain showed left FTPCA with prominent left fetal PCOM. Subsequent computed tomography (CT) of brain showed concurrent left middle cerebral artery (MCA) and PCA territories infarct. CTA brain is commonly done in ischemic stroke cases to assess presence of large vessel occlusions and intracranial or extracranial atherosclerotic disease. However, this case depicts its additional role in detecting anatomical variants of cerebral circulation. In terms of clinical importance, presence of multiple territories infarction portends a poorer neurological outcome.

MSC 2021 Virtual E-Abstract

1. Key Mirnas And Target Genes For Ischemic Stroke.

The “butterfly wings” and midbrain “V” sign of Artery of Percheron infarction

An 80-year-old woman with history of hypertension presented to the emergency department following a fall. Her mental status quickly deteriorated and became obtunded. She was stuporous, and unresponsive to verbal stimuli. She had minimally reactive pupils and was moving extremities to painful stimuli. An MRI scan was performed following an unrevealing CT brain.

MSC 2021 Virtual E-Abstract

1. Case Report: Dual Antiplatelet In Capsular Warning Syndrome.2. Anxiety, Depression And Occupational Participation Of Stroke Survivors.3. Atrial Fibrillation In Hypertensive Patient With Prior Stroke: A Case Report.4. Radiology Workflow Efficiency In Managing Stroke Patient During Pandemic Covid-19: Early Experience In A Teaching Hospital.5. Are There Missed Opportunities In Reducing Risk Of Recurrent Cardiovascular Event Among Stroke Survivors Living In The Community?6. Efficiency of Hand-Arm Language Therapy7. The Rash That Solved The Diagnostic Dilemma: An Overlooked Cause Of Ischemic Stroke.

Imaging of Acute Stroke patient with Covid-19: A serial case

Background: Coronavirus Disease 2019 (COVID-19) has been declared as a pandemic in March 2020 by WHO. Apart from respiratory symptoms, COVID-19 is also associated with various neurological manifestations, one of which is stroke. We reported three cases with diagnosis of stroke in confirmed COVID-19 patients. Case Presentation: Head CT scan without contrast in the three reported cases showed different types of strokes. The first case showed ischemia in the right insular lobe and right parietal lobe. The second case showed intracerebral hemorrhage in the left thalamus and intraventricular hemorrhage, whereas the third case showed acute infarction in right frontotemporal lobe, right lentiform nucleus, right insular cortex, that supports prelenticulostriate segment I MCA embolism. Conclusion: CT scan is an important imaging modality in stroke cases both in COVID-19 and non-COVID-19 cases. CT scans are good at detecting the presence of bleeding, widely available, faster to operate, and less expensive than MRI. The types of stroke in COVID-19 patients can appear as different types of stroke. Generally, it appears as ischemic stroke, but hemorrhagic stroke can also occur with a less frequent occurrence. Further research is needed to explain the exact correlation between stroke and COVID-19.

MSC 2021 Virtual E-Abstract

1. A Malaysian Single Centre Experience of NOAC Efficacy And Safety For Stroke Prevention in NVAF.2. An Observational Study On The Overview Of Young Stroke Patients.3. An Overview of Stroke Patterns from A Stroke Ready Hospital.4. Mortality After Stroke: A 9-Month Observational Study.5. The Characteristics of Post-Stroke Patients from Hospital Seberang Jaya.6. The Impact of COVID-19 Pandemic on Acute Stroke Care: An Experience from a Primary Stroke Centre in Malaysia.7. Young Stroke On Prevalence Of Epidemiological Factors, Stroke Subtypes And Stroke Events - An Observational Study.

Unilateral loss of the swallow tail sign in a patient with idiopathic Parkinson’s disease

A 66-year-old man with underlying hypertension and dyslipidemia presented with left hand tremor for one year. He also noticed difficulty in initiating movement and slowness in activities of daily living. On examination, he was noted to have mask-like facies with reduced blinking and monotonous speech. There was presence of resting pill-rolling tremor, bradykinesia, and cogwheel rigidity which was worst on the left upper limb. Gait assessment revealed difficulty in standing up, shuffling gait with reduced arm swing which was more prominent on the left side, and turning in numbers. No cerebellar signs and supranuclear palsy were present to suggest Parkinson-plus syndrome. Susceptibility weighted imaging (SWI) showed loss of the swallow tail sign on the right side [Figure 1]. The clinical presentation, supplemented by the imaging findings were concluded to be pathognomonic of idiopathic Parkinson’s disease (IPD), Hoehn & Yahr stage 1. He was started on levodopa and benserazide twice daily with improvement of symptoms.The nigrosomes are primary subregions of the substantia nigra where dopaminergic cells are lost in IPD. Within these nigrosomes, maximal cell loss occurs in nigrosome-1; the largest subgroup of nigrosomes. Normally, they appear as a SWI-hyperintense area surrounded by hypointensity within the dorsolateral substantia nigra, akin to a swallow’s tail. In one study, poor visualization of nigrosome-1 was significantly associated with higher motor asymmetry in the contralateral side (sensitivity 98.5%, specificity 93.6%, positive-predictive value 98.3%, negative-predictive value 98.3% and an accuracy of 96%) [1]. Noh et al [2] showed that abnormality involving nigrosome-1 can be detected at 3T MR imaging with an accuracy of 94.6%. Due to the difficulty in diagnosis of early stage IPD, a loss of the swallow tail sign serves as a useful imaging biomarker to supplement the clinical diagnosis, as seen in our patient.

MSC 2021 Virtual E-Abstract

1. Factors Influencing The Uptake Of Stroke Thrombolysis In Malaysia: A Case Study From The Healthcare Providers’ Perspective.2. Growth Hormone And Ischemic Stroke: Focus On Growth Hormone Deficiency And Therapeutic Effects Of Growth Hormone On Brain Recovery.3. Predictors Of Post-Thrombolysis Intracerebral Haemorrhage In Patients With Acute Ischemic Stroke.4. Predictors of Mortality In Thrombolysed Acute Ischemic Stroke Patients of Seberang Jaya Hospital.5. Bilateral Dejerine Syndrome: A Case Report with Diagnostic Dilemma.6. Outcome Of Ischemic Stroke Thrombolysis Treatment In Seberang Jaya Hospital, A Single Center 9 Years Review: 2012-2020.