Posterior Reversible Encephalopathy Syndrome (PRES) Associated With COVID-19 Infection—A Case Report and Review

Coronavirus disease 2019 (COVID-19) has caused a large number of systemic complications including a variety of neurological complications. Some of the neurological complications are not known. Posterior reversible encephalopathy syndrome (PRES) is a known acute neurotoxic syndrome causing a wide range of neurological symptoms. If remains untreated, it can potentially become a life-threatening condition. However, it is not a known neurological complication of COVID-19. We describe a presentation of PRES in a patient with positive COVID-19 and presented with altered mental status. A 78-year-old male with history of idiopathic epilepsy was initially admitted with respiratory illness with negative COVID-19 test. Later during his hospitalization, his respiratory condition got worse and his repeat COVID-19 test came back positive. He had continued encephalopathy and was found to have status epilepticus afterward. Magnetic Resonance Imaging brain showed extensive PRES-related changes. His blood pressure remained overall within control without significant fluctuations. No other apparent etiology was identified for PRES except for possible correlation with COVID-19. Clinicians should consider PRES early in their differential diagnoses in patients with severe COVID-19 with continued encephalopathy.

The Deception of Mass Effect: Subacute Posterior Cerebral Artery Infarction Presenting as a Mimic of Acute Middle Cerebral Artery Syndrome

Clinical data from 3 related cases sheds light on the complex presentation of subacute posterior cerebral artery strokes mimicking acute middle cerebral artery (MCA) syndrome. An expert witness in the field of interventional and diagnostic radiology defended a primary care physician against litigation for an alleged missed diagnosis using multimodality imaging to age a cerebrovascular event. The use of basic computerized tomography and magnetic resonance imaging physics principles are applied to determine whether a patient is outside the treatment window for thrombolytic administration or endovascular intervention. In the defended case, earlier stroke recognition would not have changed the patient’s outcome under question as he was deemed to have a completed infarct prior to presenting to the primary care physician’s (PCP’s) office, making the patient ineligible from acute stroke thrombolytic or endovascular treatment.

Clinical and Radiological Profile of Patients Presenting With Isolated Acute Cerebellar Infarct: A Single Tertiary Center 3 Years Retrospective Study From Central Stroke Unit, Muscat, Oman

Introduction: Cerebellar infarct can present with a broad spectrum of clinical and radiographic features. Recognizing this spectrum is extremely important for prompt diagnosis and to avoid morbidity and mortality. Objective: To identify the clinical and radiological profile of patients presenting with isolated acute cerebellar infarct. Methods: Retrospective study carried out at the central stroke unit of Oman over 27 months. Only patients with isolated acute cerebellar infarct confirmed by either magnetic resonance imaging or computerized tomography (CT) were included in this study. A total of 76 cases were identified. Results: Isolated cerebellar infarct constituted 4% of all acute ischemic strokes treated during the study period. Gait imbalance and difficulty in articulating were seen in 30/48 (63%) and 12/48 patients (25%), respectively. Ataxia and nystagmus were the main signs seen 30/48 (63%) and 10/48 (21%), respectively. Large artery atherosclerosis comprised 15/48 (31%), of the underlying etiology. Normal and complete posterior circulation was seen only in 6/36 (17%). Unilateral or bilateral hypoplasia or absence of posterior communicating artery (PCOM) were the commonest variants seen in our patients. The cerebellar arterial territory most commonly involved in this series was posterior inferior cerebellar artery (58%). Infarct extension was seen in 10/48 patients (21%), with 4/10 (40%) having bilateral absent PCOM followed by 2/10 (20%) normal posterior circulation. Conclusions: Acute gait imbalance and difficulty in articulating can be the only presenting symptoms in isolated cerebellar infarct. Plain CT in the acute phase can miss such infarcts in up to 46% cases. The majority of cases had an incomplete anatomy of the posterior circulation.

The Novel Oral Anticoagulants (NOACs) for the Treatment of Cerebral Venous Thrombosis: A Case Study of 32 Vietnamese Patients

Background and Purpose: Cerebral venous thrombosis (CVT) is a rare cause of cerebral infarction with diverse clinical presentations and outcomes. Novel oral anticoagulants (NOACs) provide an alternative option of systemic anticoagulation in various thromboembolic conditions, but uncertainty exists over the use of NOACs among patients with CVT. We present our initial experience with the use of NOACs for CVT in Vietnam. Methods: We included consecutive patients diagnosed with CVT presenting to 115 People’s Hospital in Vietnam between May 2016 and July 2017 and who were treated with NOACs. Data on patient demographics, vascular risk factors, clinical presentations, and outcomes at 180 days follow-up were obtained and analyzed. Modified Rankin scale (mRS) scores on admission, at discharge, and 180 days were assessed. Recanalization was assessed using magnetic resonance venography at 180 days follow-up. Venous thrombo-embolism events were defined as primary outcome, while bleeding complications were defined as safety outcome. Results: Among 32 patients with CVT (72% females; mean age: 40 ± 9.7 years), 15 were treated with rivaroxaban and 17 with dabigatran. A common risk factor was the usage of oral contraception (70%) on presentation. The mean mRS score on admission was 3.1 points (± 1.4). At FUP (median 8.5 months, IQR 5.5-9.5), clinical outcome (mRS ≤ 1) was excellent in most patients. All patients had at least partial recanalization and half of them achieved complete recanalization at 180 days follow-up. There were no bleeding complications. Conclusion: NOACs may offer clinical benefits with minimal complications in the treatment of CVT. Further prospective assessment with randomized controlled studies is warranted.

An Interesting Case of Acute Stroke: When Many Things Went Wrong, but the Patient Laughed at Last!

A 52-year-old lady with hypertrophic obstructive cardiomyopathy, atrial flutter, and old right hemispheric stroke in the background underwent implantable cardioverter-defibrillator implantation for complete heart block. She was yet to start her regular anticoagulant and presented to hospital emergency with acute right middle cerebral artery (MCA) territory stroke (NIH Stroke Scale/Score of 14). After ruling out absolute contraindications, she was given intravenous thrombolysis (did not have a blood vessel target for endovascular therapy). Post thrombolysis, she had clot mobilization from the internal carotid artery to the MCA and systemic embolization to kidneys and lower limbs. The patient underwent an urgent embolectomy and lower limbs were saved from amputation. Our case highlights the importance of checking peripheral pulses in acute stroke patients post thrombolysis. Though the patient had initial deterioration after thrombolysis, she gradually improved and later achieved satisfactory modified Rankin scale underscoring the ultimate potential benefits of thrombolysis in acute stroke. There is a high chance of thrombus formation in patients with atrial flutter who undergo recent cardiac procedure especially if they are off anticoagulation for even a short period. Hence, unnecessary apprehension of anticoagulant use in proper situations may create life-threatening complications.

Central Venous Occlusion in End-Stage Renal Failure—A Rare Mimic of Dural Arteriovenous Fistula (DAVF)

Intracerebral hemorrhage is a devastating form of stroke and is more common in patients with hypertension and renal disease. We present the case of a lady suffering from chronic kidney disease who presented with severe headache and aphasia. On evaluation, she was found to have an intraparenchymal hemorrhage in the left temporal lobe with prominent pial and dural veins suggestive of a dural arteriovenous fistula (DAVF). Subsequently, she was detected to have occlusion of the left brachiocephalic vein (LBCV), which resulted in venous hypertension and resulted in this rare complication. Angioplasty followed by stenting of the LBCV resulted in subsidence of her symptoms. We wish to highlight this unusual but treatable complication of limb AV fistula which can mimic intracranial DAVF.

Infrastructural and Knowledge Barriers to Accessing Acute Stroke Care at a Regional Tertiary Facility in Kenya

The delivery of definitive acute stroke care in Africaremains low due to prehospital barriers, and these are known to be country-specific. There have been no studies on elucidating these barriers in Kenya. Objectives: We sought to identify the nature of barriers to acute stroke care for patients presenting to our hospital in Nairobi, Kenya. Materials and Methods: We conducted a prospective cross-sectional study atour tertiary regional referral center from August 2018 to March 2019 for patients presenting with an acutestroke. We consented participants (patients or their registered next-of-kin) to fill out a questionnaire on their journey from stroke-onset to the ward bed, and about their knowledge about stroke. Results: We recruited 103 participants. Only 25.2% arrived to hospital within 3.5 h (early arrival) of stroke onset. The significant factors causing delay were:distance from hospital, traffic, visiting another hospital first, and lack of transport vehicle. Factors significantly associated ( P<.05) with early arrival were: older age, non-African ethnic origin, bystander present at stroke onset, living near (<15km) the hospital, and knowledge of stroke. Almost 80% believed stress was a major risk factor and that dizziness was a cardinal symptom. Only 50% knew of the availability of thrombolysis/thrombectomy and their roles in stroke treatment, and only 37.9% knew the correct time limits for these. Conclusions: We identified a number of prehospital barriers to reaching hospital on time for definitive stroke treatment, which have implications on the structure of emergency services for stroke in our city. Our study also revealed interesting observations on the public’s understanding about stroke, calling for a tailored public awareness campaign to improve stroke knowledge.

Safety and Outcome of Intravenous Recombinant Tissue Plasminogen Activator (rt-PA) in the Nursing Home Residents Following an Acute Ischemic Stroke

Background and Purpose: Intravenous recombinant tissue plasminogen activator (IV rt-PA) is an effective treatment of acute ischemic stroke. The safety and efficacy of IV rt-PA were extensively studied in adults, including both octogenarians and nonagenarians.This study provides safety outcome of exclusive nursing home (NH) residents (dependent on activities of daily living [ADLs]) , who received IV rt-PA. Not much literature or studies are available exclusively on the NH residents. Aim: To assess the safety and outcome of IV rt-PA in patients from NHs who were admitted to our university-based tertiary care hospital, using data from a prospective stroke registry. Methods: Our study is a retrospective review of patients living in nursing facilities, admitted to our neuroscience intensive care unit after receiving IV rt-PA, from January 2010 to June 2018. We reviewed the clinical symptoms, comorbid conditions, medications, diagnostic evaluation, complications, and functional outcomes. The functional outcome was assessed based on the modified Rankin Scale (mRS) at the time of discharge, and 1- and 3-month follow-up. Results: Twenty-eight NH residents (20 [71.4%] were female with a mean age of 80.96 +/− 12.43 years) were identified who had received IV rt-PA for symptoms of acute ischemic stroke. The median mRS on admission was 3, and all of them were dependent on ADL. Twenty-seven (96.5%) patients were treated within the window (≤3 h) for IV rt-PA. There were no IV rt-PA-related violations from both our hospital and outside hospital treatment protocols. The initial computed tomographic (CT) scan of 8 (28.5%) patients revealed evidence of infarction. CT angiogram of head and neck revealed an acute intracranial blood vessel occlusion in 13 (46.4%) patients, and asymptomatic stenosis of intracranial and extracranial blood vessels in 4 (14.2%) patients. Mechanical thrombectomy was attempted in 6 (21.4%) patients and among them, the procedure was unsuccessful in 2 (7.1%) patients due to severe stenosis. One (1/21; 16.6%) patient received an intra-arterial rt-PA, and 5 (5/6;83.3%) patients developed symptomatic intracranial hemorrhage within 24 h following the procedure. Families of 9/28 (32.1%) patients decided to withdraw care. The median mRS on 30 and 90 days follow-up was 4 (interquartile range: 3-6). Conclusion: In this population, mechanical thrombectomy has a high risk for hemorrhagic conversion. IV rt-PA treatment in the NH residents may not improve the outcome of ischemic stroke.

Role of S100β Glial Protein as a Serological Marker for Analysis of Acute Ischemic Stroke

Background: Stroke is a major cause of neurological disability, which can be often predicted with serological markers. Glial-derived S100β protein is a potential biomarker for cerebral ischemia and may be helpful in predicting the severity, outcome, and recovery of stroke. Aim: This study aimed to study the role of S100β glial protein as a serological marker in predicting the severity of acute ischemic stroke (AIS), outcome, and functional recovery after 1 month. Methods: A hospital-based prospective case control study included 43 consecutive patients, >18 years old, who were admitted with acute middle cerebral artery (MCA) territory infarcts within 72 h of onset of neurological deficits. Control group comprised of 43 age-matched asymptomatic volunteers. Independent t-test and chi square test were used to compare the means and evaluate the association between protein level and various parameters. P ≤ .05 was statistically significant. Results: S100β protein level in AIS patients was significantly higher compared to controls ( P < .05). Elevated serum S100β protein level was found to be associated with larger infarct volumes, higher National Institute Health Stroke Scale scores, and higher modified Rankin Scale scores at admission ( P < .05). Patients with higher S100β protein levels at admission had poor recovery at 1 month compared to patients having normal S100β protein levels. Conclusion: S100β protein levels at admission after an acute MCA territory infarct may be used as a reliable serological tool in predicting the severity, outcome, and functional recovery in stroke.