Cerebrovascular disease and neurocysticercosis

We report three cases of stroke secondary to neurocysticercosis. The first one is a 36 years old man with bilateral middle cerebral artery occlusions who had presented acute right hemiparesia and aphasia. MRI demonstrated several enhancing subarachnoid cysts surrounding the occluded vessels, a right parietal racemose cyst and a left temporal large infarction area. Angiographic study showed total occlusion of left middle cerebral artery and a subtotal occlusion of right middle cerebral artery. The second one is a 42 years old man with vasculitis of small cortical vessels who presented with headache, seizures and focal neurological deficit. CT scan demonstrated several calcifications and a left temporal infarction area. Cerebral angiographic study was normal. The third case was a woman, 53 years old, with a past history of six stroke events and an actual behavior disturbance and seizures. MRI demonstrated several cortical and subcortical infarction areas and cisternal cysts. Angiographic study showed diffuse arteritis of basilar and carotid arterial system. In all three cases CSF study showed linfomonocitic pleocytosis and positive ELISA for cysticercosis.     

Anterior inferior cerebellar artery syndrome; without hearing loss

The anterior inferior cerebellar artery (AICA) arises from the lower side of the basilar artery and supplies blood to the rostral olfactory bulb, rostral pontine base, and cerebellar regions. The AICA syndrome was first defined by Adams in 1943. Here, we present a case of a patient with a left AICA occlusion who suddenly started experiencing dizziness and had abnormal gait; he was subsequently diagnosed with ischemia in the left cerebellar hemisphere.A 55-year-old man was admitted to the hospital with complaints of sudden onset of vertigo, speech disorder, and imbalance. The neurological examination revealed gait disturbance, and left-sided ataxia. In addition, dysarthric speech left peripheral facial paralysis, loss of pain and heat sensations in the left half of the face and right half of the body. Bilateral horizontal nystagmus was observed. Babinski and Hoffman signs were also observed on the left side. The patient was evaluated with diffusion weighted (DW) magnetic resonance (MR) imaging. On DW image and apparent diffusion coefficient (ADC) maps precisely determined diffusion restrictions in the antero-inferior part of the left cerebellar hemisphere and the left part of the inferior vermis. MR angiography revealed occlusions in the right internal carotid artery and left AICA; hence, he was administered antiagregan treatment. We have presented this case because infarctions in the AICA have different clinical features from those observed in other cerebellar arteries, and such cases are rarely observed in neurological practice.     

Successful Recanalization of a Septic Embolus with a Balloon Mounted Stent after Failed Mechanical Thrombectomy

Cardiac emboli are a feared complication for patients with left ventricular assist devices (LVAD). Septic emboli are rare but carry a poor prognosis in the setting of large artery occlusion. We report the case of a 24‐year‐old woman who presents with a left internal carotid artery terminus occlusion secondary to a septic emboli from a LVAD. The patient was not a candidate for intravenous thrombolytics due to an elevated international normalized ratio, and thus was taken for intra‐arterial treatment. Initial treatment with mechanical thrombectomy and balloon angioplasty was not successful; thus, a balloon‐mounted coronary stent was placed to achieve successful recanalization. Fragments of thrombus on the mechanical thrombectomy device revealed gram‐positive bacilli on gram stain. Patients with large artery occlusion due to a septic embolus can be successfully treated with endovascular therapies in select patients.     

Agenesis of the left internal carotid artery associated with anterior communicating artery aneurysm: case report

We present a rare case of agenesis of the left internal carotid artery in a 43-year old woman, associated with an aneurysm of the anterior communicating artery and presenting with subarachnoid hemorrhage. The left internal carotid artery was not visualized on the left carotid angiogram. The left middle cerebral artery was perfused from the basilar artery via the dilated posterior communicating artery on vertebral angiogram. Absence of the left carotid canal was proven on temporal bone computed tomography. Absence of the left internal carotid artery was verified at operation. Absence of internal carotid artery is discussed in relation to aneurysm formation.     

Bilateral multiple border zone infarctions after massive bleeding: report of two cases]

We present two patients who developed bilateral border zone brain infarctions after massive bleeding. Patient 1 was a 46-year old woman who developed bilateral visual disturbance and left hand monoparesis after excessive menstruation with severe anemia. Diffusion-weighted MRI of brain showed multiple border zone infarcts bilaterally in cerebral and cerebellar hemispheres while brain MRA was normal. Patient 2 was a 67-year old man who developed disturbance of consciousness and right hemiplegia after upper gastrointestinal tract bleeding. Diffusion-weighted MRI of brain showed bilateral multiple border zone infarcts in cerebral hemispheres, although he had asymptomatic occlusion of the left internal carotid artery. The bilateral multiple border zone infarcts are one of the key findings suggesting the presence of anemic hypoxia as a result of global brain hypoperfusion caused by massive blood loss.     

Multimodality MRI and MRA for Decision Making in Minor Stroke: A Case with Internal Carotid and Distal Middle Cerebral Artery Occlusion

We report the case of a 65‐year‐old man who presented with mild, rapidly improving stroke symptoms. Acute magnetic resonance imaging disclosed no diffusion abnormalities but a tandem internal carotid artery/distal middle cerebral artery occlusion associated with a large corresponding deficit on perfusion imaging. In addition, there was a cross‐flow to the middle cerebral artery via the anterior communicating artery. Therefore, intravenous thrombolysis was initiated that led to rapid reopening of the middle cerebral artery and left the patient free of symptoms. Our observation highlights the possible benefit of systemic thrombolytic treatment even in the setting of an internal carotid artery occlusion and the substantial contribution of multimodal magnetic resonance imaging for a risk‐benefit estimate.     

Persistent primitive first cervical intersegmental artery (proatlantal artery II) with occlusion of the basilar artery--a case report

A rare case of persistent primitive first cervical intersegmental artery (proatlantal artery II) is reported. A 58-year-old man was admitted to our hospital with dysarthria and left hemiparesis. On admission he was stuporous with bilateral gaze palsy and left hemiparesis. CT scan on admission showed low density areas in the right cerebellar hemisphere and ventricular part of the pons. Right retrograde brachiography revealed occlusion of the basilar artery, aplasia of the right vertebral artery and an abnormal vessel connecting the right external carotid artery and the right vertebral artery. This anastomotic vessel was thought to be a persistent primitive first cervical intersegmental artery (Proatlantal artery II). Left carotid angiography revealed the left posterior cerebral artery was visualized through the posterior communicating artery, leading from the internal carotid artery. Left retrograde brachial angiography showed that the left vertebral artery terminated just distal from the branching of the left posterior inferior cerebellar artery. After admission the left hemiparesis deteriorated gradually and tracheotomy was done due to respiratory difficulties. The patient was then transferred to the rehabilitation center on his 34th day in hospital with neurological deficits.     

Traumatic middle cerebral artery occlusion from boxing.

A case of a traumatic middle cerebral artery occlusion resulting from a boxing injury is presented. A 22-year-old man, an amateur boxer, was admitted because of difficulty in speaking, that had appeared a day after a sparring fight. A computed tomographic scan showed low-density areas in the left globus pallidus and corona radiata. A carotid angiogram indicated complete occlusion of the left middle cerebral artery at its origin and an irregularity and narrowing of the left internal carotid artery in its supraclinoid portion. The patient was discharged 4 weeks after the admission with some persistent expressive dysphasia that diminished during the next month. The clinical features and mechanisms of the traumatic middle cerebral artery occlusion are discussed.     

A case of basilar artery occlusion successfully treated with tissue plasminogen activator]

This case concerns a stroke in the basilar artery territory that was successfully treated with a tissue plasminogen activator (t-PA). A 44-year-old man suddenly lost consciousness. It took fifty minutes to arrive to our hospital after the onset. On admission, his consciousness was in a coma state. A head CT revealed normal findings but a cerebral angiography showed complete occlusion in the basilar artery. We gave 240,000 units t-PA intravenously for 60 minutes. The intravenous t-PA dramatically improved his state of consciousness. After treatment, the brain CT scan showed low-density areas in the left occipital area and right pons. The cerebral angiography showed arterial sclerosis in the basilar artery. There was no parenchymal hemorrhage or hemorrhagic infarction in the patient. The hitherto reports showed the intravenous infusion of t-PA may be particular value in patients with thromboembolic occlusion in the middle cerebral artery. In contrast, our results support its efficacy in strokes in the basilar artery territory.     

Pure sensory stroke revealing a complex malformation of extra- and intracranial cerebral arteries

Pure sensory strokes (PSS) are usually due to thalamic lacunar infarcts. We report a case of PSS in a 34-year-old female suffering from migraine who complained of sudden isolated left-sided paresthesia involving face, upper and lower limbs. We found a complex vascular abnormality associating internal carotid artery occlusion, posterior cerebral artery agenesia, aneurysm at the posterior face of the carotid siphon and angiomatous rete at the top of the basilar artery. The acquired origin of the carotid artery occlusion by possible neonatal dissection is probable since this patient has a permeable carotid canal on CT scan.     

External carotid occlusive disease as a cause of facial pain

A 47 year old man suffered an acute left hemiparesis after several weeks of right-sided facial pain. Right carotid angiography revealed internal carotid artery thrombosis and severe occlusion of external carotid branches supplying facial structures. An ischaemic aetiology for the facial pain is suggested.     

Post-radiotherapy stenosis of the supraclinoid internal carotid artery. Moyamoya network

A 36 year-old caucasian woman was operated and then irradiated for a pituitary adenoma. Two years later, a left anterior temporal lobectomy for a grade I astrocytoma was performed. Four years later, she experienced right hemiparesis and aphasia. CT scan showed a left temporo-occipital low density area. A left carotid angiogram showed a narrowing of the left carotid artery beginning in the lower part of the siphon and progressing to a complete supraclinoid occlusion. There was a collateral circulation of the Moyamoya type. Radiation-induced narrowing or occlusion of the intracranial internal carotid artery is an infrequent finding. Most cases appear in young subjects, several years after a high dose of radiation therapy (30 to 60 grays). Some cases may show a network of the Moyamoya type. Usually, the absence of vascular abnormalities prior to radiation cannot be demonstrated. In our case, as in 3 other cases of the literature, the intracranial vessels were of normal appearance before irradiation. The vascular lesions can thus be considered as acquired and secondary to radiation therapy.     

Arterial thrombolysis and angioplasty in atheromatous basilar artery occlusion

Basilar occlusions treated with conventional therapy (anticoagulants or antiplatelets) have a poor outcome (80p. cent mortality). This unfavorable outcome may require a treatment within 6 hours by intra-arterial thrombolysis, sometimes followed by percutaneous transluminal angioplasty (PTA) in case of atherothrombotic occlusion due to a tight atherosclerotic stenosis. A 48 year-old patient, presented with left hemiparesis, left multimodal hypoesthesia, paralytic dysarthria. CT-scan showed a spontaneous hyperdensity of the basilar artery and arterial occclusion was confirmed by angiography, which showed an atherothrombotic occlusion involving the proximal part of the vessel. Intra-arterial thrombolysis began five hours after the onset with 0,25mg/kg of Rt-Pa (Actilyse((R))), given by bolus followed by 4 others bolus of 10mg. After a total dose of 60mg, arterial recanalization was obtained showing a tight atherosclerotic stenosis involving the proximal part of the basilar artery. PTA was performed 18 hours later with a ballon inflation at 6 atmospheres during 20 seconds. It allowed to decrease the stenosis from 80p. cent to 60p. cent. The patient recovered and MRI at D20 showed a small right lateral infarct involving the pons. Our study confirms the usefulness of intra-arterial thrombolysis in basilar artery occlusion. Consecutive PTA may be proposed in case of associated atherosclerotic stenosis, and the interest of PTA is further discussed.     

Acute carotid arterial occlusion after burr hole surgery for chronic subdural haematoma in moyamoya disease.

Ischaemic strokes and neurological deterioration have been described after revascularisation surgery in patients with moyamoya disease, but accelerated acute occlusion of the internal carotid artery after burr hole surgery has not been reported in this setting. A 66-year-old woman with known moyamoya disease who presented with right motor weakness underwent burr hole surgery for a bilateral chronic subdural haematoma. Postoperatively, the patient had a crescendo transient ischaemic attack and then deteriorated. Angiography showed complete occlusion of the left internal carotid artery. Burr hole surgery may cause postoperative acute occlusion of a preexisting stenotic artery in patients with moyamoya disease.     

A case of hypertensive intracerebral hemorrhage associated with ipsilateral internal carotid artery occlusion]

We report a case of intracerebral hemorrhage associated with ipsilateral internal carotid artery occlusion. The patient was a 54-year-old man, who developed a small cerebral hemorrhage in the left internal capsule. He was admitted with mild right hemiparesis to out hospital. Left carotid angiography showed an occlusion at the origin of the internal carotid artery. Right cerebral angiography revealed the slow filling of cerebral arteries of left hemisphere by the cross flow. He was treated conservatively. Two days after admission, the neurological examination revealed no notable abnormalities. The etiology of hemorrhage of this case is presumed as the arterial necrosis due to hypertension. There has been no report on the intracerebral hemorrhage associated with ipsilateral internal carotid artery occlusion. Our case suggests that the volume and enlargement of cerebral hemorrhage may be influenced by cerebral perfusion pressure.     

Repeated Cerebral Ischemia Caused by Extracranial Carotid Artery Dolichoectasia

We report the case of a 67‐year‐old man with repeating cerebral embolism caused by a dolichoectatic right common carotid artery. The patient had a history of hypertension, hypercholesterolemia, cigarette smoking, and a postoperative abdominal aortic aneurysm. He presented with a sudden onset of weakness of the left arm and leg. Magnetic resonance imaging revealed old and fresh infarction in the right cerebral hemisphere. Carotid duplex ultrasonography showed a dolichoectatic right common carotid artery with a maximum diameter of 39 mm with thick plaque and strong spontaneous echo contrast. The flow velocity was considerably reduced, which caused thrombus formation, and strong antithrombotic therapy was required. This case provides a rare example of ischemic stroke caused by extracranial carotid artery dolichoectasia.     

Intracerebral haemorrhage by cerebral hyperperfusion after carotid angioplasty in a tandem lesion. A case report

Intracerebral hemorrhage (ICH) by hyperperfusion after carotid angioplasty has a frequency of 1.2 % - 4.4% in the literature. Until now no case of ICH after carotid angioplasty in a tandem lesion has been reported. We present the case of a patient who suffered an ICH due to the hyperperfusion syndrome, after carotid angioplasty of two stenotic lesions of the left internal carotid artery (ICA) (intracranial and extracranial). He was a 58 year old man who suffered repetitive left carotid TIA despite being treated with antiplatelet therapy. An angiogram showed 76 % extracranial stenosis and 96 % intracranial stenosis of the left ICA as well as 59 % extracranial stenosis of right ICA. Angioplasty with stenting of the two stenosis of the left ICA was performed. After 48 hours of the angioplasty, the patient presented a massive ICH and died a few hours later. ICH by hyperperfusion is an infrequent complication of the carotid angioplasty. The risk factors of the ICH should be evaluated in order to decrease their incidence as well as to maintain an intensive control of the arterial pressure during and after the procedure. This case is the first one published after angioplasty of a tandem lesion. It is possible that the pathophysiologic mechanism involved was an excessively rapid restitution of the normal arterial size.     

Persistent primitive trigeminal artery presenting with Weber's syndrome: report of a case with three-dimensional CT angiographic evaluations]

We report a rare case of persistent primitive trigeminal artery(PPTA) presenting with brain stem infarction known as Weber's syndrome, and document its unique findings of three-dimensional CT angiography(3 D-CTA). A 69-year-old woman was admitted to our hospital because of gait disturbance and blepharoptosis on the right eye. Neurological examination on admission revealed the right oculomotor nerve palsy, left hemiparesis and dysarthria, all of which indicated the signs and symptoms of Weber's syndrome. Initial CT scan revealed no abnormality, but a subsequent 3 D-CTA demonstrated the PPTA originating from the right internal carotid artery penetrate into the clivus directly to the distal basilar artery, on top of which a small saccular aneurysm was incidentally visualized. Right internal carotid angiograms showed the PPTA run between the cavernous segment of the internal carotid artery and the distal portion of the basilar artery with the filling of both the posterior cerebral and superior cerebellar arteries. However, the proximal portion of the basilar artery was visualized through the right vertebral artery and there was no blood flow to its distal portion. Evidence of infarction was finally confirmed at the right midbrain and thalamus by the MRI performed 5 days after the onset. With a conservative treatment including physical therapy, the patient recovered well from the deficits and could walk by herself with a cane. With regard to the pathogenesis of vertebrobasilar insufficiency in a patient with PPTA, it is generally considered that microembolus from an atherosclerotic carotid artery may be its cause because of the presence of direct communication between the anterior and posterior circulations. In the present case, however, this mechanism may not be applied since there was no evidence of atherosclerotic plaque or stenotic lesions on the carotid arteries. Alternatively, an embolic occlusion may have occurred in the paramedian branches of the posterior cerebral artery since a dilated PPTA itself, which resembled fusiform-aneurysm in appearance, may become the origin of microembolus.     

Multiple aneurysms associated with bilateral carotid occlusion and venous angioma: surgical management risk-case report.

A unique case of multiple aneurysms associated with bilateral carotid artery occlusion and venous angioma is described. A 42 year old female presented with subarachnoid haemorrhage. Cerebral angiograms demonstrated(1) a ruptured saccular aneurysm in the right posterior cerebral artery,(2) bilateral occlusion of internal carotid arteries,(3) a rete mirabile in the subtemporal fossa fed by left external carotid artery which connected with the internal carotid artery at the cavernous portion where a saccular aneurysm had formed, and(4) a venous angioma in the posterior fossa. The ruptured aneurysm of the posterior cerebral artery was obliterated preserving the anterior choroidal arteries. However, a left hemiparesis developed and CT scan revealed a small low density area in the right posterior limb of the internal capsule postoperatively. A ruptured aneurysm associated with bilateral extracranial carotid occlusion poses a clinical dilemma and treatment of such cases is challenging and difficult. The non-surgical and surgical outcomes of ruptured cerebral aneurysms associated with internal carotid occlusion are reviewed.     

Cerebrovascular complications in patients with malignancy: report of three cases and review of the literature

A cerebrovascular thromboembolic event may precede the identification of cancer, and be the first clinical evidence of an underlying malignancy. The malignancy can cause either nonbacterial thrombotic endocarditis or hypercoagulable state, both of which may have clinical manifestions such as thrombotic or embolic occlusion of multiple major cerebral vessels. We present three cases with unusual cerebrovascular events. The first case is a 62-year-old woman who was admitted due to acute left limbs weakness and consciousness disturbance. Brain computed tomographic (CT) scan showed right middle cerebral artery (MCA) and posterior cerebral artery (PCA) infarctions with uncal herniation. The second case is a 44-year-old woman who was hospitalized due to acute bilateral limb weakness and consciousness disturbance. Bilateral MCA, left PCA, anterior cerebral artery (ACA) infarctions and deep vein thrombosis in the left leg were diagnosed. The third case is a 63-year-old man who developed sudden onset of right hemiplegia and consciousness disturbance. Brain CT scan showed bilateral MCA and left ACA infarction. The results of a series of examinations including biochemistry, lipid profile, carotid duplex, and transthoracic and transesophageal echocardiography were unremarkable. All patients had positive disseminated intravascular coagulation (DIC) tests with elevated D-dimers and fibrinogen degradation products (FDP). Further systemic evaluation for malignancy revealed ovarian cancer in the first patient, endometrial carcinoma in the second patient, and adenocarcinoma of lung in the third patient. They all died of the underlying malignancy. Because the hemostatic system can be altered by malignancy, intravascular coagulation abnormalities of these malignancy-related strokes may be disclosed by laboratory assays of hemostasis.