Case Reports in Neurology最新文献

Introduction: Although rare, common carotid artery occlusion (CCAO) causes ischemic neurological dysfunction, which can be treated by revascularization. Although several bypass approaches for CCAO have been suggested, no consensus on the surgical revascularization approach and its functional outcome have been reached. Herein, we present a case of Rile's type 1A CCAO in which a subclavian artery (SclA)-internal carotid artery (ICA) bypass using a radial artery graft (RAG) resulted in immediate recovery of cognitive function and successfully prevented ischemic stroke.

Case description: A 58-year-old man presented with recurrent episodes of right-sided weakness. Brain magnetic resonance imaging revealed multiple cerebral infarcts. Digital subtraction angiography confirmed left CCAO and no anterograde blood flow in the left ICA and ipsilateral external carotid artery. A bypass was performed from the left SclA to the left cervical ICA using a left RAG, and supraclavicular anastomosis between the SclA and ICA was performed without graft-vessel kinking. Postoperatively, no neurological deficits were observed, and his cognitive function was successfully improved.

Conclusion: SclA-ICA bypass using an RAG can be a reasonable treatment option for CCAO. CCAO revascularization can prevent ischemic stroke and improve cognitive function.

Background: Lyme borreliosis, a tick-borne illness caused by Borrelia burgdorferi, is increasingly prevalent in Nova Scotia, Canada, which has the highest incidence in North America. While most cases present as early localized disease, approximately 20% develop early disseminated disease, which can include neurological symptoms, an entity called Lyme neuroborreliosis (LNB). This case report describes an unusual LNB presentation with isolated intracranial hypertension (IH).

Case presentation: A 6-year-old female presented to our pediatric hospital with binocular horizontal diplopia, headache, fever, malaise, and suspected papilledema 47 days after an embedded tick bite. A diagnosis of Lyme disease had been made 10 days prior in the community based on positive serologies and erythema migrans, but she developed a Jarisch-Herxheimer reaction within 24 h of oral doxycycline, leading to an antibiotic change to amoxicillin. During the hospital admission, an ophthalmological examination revealed papilledema and IH was evidenced by an opening pressure of 36 mm Hg and brain MRI findings. The lumbar puncture revealed pleocytosis and positive cerebrospinal fluid antibodies for Borrelia. The patient was initially treated with 2 days of ceftriaxone, followed by a 12-day outpatient course of doxycycline for LNB. High doses of acetazolamide (500 mg TID) were needed to achieve symptom control. Two months after her hospital discharge, there was resolution of papilledema and the acetazolamide was weaned.

Conclusion: This case highlights the importance of considering Lyme disease in the differential diagnosis of IH, particularly in endemic regions. Early recognition, diagnostic workup, and appropriate treatment are crucial for optimal outcomes in LNB.

Introduction: Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is a well-established treatment for advanced Parkinson's disease (PD), offering significant symptomatic relief. Although DBS is generally considered safe, it carries risks, including the potential for delayed complications such as intracerebral hemorrhage (ICH).

Case presentation: We present a rare case of a 67-year-old male with PD who developed delayed ICH after undergoing bilateral STN DBS. Initially, the patient showed no neurological deficits postoperatively, with imaging confirming correct lead placement and no signs of hemorrhage. However, on the second postoperative day, the patient developed sudden right-sided hemiparesis. A CT scan revealed ICH alongside the left lead. The hemorrhage was managed conservatively, and the patient underwent extensive physical therapy, leading to significant improvement. Over the next 2 weeks, the patient's condition improved, and follow-up CT scans showed complete resolution of the ICH. At this point, the left lead stimulation was initiated, further improving the patient's PD symptoms. This case illustrates the potential for delayed ICH following STN DBS, emphasizing the need for ongoing monitoring and individualized treatment strategies.

Conclusion: This case underscores the importance of vigilant postoperative monitoring and individualized management strategies in STN DBS patients. Early detection and appropriate management of complications such as ICH are crucial for minimizing risks and ensuring optimal patient outcomes. The potential for delayed complications highlights the need for continuous follow-up, even in the absence of immediate postoperative issues.

Introduction: Idiopathic intracranial hypertension (IIH) is a rare cause of chronic headaches. Usually, patients with IIH present headaches and papilledema with no focal neurological signs. Classical MRI findings feature characteristic signs, i.e., dilated perioptic nerves sheath and empty sella turcica. Rarely, cranial nerve palsies existed, especially abducens nerve palsy.

Case presentation: We reported herein another rare clinical feature of IIH: trigeminal neuralgia in association with meningocele. This 35-year-old obese woman initially presented with chronic headaches and papilledema. Cerebral MRI showed classical IIH findings. The CSF opening pressure was increased. A treatment coupling acetazolamide and iterative lumbar punctures led to the regression of papilledema, but headaches were difficult to control. Ten years later, while she was lost to follow up and treated with acetazolamide by her general practitioner, she developed extremely painful neuropathic pain in the left trigeminal nerve territory, in association with a recurrence of the chronic headaches. A new MRI showed new bilateral cavum trigeminal meningoceles, predominantly on the left side, associated with an atrophy of the cisternal segment of the left trigeminal nerve. Angio-CT showed transverse sinus stenosis, treated by stenting. After this treatment, IIH symptoms disappeared, while trigeminal neuralgia amplified: a surgical procedure led to its complete disappearance.

Conclusion: To our knowledge, this is the first case reported of trigeminal neuralgia associated with meningocele formation in IIH. Our case illustrates the great efficacy of venous stenting in IIH, and one may wonder whether earlier stenting could have avoided the subsequent development of meningoceles and subsequent neuralgia.

Introduction: Patients presenting with encephalopathy and longitudinally extensive myelitis pose a significant diagnostic challenge. Area postrema-related symptoms, such as intractable hiccoughs, can aid in narrowing the differential diagnosis. Neuromyelitis optica spectrum disorders and glial fibrillary acidic protein (GFAP) autoimmune encephalitis are known causes; however, some cases remain seronegative, suggesting the presence of unidentified autoantibodies or immune targets.

Case presentation: A previously healthy man in his 70s presented with headache, fever, and confusion, followed by a seizure and persistent hiccoughs. MRI revealed brainstem involvement and extensive transverse myelitis. Cerebrospinal fluid (CSF) analysis showed inflammatory features, but testing for AQP4, MOG, and GFAP antibodies was initially negative. He was treated with intravenous corticosteroids and plasma exchange, after which serum GFAP-IgG was weakly positive, though CSF remained negative. His condition improved with immunotherapy, but significant lower limb weakness persisted. Based on clinical and radiological findings, we hypothesize that tanycytes - specialized glial cells in the area postrema - may be an additional immune target in GFAP encephalitis.

Conclusion: This case highlights a seronegative encephalomyelitis syndrome with area postrema involvement, possibly implicating glial cells beyond astrocytes. Further studies are needed to explore the role of tanycytes in autoimmune neuroinflammation.

Introduction: Ocrelizumab is a recombinant humanized anti-CD20 monoclonal antibody used to treat multiple sclerosis. Late-onset neutropenia, absolute neutrophil count <1.5 × 10⁹/L that develops >4 weeks after last drug administration, is a known adverse event associated with anti-CD20 monoclonal antibodies, including rituximab and ocrelizumab.

Case presentation: We present the case of a 27-year-old woman who developed severe late-onset neutropenia during her third trimester of pregnancy after treatment with ocrelizumab 6 months prior.

Conclusion: Neurologists should be aware of this risk and consider additional hematologic monitoring for pregnant patients who received anti-CD20 therapy as therapies such as G-CSF are available to help prevent serious infections.

Introduction: Parkinson's disease (PD) is a common neurodegenerative disorder, and its diagnosis remains a clinical one. Hence, the emergence of new symptoms warrants consideration of a new diagnostic work-up even at later disease stages. Important differential diagnoses include atypical or symptomatic parkinsonism, like multiple system atrophy, normal pressure hydrocephalus, or rarely, superficial siderosis (SS).

Case presentation: A 66-year-old woman with longstanding PD presented to our clinic with a 4-year history of progressive ataxia and gait impairment. The emergence of a new symptom (ataxia) prompted us to conduct a new, broad diagnostic work-up. Clinical examination revealed both parkinsonian (hypomimia, dyskinesias, right dominant bradykinesia and rigidity, intermittent resting tremor) and cerebellar signs (scanning dysarthria, gaze-evoked nystagmus, severe ataxia of extremities and gait). No signs or symptoms of autonomic dysfunction were present. Magnetic resonance imaging of brain and spine showed extensive hemosiderin depositions and ventral intraspinal fluid collection, establishing a diagnosis of SS. No apparent dural leak was detected in cerebrospinal fluid scintigraphy. The patient was treated with epidural blood patch.

Conclusion: The occurrence of new symptoms in PD, especially "red flags" or exclusion criteria, calls for a repeated diagnostic work-up to exclude potentially treatable causes of parkinsonism. While SS has been reported as a cause of symptomatic parkinsonism, we favor a diagnosis of idiopathic PD and comorbid SS in this case. This case report highlights the clinical importance of diagnostic criteria in differentiating PD from atypical parkinsonian disorders or symptomatic parkinsonism as well as signs and symptoms, pathophysiological aspects, and treatment of SS.

Introduction: Reflex epilepsies are rare syndromes where seizures are triggered by particular stimuli or activities that may be motor, sensory, or cognitive in nature. Eating-induced seizures are an uncommon presentation of reflex epilepsy. Many etiologies, including genetics, ethnicity, and specific foods and eating behaviors, are linked to eating epilepsy.

Case presentation: In this case report, a 55-year-old man who was admitted to the neurology clinic with epileptic seizures that occurred many times after spicy meals is presented. His neurological examination and metabolic values were normal. MRI showed nonspecific white matter changes. An interictal active epileptic focus was detected in the left temporal region in interictal EEG. The patient was started on valproic acid treatment at 1,000 mg/day. Anti-seizure treatment controlled the seizures and normalized the EEG abnormalities.

Conclusion: In this case report, it is emphasized that eating epilepsy should be considered in patients with a history of seizures induced with eating, and the diagnosis and treatment process of eating epilepsy is also mentioned.

We describe maternal and fetal outcomes in a patient who had three successful pregnancies while being treated with eculizumab for AChR+ gMG. This is a follow-up to our previously published report describing outcomes with this C5 complement inhibitor during the patient's first pregnancy. Eculizumab conferred adequate gMG disease control during these pregnancies, although there were instances of increased gMG symptoms during the first trimester and postpartum period without requirement for rescue therapy. The patient experienced disseminated gonococcal infection once during her second pregnancy, a serious adverse event that was likely related to complement inhibition by eculizumab. The patient additionally experienced two nonserious and treatment responsive yeast infections. There were no negative outcomes reported with any of the pregnancies in fetal, neonatal, or infantile periods. In the context of the existing literature, this report provides additional insight on potential outcomes with use of eculizumab in patients with gMG. While the report suggests favorable effectiveness and fetal outcomes, it also highlights potential for adverse events, namely, maternal infections. Additional reports on clinical outcomes in pregnancy in patients with gMG are needed to guide risk-benefit stratification for eculizumab.

Introduction: Posterior circulation infarctions, particularly basilar artery occlusions, contribute significantly to morbidity and mortality in ischemic stroke. However, literature supporting mechanical thrombectomy in the posterior circulation, especially beyond the 24-h window, is limited.

Case presentation: We present the case of a 64-year-old male diagnosed with basilar artery occlusion who underwent a successful mechanical thrombectomy 11 days after symptom onset. Despite complications such as hemorrhagic transformation and herniation, the patient was stabilized and showed functional improvement 3 months post-stroke.

Conclusion: This case suggests that delayed thrombectomy may provide benefits for selected patients, even beyond the recommended 24-h window. Further research is essential to refine treatment strategies and potentially extend the intervention window for posterior circulation strokes.