Cerebral Venous Thrombosis Combined with Spontaneous Intracranial Hypotension: A Case Report and Review of the Literature

Jinyoung Oh,Sang Won Han,Sun Yoon Chung 대한신경초음파학회 2023 대한신경초음파학회지 (JNN) Vol.15 No.1

Several cases of cerebral venous thrombosis (CVT) due to spontaneous intracranial hypotension (SIH) have been reported, with an estimated occurrence rate of 1–2% among patients with decreased intracranial pressure. However, the causal relationship between SIH and CVT as a potential risk factor is not well understood. According to the Monro-Kellie principle, this is thought to be caused by compensatory expansion of the cerebral venous system, damage to the intravenous wall due to changes in cerebral buoyancy, or increased venous blood viscosity. Although anticoagulation therapy is typically the first choice of treatment for patients diagnosed with CVT, considering the potential risk of intracerebral hemorrhage in patients with CVT secondary to SIH is important. We report the case of a patient who developed CVT as a complication of SIH and discuss its mechanisms and treatment options. Early identification and appropriate treatment can lead to successful outcomes and the prevention of potential complications.

Childhood Primary Angiitis of the Central Nervous System Presenting as Isolated Middle Cerebral Artery Dissection

Matthew Chung,Yong Woo Shin,권형민 대한신경초음파학회 2022 대한신경초음파학회지 (JNN) Vol.14 No.1

Isolated middle cerebral artery dissection and primary angiitis of the central nervous system are two rare but serious causes of ischemic stroke in children. We report a case of a patient who presented with headache, left-sided hemiparesis, and left hemi-hypoesthesia with acute cerebral infarction in the right middle cerebral artery territory. Brain magnetic resonance imaging showed isolated right middle cerebral artery dissection with arterial wall contrast enhancement extending beyond the length of the dissection and diffuse narrowing with stenosis in the right posterior cerebral artery suggesting angiitis. After exclusion of other diagnoses the patient was treated with corticosteroids and dual antiplatelet therapy. Follow up magnetic resonance imaging performed 4 months later showed partially improved contrast enhancement in the right middle cerebral artery and persistent narrowing and focal stenosis of the right posterior cerebral artery. Although rare, primary angiitis of the central nervous system should be considered in the differential diagnosis of acute stroke in children. High-resolution vessel wall imaging magnetic resonance studies can provide important information in determining the etiology of stroke.

Successful Treatment of Central Nervous System Vasculitis Associated with Antiphospholipid Syndrome

Eung-Joon Lee,Haelim Kim,Kichul Shin,권형민 대한신경초음파학회 2022 대한신경초음파학회지 (JNN) Vol.14 No.1

We report a case of severe, non-migraine headache accompanied by multifocal cerebral artery stenosis in a 41-year-old man with antiphospholipid syndrome (APS). He visited the emergency department with a headache that had occurred 2 days prior to presentation. He was administered low-dose aspirin (100 mg) daily after being diagnosed with antiphospholipid syndrome. Magnetic resonance angiography revealed severe multifocal cerebral artery stenosis. We assumed that multiple stenoses of the cerebral blood vessels were caused by APS; hence, we initiated pulse intravenous methylprednisolone therapy. Oral anticoagulation with warfarin was continued. After treatment, the symptoms and stenosis of the cerebral arteries gradually improved. Awareness of central nervous system vasculitis (with non-migraine headaches) caused by APS should be created among clinicians.

Reversal of a Large Ischemic Lesion with Low Apparent Diffusion Coefficient Value by Rapid Spontaneous Recanalization

Byeong Joo Choi,Taedong Ok,Yunjung Choi,이경열 대한신경초음파학회 2022 대한신경초음파학회지 (JNN) Vol.14 No.1

Cytotoxic edema at the site of a lesion following cerebral infarction is shown as a high signal on diffusion-weighted imaging, with a corresponding decreased apparent diffusion coefficient value on magnetic resonance imaging. These imaging findings have been used clinically as imaging markers of the infarction core, implying irreversible ischemic damage. However, reversal of diffusion lesions has been reported in patients with small lesions, relatively higher values of the apparent diffusion coefficient, or rapid endovascular reperfusion. Herein, we report a case of reversal of a large ischemic lesion on diffusion-weighted imaging with corresponding low apparent diffusion coefficient values in an acute middle cerebral artery infarction after immediate spontaneous recanalization. This case suggests that large ischemic lesions revealed by diffusion-weighted imaging may be reversed upon timely reperfusion, and could be considered as therapeutic targets.

Acute Stroke Caused by Large Vessel Vasculitis in a Patient with Systemic Lupus Erythematosus

Min A Lee,Byoung Wook Hwang,Dong Kun Lee,Chang Ju Lee,Ju Hye Kim,안성환 대한신경초음파학회 2022 대한신경초음파학회지 (JNN) Vol.14 No.1

Systemic lupus erythematosus is an uncommon cause of ischemic stroke. The subcortical and periventricular white matter are most commonly involved in the central nervous system. Although vasculitis is the most frequently mentioned etiology of stroke, it has been mainly documented in the vicinity of small-diameter vessels. In the present case, we report a young women with lupus nephritis who presented with stroke caused by large-vessel vasculitis, which was confirmed by vessel wall magnetic resonance imaging.

Atherogenic Index of Plasma Predicts Early Recurrent Ischemic Lesion in Acute Ischemic Stroke

Ki-Woong Nam,권형민,이용석 대한신경초음파학회 2022 대한신경초음파학회지 (JNN) Vol.14 No.1

Background: Atherogenic index of plasma (AIP) is an index representing the lipid profile of atherogenic dyslipidemia and has been shown to be associated with various atherosclerosis, metabolic diseases, and cardiovascular diseases. However, studies in patients with cerebrovascular disease are still insufficient. In this study, we evaluated the association between AIP and early recurrent ischemic lesions (ERILs) in patients with acute ischemic stroke (AIS). Methods: We included consecutive patients with AIS between 2010 and 2016. ERILs were defined as new diffusion-weighted imaging lesions outside the initial symptomatic lesion area. AIP was calculated using the following formula: AIP=log (triglyceride [mg/dL]/high-density lipoprotein cholesterol [mg/dL]). For subgroup analysis according to stroke mechanism, participants were classif ied into the following four groups: intracranial-large artery atherosclerosis (LAA), extracranial- LAA, cardioembolism, and cryptogenic stroke. Results: A total of 182 patients with AIS were evaluated (median age: 72 years, median initial NIHSS score: 4 [2-13]). In the multivariable analysis, AIP (adjusted odds ratio [aOR], 3.73; 95% confidence interval [CI], 1.01-13.82) was closely associated with ERIL after adjusting confounders. Age and initial NIHSS score were also related to ERIL. Among the four stroke mechanisms, only extracranial-LAA showed significant differences in AIP values between patients with and without ERIL (p=0.028). Conclusion: High AIP was closely related to ERIL in patients with AIS, especially extracranial-LAA stroke. Judging from our results, AIP seems to be involved in the development of new lesions in AIS patients through the mechanisms of atherosclerosis.

Spontaneous Cervical Epidural Hematoma Mimicking Acute Ischemic Stroke

황병욱,이동근,이민아,이창주,안성환 대한신경초음파학회 2021 대한신경초음파학회지 (JNN) Vol.13 No.1

In acute reperfusion therapy, the onset to needle time is correlated with the prognosis. Rapid diagnosis is essential to reduce the in-hospital delay. Meanwhile, intravenous thrombolysis requires strict indications and careful decisions to prevent hemorrhagic complications. If patients present with symptoms that mimic stroke, it may not be easy to reveal the underlying critical illness with only restricted assessment in the emergency room. Spontaneous cervical epidural hematoma usually presents with quadriplegia, but it may present with hemiplegia following neck pain, and no cranial abnormalities can easily be misdiagnosed as stroke. We report two cases of spontaneous cervical spinal epidural hematoma, which may be a harmful stroke mimicking intravenous thrombolysis.

Hemorrhagic Stroke and Blindness after Hyaluronic Acid/Polylactic Acid Filler Injection

Yeo Jun Yoon,Doyeon Kook,Hye Sun Choi,Jiyun Lee,Yo Han Jung 대한신경초음파학회 2023 대한신경초음파학회지 (JNN) Vol.15 No.1

The number of people receiving facial filler injections is increasing as it is relatively safe than the other cosmetic procedures. However, complications of facial filler injection range from mild redness and inflammation to cerebral infarction. We report the case of a patient who was diagnosed with cerebral infarction and intracranial hemorrhage after facial filler injection. A 61-year-old male presented to the emergency department with ocular pain and visual loss in the left eye after filler injection into the glabella. Neurological examination revealed monocular blindness. Initial brain magnetic resonance imaging (MRI) revealed small, acute multifocal infarctions in the left frontal, parietal, and temporal lobes. Follow-up MRI revealed subarachnoid hemorrhages in the left frontal and parietal lobe. Follow-up brain computed tomography showed small intracerebral hemorrhage in the left frontal lobe. Clinicians must be aware that not only cerebral infarction, but intracranial hemorrhage could also be a potential adverse effect of the cosmetic filler injection in the face.

Transcranial Doppler Ultrasound Role for Patients with Traumatic Brain Injury

Alexander Razumovsky 대한신경초음파학회 2023 대한신경초음파학회지 (JNN) Vol.15 No.1

Neurologists, neurosurgeons, and neurointensivists, including military, have a large armamentarium of diagnostic and monitoring devices available to detect primary and secondary brain injury and guide therapy in patients with acute traumatic brain injury (TBI) to avoid cerebral ischemia due to the posttraumatic vasospasm (PTV) and intracranial hypertension (ICH). This review summarizes the advantages and the specific roles of transcranial Doppler (TCD) ultrasonography for patients with acute and longterm effects of TBI. In critical care setting numerous publications showed that TCD is predictive of angiographic PTV and onset of ICH. The post TBI status of cerebrovascular reactivity and cerebral hemodynamics also has important implications with regard to the treatment of long-term effects of mild TBI (mTBI). Today it is abundant evidence that TCD is an important tool for monitoring the natural course of acute moderate and severe TBI, for evaluating the effect of medical treatment or intervention, for forecasting, and for identifying high-risk patients for onset of cerebral ischemia after TBI. TCD makes good clinical and economic sense as it is a reliable, quantitative, non-invasive and non-expensive “biomarker” to the acute clinical manifestations of TBI. TCD clinical utilization holds promise for better detection, characterization, and monitoring of objective cerebral hemodynamics changes in symptomatic patients with TBI not readily apparent by standard CT or conventional MRI techniques. TCD utilization will improve the sensitivity of neuroimaging to subtle brain perturbations and combining these objective measures with careful clinical characterization of patients may facilitate better understanding of the neural bases and treatment of the signs and symptoms of TBI. This review summarizes the advantages and the specific roles of TCD ultrasonography for patients with acute and long-term effects of TBI.

False Normalization of Ankle Brachial Index: A Case of Lower Extremity Peripheral Arterial Disease with Normal Ankle-Brachial Index

Minsoo Sung,Yo Han Jung,Kyung-Yul Lee 대한신경초음파학회 2023 대한신경초음파학회지 (JNN) Vol.15 No.1

Screening for lower extremity peripheral arterial disease (PAD) is essential in assessing a patient’s risk of cerebrovascular disorders. The ankle-brachial index (ABI) is widely used as a screening tool for PAD, but it can produce falsely normalized results due to factors like artery calcification and collateral vessels. We report a patient with normal ABI but confirmed lower extremity PAD through ultrasound and computed tomography (CT). This case shows the limitation of ABI for PAD diagnosis. Additional tests, such as CT or ultrasound, should be considered when PAD is suspected, even if the ABI is normal.