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intracellular signaling during PV pathogenesis [ 2 , 4 - 6 ]. For JAK2-negative PV patients, more diagnostic criteria are required than for classical P V. A previous case report indicated that there is no difference in the clinical presentation between JAK2-positive and negative PV patients [ 2 , 6 ]. However, to our knowledge, there is no previously published report describing the clinical course and treatment outcome of JAK2-negative PV. Case report A 53 year-old Thai man presented to our emergency department with left hemiparesis and slurred speech. He had a history of
showing that hot spot of lower left and lower right looks almost as a mirror image. Four months later, the tumor rapidly extended to the pyramidal tract, basal ganglia and corpus callosum four months after the fourth surgery ( Figure 3 , upper). She had mild motor aphasia and right hemiparesis: proximal U/E MMT 2, distal U/E MMT 4, lower extremity (L/E) MMT 2. Her Karnofsky performance state score was 70%. Figure 3 MRI before fifth operation revealing that the enhanced lesion invades to the basal ganglia, left lateral ventricle, splenium, and internal capsule (upper
, uncoordinated movements and ataxic gait, and slurred speech. Numbness was the more common clinical history ( Table 2 ). Muscle fatigue was a common clinical presentation in younger patients (<39 years). Psychosomatic effects, e.g. sensory or motor system problems were found in 70 patients with MS detected on MRI. We found 54 cases with musculoskeletal problems, e.g. hemiparesis or monoparesis ( Table 2 ), 2 cases had genitourinary symptoms. Table 2 Pathological correlation of multiple sclerosis with musculoskeletal disability Symptoms No. of patients Musculoskeletal disease
Traumatic bilateral dissection of the carotid arteries is a rare condition with potentially life-threatening complications. The case of a 57-year-old male patient with acute onset left sided hemiparesis, twelve hours after a blunt head injury, caused by a horse kick, is reported. A cerebral CT scan revealed right middle cerebral artery (MCA) territory infarction. Based on Duplex ultrasound and Angio CT scan findings, a diagnosis of bilateral ICA dissection was established. Despite antithrombotic treatment, the patient presented with a progressive worsening of his neurological status. The control CT scan evidenced malignant right MCA territory infarction that required decompressive craniotomy. The patient was discharged with significant neurological deficits. Together with this case, the aetiologies, clinical manifestations, diagnostic and therapeutical options and outcome of carotid artery dissection are discussed.
Brain metastases (BM) represent the most common tumours of the central nervous system with ranged between 2.8 and 14.3 per 100.000. Despite advances in the diagnosis and treatment of brain metastases, such as surgery, chemotherapy and radiotherapy only 2.4% of patients will survive 5 years. BM causes a wide spectrum of neurological symptoms, such as hemiparesis, impaired coordination or walking, aphasia, and seizures. Despite the effective treatment of the primary tumor, in many cases, it does not protect against brain metastases. The main source of BMs in adults is, in descending order, non-small cell lung cancer, followed by breast cancer and melanoma and then renal cancer. Some malignancies particularly tend to produce “late” or “delayed” cerebral metastasis years or even decades after the anti-cancer treatment has been accomplished. There is still a need to develop more effective treatments for cancer and metastases to the brain.
A mobile thrombus in the carotid arteries is a very rare ultrasonographic finding and is usually diagnosed after a neurological emergency, such as a transient ischemic attack or cerebral infarction. We present the case of a 54-year-old man with vascular risk factors (a heavy smoker, untreated hypertension) who was admitted to the emergency unit with right sided hemiparesis and aphasia. A cerebral CT scan showed a left middle cerebral artery territory infarction. The duplex ultrasound examination revealed mild atherosclerotic changes in the right common and internal carotid arteries, right-sided complete subclavian steal phenomenon and a complicated hypoechoic atherosclerotic plaque in the left common carotid artery with a large mobile thrombus. Due to the high embolization risk, the patient was hospitalised and prescribed Aspirin together with low molecular weight Heparin. We recorded an improvement in the patient’s neurological status and the control duplex scan revealed disappearance of the thrombus. The presence of floating thrombus in a patient with clinical and imagistic evidence of stroke is a major therapheutic challenge for the neurologist. The treatment strategies are not standardized and must be individualized, however in our case parenteral anticoagulation proved to be successful.
Introduction: Lesions of the carotid and vertebral arteries secondary to direct trauma, called blunt cerebrovascular injuries (BCVI) are relatively rare and are markedly different from spontaneous dissections. Ischaemic stroke is a significant complication, with high morbidity and mortality rates. The basis of a diagnosis relies on appropriate, high sensitivity imaging screening.
Case report: We present the case of a 31 years old male patient with polytraumatism secondary to a motor vehicle accident, who was admitted to an orthopaedic clinic for multiple lower extremity fractures. His fractures were treated surgically. He developed in the 3rd day after the admission left sided hemiparesis secondary to ischaemic stroke. The diagnosis of traumatic carotid artery injury (TCAI) was based on duplex ultrasound and angio CT scans. The outcome was favourable despite the severe carotid lesions presenting with occlusion secondary to dissection.
Conclusions: In the majority of BCVI cases there is a variable latent period between the time of injury and the development of stroke. The management of cases is challenging because in the majority of cases there are multiple associated injuries. Although antithrombotics are widely used in the treatment, there is no consensus regarding the type of agent, the optimal dose or treatment duration.
Craniocervical carotid artery dissection (CCAD) is an important cause of stroke in young adults, but it has rarely been reported as a cause of stroke in puerperium.
We report the case of a 27-year-old female with a history of migraine who presented with unilateral left headache, transient episodes of dysphasia and right hemiparesis 30 days after vaginal delivery. The first symptoms started six days after the prolonged childbirth. The first magnetic resonance angiography revealed dissection in the supraclinoid and a cavernous segment of the left Internal carotid artery (ICA). We followed up the patient for two years and she had an unstable course. During this time, she had occlusion of the supraclinoid segment of the left ICA, with caudal extension on the extracranial segment and recanalisation one month later. Two months later, she had intracranial extension with dissection of the left anterior cerebral artery. During this time, she suffered from two strokes with minimal neurological impairment and good clinical recovery.
The pathophysiology of CCAD appears to be multifactorial. Vessel wall injury related to the Valsalva manoeuvre during labour, as well as hemodynamic and hormonal changes of the vessel wall related to pregnancy in a patient with a history of migraine, may be causes of postpartum spontaneous craniocervical artery dissection in healthy women.
Thrombosis of veins and venous sinus (CVT) is the rare cerebral vascular disorder which makes less than 1% of all strokes. Thrombosis of veins and venous sinuses is picturesquely called “мајоr neurological forger” since it is characterized by very varied clinical picture. Among the various causes of CVT, which can be of infective or non-infective nature, the congenital hyper coagulations especially stand out, diagnosis is based on highly sophisticated diagnostic tests.
We present the case of a female patient, 36 years old, who was hospitalized at the Clinic for Neurology in Clinical Center because of the diffuse headache she had for the last few days, with milder right-sided hemiparesis and one generalized tonic-clonic epileptic seizure. With nuclear magnetic resonance (MR/2D venography) the thrombosis of the upper and lower sagittal sinuses is confirmed. By appropriate laboratory tests, as well as by confirmatory immunological and genetic analyses, the impact of the most of the factors is excluded which can contribute to the occurrence of venous thrombosis. The only pathological findings which indicated the possible congenital thrombophilia as the cause of the sagittal sinus thrombosis was the determination of the specific polymorphism of the 4G/5G gene for plasminogen activator inhibitor 1.
According to our knowledge, this is the first decribed case of the possible impact of the specific polymorphism of the 4G/5G gene for plasminogen activator inhibitor of 1 on the development of cerebral venous thrombosis.