Bilateral Medial Medullary Infarct with Unique Radiological Presentation

Bilateral medial medullary infarction is a rare subtype of stroke.The typical heart-shaped appearance on magnetic resonance imaging is pathognomonic for bilateral medial medullary syndrome. Vertebrobasilar dolichoectasia is a condition characterized by tortuous dilatation and marked enlargement of the basilar and vertebral arteries, and it may cause posterior circulation infarction. We present the case of a 55-year-old female patient with complaints of speech disorder, regression in consciousness, and difficulty breathing. Diffusion-weighted imaging examination was normal on arrival. In the cranial imaging after 24 hours, acute infarction was observed in the bilateral medial medullary area. Time-of-flight magnetic resonance angiography revealed vertebrobasilar dolichoectasia. In this report, a case of bilateral medial medullary infarction with a unique radiological appearance accompanied by vertebrobasilar dolichoectasia, which is rarely reported in the literature, is presented. Keywords: Stroke, infarct, bilateral medial medullary infarction, heart appearance.

Retrospective Evaluation of the Results of Low-Dose Intravenous Thrombolytic Therapy in Acute Ischemic Stroke

Objectives

This study aimed to investigate the clinical data of patients with acute ischemic stroke who received low-dose intravenous (IV) thrombolytic therapy (0.9 mg/kg; maximum 50 mg) for various reasons, compare the obtained results with those of patients who received standard-dose thrombolytic therapy, and discuss them in light of the literature.

Methods

Patients who received IV thrombolytic therapy within 4.5 h of symptom onset between January 2015 and June 2018 were retrospectively reviewed. Patients were divided into the low-dose group (0.9 mg/kg; max. 50 mg) and the standard-dose group (0.9 mg/kg; max 90 mg) according to the thrombolytic therapy dose, after which demographic data and clinical results were analyzed.

Results

A total of 109 patients receiving thrombolytic therapy (19 patients in the low-dose group and 90 patients in the standard-dose group) were included in the study. There was no significant difference between the two groups in terms of good outcome rates (47.4% vs. 52.2%). There was no statistically significant difference in terms of symptomatic and asymptomatic intracerebral hemorrhage rates.

Conclusion

Our study showed similar efficacy and safety for low-dose IV thrombolytic therapy compared with standard-dose IV thrombolytic therapy administered within 4.5 h of symptom onset in patients with acute ischemic stroke.

Reversible Intracranial Cytotoxic Edema Associated with COVID-19: A Case Report

BACKGROUND

It is well-known that COVID-19 causes pneumonia and acute respiratory distress syndrome, as well as pathological neuroradiological imaging findings and various neurological symptoms associated with them. These include a range of neurological diseases, such as acute cerebrovascular diseases, encephalopathy, meningitis, encephalitis, epilepsy, cerebral vein thrombosis, and polyneuropathies. Herein, we report a case of reversible intracranial cytotoxic edema due to COVID-19, who fully recovered clinically and radiologically.

CASE REPORT

A 24-year-old male patient presented with a speech disorder and numbness in his hands and tongue, which developed after flu-like symptoms. An appearance compatible with COVID-19 pneumonia was detected in thorax computed tomography. Delta variant (L452R) was positive in the COVID reverse-transcriptase polymerase chain reaction test (RT-PCR). Cranial radiological imaging revealed intracranial cytotoxic edema, which was thought to be related to COVID-19. Apparent diffusion coefficient (ADC) measurement values in the magnetic resonance imaging (MRI) taken on admission were 228 mm2/sec in the splenium and 151 mm2/sec in the genu. During the follow-up visits of the patient, epileptic seizures developed due to intracranial cytotoxic edema. ADC measurement values in the MRI taken on the 5th day of the patient's symptoms were 232 mm2/sec in the splenium and 153 mm2/sec in the genu. ADC measurement values in the MRI taken on the 15th day were 832 mm2/sec in the splenium and 887 mm2/sec in the genu. He was discharged from the hospital on the 15th day of his complaint with a clinical and radiological complete recovery.

CONCLUSION

Abnormal neuroimaging findings caused by COVID-19 are quite common. Although not specific to COVID-19, cerebral cytotoxic edema is one of these neuroimaging findings. ADC measurement values are significant for planning follow-up and treatment options. Changes in ADC values in repeated measurements can guide clinicians about the development of suspected cytotoxic lesions. Therefore, clinicians should approach cases of COVID-19 with CNS involvement without extensive systemic involvement with caution.

How to manage MuSK antibody-positive myasthenic crisis during pregnancy?

Myasthenia gravis (MG) is an autoimmune disease that is characterised by the formation of antibodies against acetylcholine receptors in the postsynaptic membrane of the neuromuscular junction. The course of the disease cannot be predicted during pregnancy. A subtype of MG with positive muscle-specific receptor tyrosine kinase (anti-MuSK) antibodies exhibits more localised clinical characteristics and a poor response to treatment compared with the disease subtype that involves positivity for acetylcholine receptor antibodies. Myasthenic crisis is more frequently observed in anti-MuSK-positive myasthenia patients. Anti-MuSK-positive myasthenic crisis management is very difficult and a risky situation during pregnancy. The reported case was 30 years old, female, 9 weeks pregnant and musk antibody positive. She stopped her treatment without asking her doctor because she was planning pregnancy in the 6-month period before her hospitalization. She was intubated for a long time in the intensive care unit due to myasthenic crisis and was very resistant to treatment. During this period, her pregnancy was terminated due to fetal anomaly. Plasmapheresis, IVIg and immunosuppressive treatments were applied. Our patient was discharged after a period of about 10 weeks. We share our treatment management.

Effect of adiponectin on acute experimental cerebral ischemia/reperfusion injury

AIM

To examine the effect of adiponectin administration on acute brain injury in an experimental model of cerebral ischemia/ reperfusion (I/R) in rats.

MATERIAL AND METHODS

The study animals were divided into the following four groups: group I, sham (did not undergo surgical intervention and did not receive drugs); group II, the I/R model (received the intervention, but did not receive drugs); group III (I/Radiponectin) (the I/R model was used, and the animals were treated with 5 mg/kg adiponectin peritoneally 30 minutes after the ischemia); and group IV (I/R-tirofiban)( the I/R model was used, and the animals were treated with 0.5 mg/kg tirofiban peritoneally 30 minutes after the ischemia).

RESULTS

Tumor necrosis factor-? (TNF-?) and interleukin (IL)-1? levels were statistically higher in the I/R group (group II) than in other groups. In the post-hoc (Tukey) test analysis, groups I, III, and IV had significantly lower TNF-? and IL-1? levels after treatment with both tirofiban and adiponectin than group II. No statistically significant difference was found between groups III and IV in terms of TNF-? levels. However, the decreased IL-1? level was more pronounced in group IV (tirofiban) than in other groups. The mean neurologic deficit scores were statistically significantly different among the groups. In the post-hoc (Tukey) test analysis, neurologic deficit scores were statistically significantly lower in groups III and IV than in group II.

CONCLUSION

Adiponectin has anti-inflammatory and cerebral protective effects in experimental cerebral I/R injury.