Access to cavernous dAVF via occluded superior petrosal Sinus
Raz, Eytan; Sharashidze, Vera; Grossman, Scott; Ali, Aryan; Narayan, Vinayak; Nossek, Erez; Stein, Evan; Nelson, Peter Kim; Shapiro, Maksim
There are multiple treatment alternatives for cavernous dAVFs, with transvenous routes being most common. Among these routes, occluded inferior petrosal sinus is well-described, and, apart from being imaginative and elegant, it is also safe and effective. Herein we describe the application of this method to reach the fistulous pouch of a cavernous dAVF via an occluded superior petrosal sinus.
The Spectrum of Neuroimaging findings on CT and MRI in Adults with Coronavirus Disease (COVID-19)
Moonis, Gul; Filippi, Christopher G; Kirsch, Claudia F E; Mohan, Suyash; Stein, Evan G; Hirsch, Joshua A; Mahajan, Amit
Neurologic involvement is well-recognized in coronavirus disease (COVID-19). This article reviews the neuroimaging manifestations of COVID-19 on CT and MRI, presenting cases from the New York City metropolitan region encountered by the authors during the first surge of the pandemic. The most common neuroimaging manifestations are acute infarcts with large clot burden and intracranial hemorrhage, including microhemorrhages. However, a wide range of additional imaging patterns occur, including leukoencephalopathy, global hypoxic injury, acute demyelinating encephalomyelitis, cytotoxic lesions of the corpus callosum, olfactory bulb involvement, cranial nerve enhancement, and Guillain BarrÃ© syndrome. The described central nervous system abnormalities largely represent secondary involvement from immune activation that leads to a prothrombotic state and cytokine storm; evidence for direct neuroinvasion is scant. Comorbidities such as hypertension, complications of prolonged illness and hospitalization, as well as associated supportive treatments, also contribute to the central nervous system involvement in COVID-19. Routine, long-term, neurologic follow-up may be warranted, given emerging evidence of long-term microstructural and functional changes on brain imaging, after COVID-19 recovery.
Intracranial Hemorrhage in COVID-19 Patients
Mishra, Sanskriti; Choueka, Murray; Wang, Qiang; Hu, Chloe; Visone, Stephanie; Silver, Michael; Stein, Evan G; Levine, Steven R; Wang, Qingliang T
OBJECTIVE:To describe the clinical, laboratory, temporal, radiographic, and outcome features of acute Intracranial Hemorrhage (ICH) in COVID-19 patients. METHODS:Retrospective, observational, consecutive case series of patients admitted with ICH to Maimonides Medical Center from March 1 through July 31, 2020, who had confirmed or highly suspected COVID-19. Demographic, clinical, laboratory, imaging, and outcome data were analyzed. ICH rates among all strokes were compared to the same time period in 2019 in two-week time intervals. Correlation of systolic blood pressure variability (SBPV) and neutrophil-to-lymphocyte ratio (NLR) to clinical outcomes were performed. RESULTS:Of 324 patients who presented with stroke, 65 (20%) were diagnosed with non-traumatic ICH: 8 had confirmed and 3 had highly suspected COVID-19. Nine (82%) had at least one associated risk factor for ICH. Three ICHs occurred during inpatient anticoagulation. More than half (6) suffered either deep or cerebellar hemorrhages; only 2 were lobar hemorrhages. Two of 8 patients with severe pneumonia survived. During the NYC COVID-19 peak period in April, ICH comprised the highest percentage of all strokes (40%), and then steadily decreased week-after-week (pâ€¯=â€¯0.02). SBPV and NLR were moderately and weakly positively correlated to discharge modified Rankin Scale, respectively. CONCLUSIONS:COVID-19 associated ICH is often associated with at least one known ICH risk factor and severe pneumonia. There was a suggestive relative surge in ICH among all stroke types during the first peak of the NYC pandemic. It is important to be vigilant of ICH as a possible and important manifestation of COVID-19.
Three unsuspected CT diagnoses of COVID-19 [Case Report]
Vu, David; Ruggiero, Maryanne; Choi, Woo Sung; Masri, Daniel; Flyer, Mark; Shyknevsky, Inna; Stein, Evan G
PURPOSE/OBJECTIVE:Coronavirus disease 2019 (COVID-19) is caused by a novel strain of coronavirus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that has quickly spread around the globe. Health care facilities in the USA currently do not have an adequate supply of COVID-19 tests to meet the growing demand. Imaging findings for COVID-19 are non-specific but include pulmonary parenchymal ground-glass opacities in a predominantly basal and peripheral distribution. METHODS:Three patients were imaged for non-respiratory-related symptoms with a portion of the lungs in the imaged field. RESULTS:Each patient had suspicious imaging findings for COVID-19, prompting the interpreting radiologist to suggest testing for COVID-19. All 3 patients turned out to be infected with COVID-19, and one patient is the first reported case of the coincident presentation of COVID-19 and an intraparenchymal hemorrhage. CONCLUSION/CONCLUSIONS:Using imaging characteristics of COVID-19 on abdominal or neck CT when a portion of the lungs is included, patients not initially suspected of COVID-19 infection can be quarantined earlier to limit exposure to others.
Thoracic Endodermal Sinus Tumor with Root Compression Mimicking Guillain-Barre Syndrome in Clinical Presentation, CSF Studies, and EMG/NCV Findings
Barbut, Gal; Brosgol, Yuri; Celiker, Mahmut; Stein, Evan G.; McAbee, Gary N.
Spontaneous Hemorrhage followed by paraparesis in a patient with a Spinal Meningioma
Kim, Joseph K; Lieberman, Evan; Stein, Evan G; Betchen, Simone A
BACKGROUND:Although rare, spinal meningiomas may cause motor and sensory deficits or difficulty with bladder or bowel function due to spinal cord compression. While hemorrhage of intracranial meningiomas is well documented, there are very few cases of hemorrhage or hematoma associated with spinal meningiomas in the literature. Spinal meningiomas have been reported to be associated with subdural, epidural, intratumoral, and subarachnoid hemorrhage and usually in the setting of inciting event such as lumbar puncture or anti-coagulation therapy. CASE DESCRIPTION/METHODS:A 68-year old women presented to the emergency room with acute onset of paraparesis in the lower extremities. MRI findings were inconclusive for cause but showed cord compression. Intra-operative findings demonstrated an intratumoral hemorrhage and pathology was consistent with meningioma. CONCLUSIONS:This is the first report found in the English literature of a patient who first develops symptoms from a spinal meningioma with spontaneous intratumoral hemorrhage presenting with acute paraparesis. MRI findings in retrospect match surgical intra-operative findings. Prompt surgical intervention can result in complete resolution of neurological deficits.
Internal carotid artery dissection and pseudoaneurysm formation with resultant ipsilateral hypoglossal nerve palsy [Case Report]
Cruciata, Giuseppe; Parikh, Rikesh; Pradhan, Meera; Shah, Jay; Greif, Eric; Stein, Evan G
Craniocervical artery dissection is a potentially disabling condition caused by an intimal tear allowing blood to enter and dissect the media in the cranial direction which can occur spontaneously or as a result of trauma. When the dissection extends toward the adventitia, it can form a protrusion from the weakened vessel wall called a pseudoaneurysm, which may become a nidus for distal thromboembolism or cause mass effect on adjacent structures. Accurate and prompt diagnosis is critical as timely treatment can significantly reduce the risk of complications such as stroke. Here, we present a case of cervical ICA dissection and pseudoaneurysm formation causing mass effect with resultant compressive ipsilateral hypoglossal nerve palsy.
Clinical Correlates of Posterior Reversible Encephalopathy Syndrome in Pregnancy
Fisher, Nelli; Saraf, Sumit; Egbert, Neha; Homel, Peter; Stein, Evan G; Minkoff, Howard
The authors aimed to determine whether clinical findings of preeclampsia predict magnetic resonance imaging (MRI) diagnosis of posterior reversible encephalopathy syndrome (PRES). The course among preeclamptics/eclamptics with clinically suspected PRES with vs without MRI diagnosis of PRES was compared. Of 46 patients who underwent MRI (eight eclamptics, 38 preeclamptics), five eclamptics (62.5%) and four preeclamptics (10.5%) had confirmed PRES (P=.004). Patients with PRES were younger (26 years vs 31 years, P=.008) and had a higher prevalence of thrombocytopenia (33% vs 8%, P=.04), a greater prevalence of proteinuria (100% vs 61%, P=.04), and higher peak systolic and diastolic blood pressures (P<.05). As opposed to findings from previous reports, PRES was not seen uniformly among eclamptic women and was found in 10.5% of preeclamptics with clinical suspicion of PRES inÂ this study. Given that no single or set of findings wereÂ reliable predictors of PRES, consideration for rigorous management of hypertension should be applied to all patients with preeclampsia and eclampsia.
Late Postpartum Eclampsia with Postpartum Angiopathy: An Uncommon Diagnosis in the Emergency Department [Case Report]
Garg, Deepika; Rahaman, Brad; Stein, Evan G; Dickman, Eitan
BACKGROUND:Late postpartum eclampsia is defined as occurrence of eclampsia >48 h after delivery and is a rare clinical entity. The delayed onset and nonspecific symptoms at presentation make this entity a challenge to diagnose in patients presenting to the emergency department (ED); however, early recognition and timely interventions are the keys to reducing morbidity and mortality in patients with late postpartum eclampsia. CASE REPORT/METHODS:A 28-year-old woman presented to our ED with a chief complaint of headache of 4 days duration, 8 days after an uncomplicated, normal vaginal delivery. Her past medical history was unremarkable and her entire pregnancy was without medical incident. The patient's examination was within normal limits other than a blood pressure of 152/111 mm Hg and pulse of 54 beats/min. Given her undifferentiated headache and the possibility of preeclampsia, the patient was treated with magnesium sulfate, which was subsequently stopped due to worsening bradycardia. Hydralazine was administered for blood pressure control. Three hours after the magnesium was stopped, the patient reported blurry vision, which was immediately followed by a generalized tonic-clonic seizure. After the seizure, lorazepam was given for control of seizures, and the patient was admitted to the medical intensive care unit. The patient was transferred to the postpartum floor 6 days later in stable condition and without any further seizure activity. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Patients with late postpartum eclampsia are infrequently encountered in the ED due to the rarity of this condition. Increased awareness of this entity among emergency physicians will lead to early interventions, which are crucial in decreasing morbidity and mortality in these patients.
Rapid spontaneous cerebrospinal fluid leak detected in the gastrointestinal tract [Case Report]
Ma, Hong Yun; Sen, Papia; Stein, Evan G; Freeman, Leonard M
There are many causes of cerebrospinal (CSF) leaks. Most cases are secondary to blunt trauma and iatrogenic trauma caused by postoperative sequelae. Occasionally, CSF leakage may occur from nontraumatic or "spontaneous" causes, such as benign intracranial hypertension and "empty sella syndrome." Mass effect due to an encephalocele or meningocele may also be seen. Radionuclide cisternography is a sensitive method of determining CSF leak when combined with intranasal cotton pledget placement and analysis. We present a spontaneous CSF fluid leak that was detected when scintigraphic activity appeared first in the gastrointestinal tract.