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Teaching Video NeuroImages: Upbeat and horizontal gaze-evoked nystagmus in bilateral medial medullary infarction
A 41-year-old man with progressive quadriparesis and generalized tingling sensation showed spontaneous upbeating nystagmus and horizontal gaze-evoked nystagmus (video at Neurology.org). The initial diffusion-weighted images showed an equivocal hyperintensity at midline of rostral medulla (upper row). Follow-up MRIs (lower row) showed characteristic heart appearance sign (figure).
Source: Neurology - November 6, 2017 Category: Neurology Authors: Lee, E.-S., Sung, K.-B., Lee, T.-K. Tags: Clinical neurology examination, Nystagmus, All Cerebrovascular disease/Stroke, Infarction RESIDENT AND FELLOW SECTION Source Type: research

Teaching NeuroImages: Bilateral hypertrophic olivary degeneration following posterior circulation stroke
A 40-year-old comatose man was brought to the hospital with a history of posterior circulation stroke 4 months earlier due to hypertension. On examination, he had spastic quadriplegia, bilateral extensor plantar reflex, and palatal myoclonus. MRI revealed enlarged olives (figure 1) and chronic infarcts involving midbrain and pons (figure 2) suggestive of hypertrophic olivary degeneration seen after 4 months of insult. Hypertrophic olivary degeneration is a transsynaptic degeneration involving interconnecting fibers of inferior olivary nucleus, red nucleus, and contralateral dentate nucleus forming the 3 corners of the Guil...
Source: Neurology - October 30, 2017 Category: Neurology Authors: Venkatesh, M., Prasad, V. R. S., Basha, S. U., Priya, G. H. J. Tags: MRI, Coma, All Cerebrovascular disease/Stroke, All Education, Infarction RESIDENT AND FELLOW SECTION Source Type: research

Teaching NeuroImages: Artery of Percheron thrombosis causing selective downgaze palsy
A 47-year-old man with migraines presented with sudden onset of vertical diplopia, dysarthria, right facial weakness, and downgaze palsy (figure 1). Brain MRI revealed ischemic strokes in the midbrain periaqueductal gray, bilateral thalamic–midbrain junction, and thalamus (figure 2, A–C). Gradient echo and T1 MRI showed hypointensity in the interpeduncular fossa (figure 2, D and E). No flow could be visualized in this structure on CT angiogram or catheter angiogram, demonstrating a thrombosed artery of Percheron (figure 2, F–H). Downgaze palsy, which improved 18 months later, may result from bilateral les...
Source: Neurology - October 16, 2017 Category: Neurology Authors: Sechler, M., Singh, J., El Husseini, N. Tags: MRI, DWI, All Cerebrovascular disease/Stroke, Infarction RESIDENT AND FELLOW SECTION Source Type: research

Teaching Video NeuroImages: My weeping patient: Avoiding the pitfalls of a functional diagnosis
A 54-year-old man presented with symptoms of a posterior circulation stroke. A right facial palsy and horizontal right end gaze nystagmus was noted. On resolution, episodes of uncontrolled weeping without a provoking stimulus was observed (video at Neurology.org). These were initially unremitting, lasting minutes, with complete resolution after 1 month. An early consideration was of a functional neurologic disorder. Subsequent MRI brain demonstrated bilateral anterior pontine infarcts (figure). It has been hypothesized that pseudobulbar affect (PBA) results from the loss of frontal cortex input to the cerebellum during emo...
Source: Neurology - October 16, 2017 Category: Neurology Authors: Peters, J., Vijiaratnam, N., Wijeratne, T. Tags: All Cerebrovascular disease/Stroke, All Education RESIDENT AND FELLOW SECTION Source Type: research

Teaching NeuroImages: Giant cell arteritis presenting with acute ischemic strokes due to diffuse intracranial stenoses
A 72-year-old woman with unremarkable medical history was admitted with acute ischemic strokes (AIS) in multiple arterial distributions in anterior and posterior circulation (figure 1A and supplemental data at Neurology.org). Elevated erythrocyte sedimentation rate (98 mm/h) prompted the evaluation of superficial temporal arteries (STA) with duplex sonography (halo sign; figure 1B) and contrast angiography (right STA [figure 2A] and multiple intracranial arterial stenoses [figure 2, A–D]). STA biopsy confirmed the diagnosis of giant cell arteritis (GCA; figure 1, C and D).
Source: Neurology - October 9, 2017 Category: Neurology Authors: Kargiotis, O., Safouris, A., Petrou, V. N., Magoufis, G., Stamboulis, E., Tsivgoulis, G. Tags: MRI, Ultrasound, Vasculitis, All Cerebrovascular disease/Stroke RESIDENT AND FELLOW SECTION Source Type: research

Teaching NeuroImages: Typical neuroimaging features in high-altitude cerebral edema
A 61-year-old man presented with thunderclap headache followed by loss of consciousness, 2 days after arriving in Atacama Desert, Andes Mountains, Chile, at 4,000 meters. Examination showed coma. Mechanical ventilation was necessary. He had progressive improvement after transfer to low altitudes. Brain MRI showed diffuse vasogenic edema and microhemorrhages (figure), and high-altitude cerebral edema (HACE) was diagnosed.
Source: Neurology - October 2, 2017 Category: Neurology Authors: Marussi, V. H. R., Pedroso, J. L., Piccolo, A. M., Barsottini, O. G., Moraes, F. M. d., Oliveira, A. S. B., Freitas, L. F., Amaral, L. L. F. d. Tags: MRI, Other cerebrovascular disease/ Stroke, All Clinical Neurology RESIDENT AND FELLOW SECTION Source Type: research

Teaching NeuroImages: Wallerian degeneration in evolving pediatric stroke
An 8-year-old girl presented with acute hemiparesis and facial palsy. MRI demonstrated right middle cerebral artery territory infarction (figure, A and B), secondary to traumatic dissection. Following discharge, multiple visits for nonspecific neurologic symptoms prompted repeat short-term imaging, initially concerning for right midbrain infarction (figure, C–H).
Source: Neurology - September 25, 2017 Category: Neurology Authors: Jimenez-Gomez, A., Stowe, R. C. Tags: Childhood stroke, MRI, DWI, Other Education RESIDENT AND FELLOW SECTION Source Type: research

Teaching NeuroImages: RCVS causing simultaneous convexity subarachnoid hemorrhage and hemimedullary infarction
A 34-year-old previously healthy man presented with thunderclap headache, dysphagia, dysarthria, and oscillopsia. Neurologic examination revealed right-beating nystagmus, dysphagia, hypophonia, right hemianesthesia, and left hemiparesis. Brain imaging showed convexity subarachnoid hemorrhage (figure 1A) and left hemimedullary infarct (figure 1B). Catheter angiography showed tapering of left vertebral artery and diffuse segmental vasoconstriction (figure 2). Routine serum and CSF results were unremarkable. Thorough infectious, immunologic, and coagulopathy workup was negative. Reversible cerebral vasoconstriction syndrome (...
Source: Neurology - September 18, 2017 Category: Neurology Authors: Selvan, P., Levine, S. R. Tags: Stroke in young adults, Other cerebrovascular disease/ Stroke, All Cerebrovascular disease/Stroke, Infarction, Subarachnoid hemorrhage RESIDENT AND FELLOW SECTION Source Type: research

Teaching NeuroImages: Artery of Percheron aneurysm masquerading as ICH spot sign
A 50-year-old Japanese woman presented with left thalamic intracerebral hemorrhage (ICH). CT angiography demonstrated an ICH spot sign and intracranial vasculopathy consistent with Moyamoya disease (figure 1). Conventional angiography demonstrated that the spot sign was actually a pseudoaneurysm arising from the artery of Percheron (figure 2). Intracranial aneurysms may complicate Moyamoya disease and occur at the circle of Willis, distal peripheral arteries, or Moyamoya vessels at a ratio of 3:1:1.1 Aneurysms in thalamo-perforating arteries are rare2 and an artery of Percheron aneurysm in Moyamoya disease has not been rep...
Source: Neurology - August 7, 2017 Category: Neurology Authors: Moughamian, A. J., Morshed, R. A., Colorado, R. A., Liner, Z., Cooke, D., Hemphill, J. C. Tags: All Cerebrovascular disease/Stroke, Intracerebral hemorrhage RESIDENT AND FELLOW SECTION Source Type: research

Teaching NeuroImages: Abnormal cervical and cerebral vasculature in 22q11 deletion syndrome
A 12-day-old girl with a postnatal microarray diagnosis of 22q11.2 deletion syndrome was transferred for surgical repair of truncus arteriosus. Neurologic examination at the time of transfer was unremarkable. Brain MRI on day of life 9 demonstrated an absent left internal carotid flow void. Magnetic resonance angiography of the head (figure, A) and neck (figure, B) was subsequently obtained prior to cardiac repair. Patients with 22q11 deletion syndromes may have abnormal cervical vessel development.1 Children with congenital heart disease have an elevated stroke risk, particularly for periprocedural stroke.2 Understanding ...
Source: Neurology - July 3, 2017 Category: Neurology Authors: Mithal, D. S., Kurz, J. E. Tags: All Cerebrovascular disease/Stroke, Pediatric stroke; see Cerebrovascular Disease/ Childhood stroke, All Genetics RESIDENT AND FELLOW SECTION Source Type: research

Teaching NeuroImages: Takayasu arteritis: Neuroimaging progression after immunosuppressant treatment
A 29-year-old woman presented with a 2-year history of heel pain, constitutional symptoms, and increased acute phase reactants. CT and magnetic resonance (MR) angiography revealed a thickening of aortic walls and a thread-like appearance of bilateral subclavian and common carotid arteries. The findings were consistent with Takayasu arteritis (TA)1 and the patient was prescribed methylprednisolone, followed by azathioprine. Follow-up MR angiography, 6 years later, showed an important improvement with only a mild luminal narrowing of both common carotid arteries (figures 1 and 2, A and B). TA is a large-artery inflammatory d...
Source: Neurology - May 15, 2017 Category: Neurology Authors: Martinez Rodriguez, L., Caminal Montero, L., Pena Suarez, J., Garcia-Cabo Fernandez, C., Calleja Puerta, S. Tags: MRI, Vasculitis, All Cerebrovascular disease/Stroke RESIDENT AND FELLOW SECTION Source Type: research

Teaching NeuroImages: Acute infarction of the left medial lemniscus masquerading as a peripheral neuropathy
A 58-year-old woman with hypertension and bilateral carpal tunnel syndrome presented with acute paresthesias in her right hand and foot. She had decreased sensation to vibration and pinprick in a right-sided stocking-glove distribution. MRI of the pons confirmed an acute infarction of a paramedian branch of the basilar artery in the left medial lemniscus (figure). In the posterior column pathway, sensory projections from the face, arm, and leg are somatotopically arranged medially to laterally within the medial lemniscus.1,2 Although strokes classically present with numbness, both thalamic and medial lemniscal infarcts can...
Source: Neurology - April 24, 2017 Category: Neurology Authors: Aamodt, W. W., Siegler, J. E., Elman, L. Tags: MRI, DWI, All Cerebrovascular disease/Stroke, Central pain, Infarction RESIDENT AND FELLOW SECTION Source Type: research

Historical Perspective of Cambodian Medicine with a focus on Neurology (P2.051)
Conclusions:The Keck School of Medicine of USC received a grant from World Federation of Neurology, which allowed faculty to travel to Cambodia and teach the clinical and diagnostic aspects of neurology over the course of two years. We expect a neurology residency to start in 2017 to help the patient population that suffers from stroke, seizure disorders and various other types of neurological disorders. Even though the past has had its rough patches, the future has untapped potential.Study Supported by: This study was supported by World Federation of Neurology.Disclosure: Dr. Singh has nothing to disclose. Dr. Sahai-Sriva...
Source: Neurology - April 17, 2017 Category: Neurology Authors: Singh, S., Sahai-Srivastava, S., Khosa, S., Mishra, S. Tags: History of Neurology Source Type: research

Teaching NeuroImages: Acute Parinaud syndrome
An 82-year-old man with atrial fibrillation, nonadherent to rivaroxaban, presented with sudden bilateral ptosis. Examination demonstrated bilateral ptosis (figure 1), pupils midline, fixed midsize, not reactive to light but constricting to accommodation, impaired vertical eye movements, paresis of superior greater than inferior rectus, and upgaze convergence nystagmus. MRI showed infarction of bilateral third nerve nuclei and mesial thalami consistent with an artery of Percheron infarct (figure 2), presumed cardioembolic origin. Artery of Percheron is a single P1 branch that supplies the bilateral paramedian thalami and ro...
Source: Neurology - April 17, 2017 Category: Neurology Authors: Swinkin, E., Bui, E. Tags: MRI, All Cerebrovascular disease/Stroke, Embolism, Infarction RESIDENT AND FELLOW SECTION Source Type: research

Non-Neurologist Self Assessment of Emergency Neurology Proficiency and Interest in a Novel Intensive Stroke and Neurocritical Care Training Program: The X-CHANGE Program (P1.045)
Conclusions:Hospital based non-neurology physicians have significant exposure to critically ill neurological patients. Many are not comfortable with important fundamental skills, such as the neurological exam. There is strong interest in a proposed intensive training program emphasizing bedside teaching. Based upon these results, we are developing a formal intensive training program for practicing non -neurology physicians called the "Cross-disciplinary Cerebrovascular HospitAl NeuroloGy Education" program.Disclosure: Dr. Yee has nothing to disclose. Dr. Ke has nothing to disclose. Dr. Wong has nothing to disclose. Dr. Bar...
Source: Neurology - April 17, 2017 Category: Neurology Authors: Yee, A., Ke, M., Wong, C., Barazangi, N., Tong, D., Chen, C. Tags: Graduate Medical Education Research Source Type: research

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