Recurrent stereotyped TIAs: atypical Bow Hunter's syndrome due to compression of non-dominant vertebral artery terminating in PICA

Neurological vertigo in the emergency room in pediatric and adult age: systematic literature review and proposal for a diagnostic algorithm

Neurological vertigo is a common symptom in children and adults presenting to the emergency department (ED) and its evaluation may be challenging, requiring often the intervention of different medical specialties. When vertigo is associated with other specific symptoms or signs, a differential diagnosis may be easier. Conversely, if the patient exhibits isolated vertigo, the diagnostic approach becomes complex and only through a detailed history, a complete physical examination and specific tests the clinician can reach the correct diagnosis. Approach to vertigo in ED is considerably different in children and adults due to the differences in incidence and prevalence of the various causes. The aim of this systematic review is to describe the etiopathologies of neurological vertigo in childhood and adulthood, highlighting the characteristics and the investigations that may lead clinicians to a proper diagnosis. Finally, this review aims to develop an algorithm that could represent a valid diagnostic support for emergency physicians in approaching patients with isolated vertigo, both in pediatric and adult age.

A Loop That Matters—An Unusual Case of Bow Hunter’s Syndrome

Bow Hunter’s syndrome (BHS), also known as rotational vertebral artery occlusion (VAO), is a rare entity in which vertebral artery is reversibly compressed due to rotation or extension of the head, causing vertebrobasilar insufficiency. Because of VAO, BHS should be considered as a possible life-threatening condition. Diverse aetiologies of BHS may trigger a broad spectrum of non-specific symptoms and may result in frequent misdiagnosis of this disorder in daily clinical practice. Herein, we present a case of BHS caused by previously non-described vascular aetiology.

Bow hunter’s syndrome successfully treated with a posterior surgical decompression approach: A case report and review of literature

BACKGROUND

Bow hunter’s syndrome (BHS) is a rare but surgically treatable cause of vertebrobasilar insufficiency due to dynamic rotational occlusion of the vertebral artery. Typically, patients present with posterior circulation transient ischaemic symptoms such as presyncope, syncope, vertigo, diplopia, and horizontal nystagmus, but irreversible deficits, including medullary and cerebellar infarctions, have also been described.

CASE SUMMARY

A 70-year-old patient presented an acute onset of vertigo and gait instability triggered by right head rotation. His medical history included previous episodes of unilateral left neck and occipital pain followed by light-headedness, sweating, and blurred vision when turning his head, and these episodes were associated with severe degenerative changes in the atlanto-dens and left atlanto-axial facet joints and right rotation of the C2 cervical vertebrae. Brain magnetic resonance imaging revealed the presence of acute bilateral cerebellar ischaemic lesions, while static vascular imaging did not reveal any vertebral artery abnormalities. Dynamic ultrasonography and angiography were performed and confirmed the presence of a dynamic occlusion of the vertebral artery V3-V4 segment when the head was rotated to the right secondary to left C1-C2 bone spur compression. Surgical decompression led to complete resolution of paroxysmal symptoms without neurological sequelae.

CONCLUSION

BHS should be considered in cases of repeated posterior circulation transient ischaemic attack or ischaemic stroke, particularly when associated with high cervical spine abnormalities.

Successful thrombolysis in essential thrombocythemia-related acute ischaemic stroke

Essential thrombocythemia (ET)-related acute ischaemic stroke (AIS) may account for approximately 0.25%-0.5% of all ischaemic strokes. If left undiagnosed and untreated, patients with ET carry an increased risk of recurrent thrombosis involving major organs including the brain. We report an interesting case of a 67-year-old man, who was successfully thrombolysed for AIS resulting from ET. He presented with sudden onset of left-sided hemiparesis with a left-ventricular clot. His subsequent investigations including positive JAK2 V617F mutation confirmed the diagnosis of ET. He made a significant recovery with thrombolysis, anticoagulation, antiplatelet and hydroxyurea. A fear of post-thrombolytic haemorrhagic complications appears the major reason for the lack of reports of thrombolysis in ET-related AIS. Although the diagnosis of ET was confirmed on subsequent investigations, successful thrombolysis in our case provides preliminary evidence that ET-related AIS cases can undergo successful thrombolysis using tenecteplase. To date, ours is only the second case of ET-related AIS being thrombolysed.

Diagnostic and therapeutic aspects of hemiplegic migraine

Hemiplegic migraine (HM) is a clinically and genetically heterogeneous condition with attacks of headache and motor weakness which may be associated with impaired consciousness, cerebellar ataxia and intellectual disability. Motor symptoms usually last <72 hours and are associated with visual or sensory manifestations, speech impairment or brainstem aura. HM can occur as a sporadic HM or familiar HM with an autosomal dominant mode of inheritance. Mutations in CACNA1A, ATP1A2 and SCN1A encoding proteins involved in ion transport are implicated. The pathophysiology of HM is close to the process of typical migraine with aura, but appearing with a lower threshold and more severity. We reviewed epidemiology, clinical presentation, diagnostic assessment, differential diagnosis and treatment of HM to offer the best evidence of this rare condition. The differential diagnosis of HM is broad, including other types of migraine and any condition that can cause transitory neurological signs and symptoms. Neuroimaging, cerebrospinal fluid analysis and electroencephalography are useful, but the diagnosis is clinical with a genetic confirmation. The management relies on the control of triggering factors and even hospitalisation in case of long-lasting auras. As HM is a rare condition, there are no randomised controlled trials, but the evidence for the treatment comes from small studies.