Cerebral Autosomal Dominant Arteriopathy With Subcortical Infarcts and Leukoencephalopathy (CADASIL) Syndrome: A Case Report and Review of Literature

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is an autosomal dominant genetic disorder of the small arteries that causes ischemic vascular events, subcortical dementia, behavioral changes, and migraine-like headaches. It is caused by a mutation in the NOTCH3 gene; this disease was first described in 1955 by van Bogaert. We present a 29-year-old woman who presented to the neurology department. She has no history of chronic degenerative diseases. She has been complaining of migraine-like headaches for the past six months. She has cognitive impairment with arithmetic and executive function deficits on neurological examination. Blood biometry and blood chemistry are within normal parameters in her laboratory studies. A viral panel and immunological profile were also performed and were not reactive. A lumbar puncture was performed, and the composition of the cerebrospinal fluid was within normal limits. An MRI was performed, which showed bilateral and symmetric white matter hyperintensities consistent with CADASIL syndrome. There is no specific treatment. Management of these patients is based on symptom control. Neurological sequelae have an important impact on the quality of life and mortality of these patients. For this reason, pharmacological preventive therapies have been sought with controversial evidence.

A Young Female Newly Diagnosed With Takayasu's Arteritis Masquerading As Cerebrovascular Stroke

The condition known as Takayasu's disease or Takayasu's arteritis is a type of vascular inflammation that affects the large and medium arteries. It can lead to a reduction in blood flow to various parts of the body, and it can cause severe complications. Patients with this disease may not have specific symptoms, which can lead to their diagnosis not being confirmed. Takayasu's disease is believed to be a probable cause of stroke in young patients. Although stroke is a common cause of morbidity, it is usually not an initial presentation in Takayasu's disease. In this study, a young female with left-sided hemiparesis was diagnosed with Takayasu's disease after a clinical and angiographic examination.

Bilateral Middle Cerebral Artery Occlusion: A Successful Case of Bilateral Thrombectomy

Single-vessel occlusions often cause an acute ischemic stroke (AIS) but can rarely be caused by multi-vessel occlusions. Although bilateral AIS is rare, these patients often undergo mechanical thrombectomy as long as they are within the 24-hour window since symptom presentation. We present a case of a female in her 70s who presented to an outside facility with right-sided weakness in her upper and lower extremities, drooping of the right lower face, and aphasia. The patient developed bilateral symptoms on transfer to a tertiary center with neuro-interventional capabilities. Due to concern for a possible bilateral stroke, magnetic resonance imaging was ordered and was remarkable for bilateral middle cerebral artery occlusion. The patient underwent a successful bilateral mechanical thrombectomy within 24 hours of the last known normal. This case demonstrates that mechanical thrombectomy is an excellent treatment option for patients with bilateral occlusions that present within the recommended 24 hours from the last known normal.

Neurological Complications Secondary to Intimate Partner Violence: A Brief Review and Case of Posterior Cerebral Artery Cerebrovascular Accident Following Domestic Abuse

Intimate partner violence (IPV) is a growing public health concern, with millions of individuals experiencing IPV each year. Consequences of IPV include psychological disturbances, changes in physical health, and in extreme cases, severe disablement or death. Here, we describe a case of a patient who experienced IPV, leading to a variety of neurological symptoms, and was diagnosed with a posterior cerebral artery (PCA) cerebrovascular accident (CVA) 10 days later. While cases of traumatic brain injury leading to CVA, or stroke, have been documented, there is currently limited reported literature on the neurological complications, specifically stroke, secondary to IPV in adults. Due to this limited reporting, future studies on IPV will be needed to fully understand the long-term neurological complications that may occur.

Anesthesia for a Patient With Cerebrovascular Accident with Seizure Disorder Undergoing Medical Termination of Pregnancy: A Case Report

The term "total intravenous anesthesia" refers to the preservation of an anesthetic plane with the use of an injectable anesthetic, a sedative that is often given in intermittent boluses. The tendency to have recurrent unprovoked seizures is known as epilepsy. Its prevalence ranges from 0.5% to 1%. The highest incidence rates are in those with anatomical or developmental brain abnormalities, as well as at the extremes of age. The most common triggering factors for epilepsy are stress and fear. The main advantage of total intravenous anesthesia is the patient's rapid recovery and early ambulatory. Conscious sedation is a strategy for giving patients excellent anesthesia and analgesia. In this case report, we will describe a high-risk epileptic patient who required conscious sedation to perform a medical termination.

The Value of Interdisciplinary Collaboration in Lateral Medullary Syndrome Rehabilitation: A Case Report

Wallenberg's syndrome, also known as lateral medullary syndrome (LMS), is a neurological condition resulting from damage to the lateral portion of the medulla oblongata. We present a case of a 64-year-old man with Wallenberg's syndrome who presented for acute rehabilitation after sustaining a cerebrovascular accident (CVA). As seen in our patient, common symptoms of LMS include difficulty swallowing, hoarseness, ipsilateral weakness, and ipsilateral loss of sensation or numbness. Although the prognosis following infarction is often good, dysfunction in swallowing is one of the key deficits that have a long-term impact on patient quality of life. We aim to emphasize the significance of the interdisciplinary approach to achieving favorable health outcomes in patients with LMS.

An Unfortunate Miss of Undiagnosed Arterial Ischemic Stroke (AIS) in the Setting of Diabetic Ketoacidosis in an Adult: A Case Report

We present the case of a 43-year-old male with a history of poorly controlled type II diabetes who presented with altered mental status, urinary incontinence, and diabetic ketoacidosis (DKA). Initial brain imaging studies were negative for acute intracranial pathology; however, the next day, the patient was found to have left-sided paralysis. Repeat imaging studies revealed a right middle cerebral artery infarct with hemorrhagic conversion. Given that the rate of reported strokes in the setting of DKA in adults is limited, this case report affirms to discuss the importance of prompt recognition, evaluation, and adequate treatment of DKA to prevent neurological complications, as well as the pathophysiology behind the etiology of DKA-induced stroke. This case also underscores the importance of early recognition and missed strokes in the emergency department (ED) and emphasizes the need for stroke evaluation in patients with altered mental status even though an alternative diagnosis is apparent to avoid anchor bias.

Predictors of Outcomes After Coronary Artery Bypass Grafting: The Effect of Concomitant Mitral Repair

Background Ischemic mitral regurgitation (IMR) or functional MR intensity with or without repair increases the risk of coronary artery bypass grafting (CABG), and if the contaminant is undertaken, it doubles the risk of the surgery. This study aimed to characterize patients with concomitant CABG and mitral valve repair (MVR) and assess the surgical and long-term outcomes. Methods We conducted a cohort study from 2014 to 2020 on 364 patients who underwent CABG. A total of 364 patients were enrolled and divided into two groups. Group I (n= 349) included patients with isolated CABG, and Group II included patients who underwent CABG with concomitant mitral valve repair (MVR) (n= 15). Results Regarding preoperative presentation, most patients were male: 289 (79.40%), hypertensive 306 (84.07%), diabetic 281 (77.20%), dyslipidemic 246 (67.58%), presenting with NYHA classes III-IV: 200 (54.95%), and upon angiography, found to have the three-vessel disease: 265 (73%). Regarding their age mean± SD and Log EuroSCORE median (Q1-Q3), they had a mean age of 60.94± 10.60 years and a median score of 1.87 (1.13-3.19). The most prevalent postoperative complications were low cardiac output 75 (20.66%), acute kidney injury (AKI) 63 (17.45%), respiratory complications 55 (15.32%), and atrial fibrillation (AF) 55 (15.15%). Regarding long-term outcomes, most patients reported class I NYHA 271 (83.13%) and an echocardiographic decrease in MR severity. Patients with a CABG + MVR were significantly younger (53.93± 15.02 vs. 61.24± 10.29 years; P= 0.009), had a lower ejection fraction (33.6 [25-50] vs. 50 [43-55] %; p= 0.032), and had a higher prevalence of LV dilation (32 [9.17%]). EuroSCORE was significantly higher in patients with mitral repair (3.59 [1.54-8.63] vs. 1.78 (1.13-3.11); P= 0.022). The mortality percentage was higher with MVR but did not attain statistical significance. Intraoperative CPB and ischemic durations were longer in the CABG + MVR group. Furthermore, neurological complications were higher in patients with mitral repair (4 (28.57%) vs. 30 (8.65%), P= 0.012). The study's follow-up duration median was 24 (9-36) months. The composite endpoint occurred more frequently in older patients (HR: 1.05 [95% CI: 1.02-1.09]; 0.001), patients with low ejection fraction (HR: 0.96 [95% CI: 0.93-0.99]; P= 0.006) and in patients with preoperative myocardial infarction (MI) (HR: 2.3 [95%: 1.14- 4.68]; P= 0.021). Conclusion Most IMR patients benefited from CABG and CABG + MVR, as evident by NYHA class and echocardiographic follow-up. CABG + MVR had a higher Log EuroSCORE risk with increased intraoperative cardiopulmonary bypass (CPB) and ischemic durations, which may have played a role in increasing the incidence of postoperative neurological complications. On follow-up, no differences were reported between the two groups. However, age, ejection fraction, and a history of preoperative MI were identified as factors affecting the composite endpoint.

Cerebral Air Embolism: A Case of a Rare Transthoracic Needle Biopsy Complication

Transthoracic needle biopsy (TNB) is a fundamental procedure in the diagnosis of a wide spectrum of thoracic diseases replacing more invasive surgical procedures. The procedure may be performed with computed tomography (CT) or ultrasound imaging guidance, with CT being the more commonly utilized. Although less invasive than surgery, there is still a complication risk associated with this procedure. These can be local such as pneumothorax, parenchymal hemorrhage, tumor seeding, and hemoptysis, or systemic such as air embolism. The authors report a case of cerebral circulation air embolism as a complication of TNB in a 54-year-old male with suspected lung tumor followed by a brief review of the current literature.

Cognitive Impairment in Strategic Infarct Dementia: A Report of Three Cases

Strokes involving specific areas regulating cognition and behavioral functions constitute strategic infarct vascular dementia. We present three patients with acute behavioral changes and cognitive impairment following a strategic infarct. Case 1 is of a 59-year-old male, a known patient of diabetes mellitus under treatment, who presented with acute onset of memory deficit along with difficulty in recognizing faces, and left hemispatial neglect. Case 2 is of a 62-year-old male, a smoker, who presented with acute onset of behavioral abnormalities, gait apraxia, and decreased word output. Case 3 is of a 64-year-old female, a known patient of type 2 diabetes mellitus and cerebrovascular accident with left hemiparesis, who presented with psychomotor withdrawal, depression, and cautious gait. One of the most prevalent forms of dementia in adults is vascular dementia, often caused by multiple small strokes, termed multi-infarct dementia. Strategic infarct dementia, on the other hand, is usually caused by a small, single cerebral infarct. The strategic brain regions specifically involved in post-stroke cognitive impairment requires detailed clinical examination along with radiological imaging for accurate localization. Thus the cognitive impact of ischemic strokes can be understood and predicted by clinicians with the help of maps of strategic brain regions associated with global and domain-specific cognitive functions.

A Cerebrovascular Accident Presenting With Bilateral Vocal Cord Paresis

Diagnosing a stroke requires careful attention to clinical indicators on physical exam, especially the more subtle manifestations of cerebellar lesions. An 85-year-old male with vascular risk factors and new-onset atrial fibrillation was admitted for left upper extremity weakness, headaches, and tremors. The patient developed stridor during hospitalization and was found to have a new cerebellar infarct with hemorrhagic transformation on computed tomography (CT) of the head, with laryngoscopy showing bilateral vocal cord paresis. While strokes outside of the cerebellum are a known cause of unilateral vocal cord paresis, cerebellar strokes are a rare culprit and rarely cause bilateral cord paresis. Consideration beyond the more common pulmonary and iatrogenic causes of vocal cord paresis should be considered, with particular attention to stroke.

An Unexpected Case of Posterior Reversible Encephalopathy Syndrome

This study presents an 86-year-old gentleman who was admitted under the acute stroke team for a possible posterior cerebral infarct. Radiologic imaging revealed that the diagnosis was in fact posterior reversible encephalopathy syndrome (PRES). Through a process of elimination by means of investigations, the most likely cause was found to be mild hypertension on a background of vascular dementia causing a possible exacerbation of PRES symptoms. A multidisciplinary approach was found to be beneficial, providing safe and effective care for this patient, allowing a brief recovery period and restoration of baseline function and thus minimising permanent sequelae.