Vertebral Artery Dissection: A Pain in the Neck

Introduction: Vertebral artery dissection (VAD) accounts for less than 2.5% of all strokes. VAD disproportionately affects younger, healthier patients. VAD can cause vague symptoms and may be easily misdiagnosed. Patients most commonly present with neck pain, headache, visual disturbance, or focal extremity weakness. We present a case of spontaneous VAD in an otherwise healthy patient whose only symptoms were neck pain and headache. Case Presentation: A 42-year-old male presented with 8 days of left neck pain and headache. CT neck with contrast was initially ordered to rule out tonsillitis. CT revealed an incidental anterior communicating artery (ACOM) aneurysm, however a left VAD was initially missed. Digital subtraction angiography (DSA) performed for ACOM aneurysm coiling demonstrated a left VAD as the culprit for the patient’s symptoms. Brain MRI revealed a small acute left occipital lobe infarct secondary to the VAD. The patient underwent endovascular coiling of the ACOM aneurysm and received aspirin for VAD, obtaining resolution of his symptoms. Discussion: VAD is increasingly identified as a cause of ischemic stroke in young adults. VAD involves an intimal tear of the vasa vasorum leading to narrowing of the vessel lumen and thromboembolic complications. Triggers for VAD include neck manipulations, trauma, or abnormal posturing. While DSA remains the gold standard, recognition of VAD on CT or MR angiogram remains critical. Early diagnosis and treatment of VAD lowers the risk of long-term neurologic sequela. Given clinical presentation variability, the differential diagnosis of young patients with craniocervical pain, with or without neurologic deficits, should include VAD

A Unique Case of Concomitant Acute Arterial Stroke and Dural Venous Thrombosis as Initial Presentation in a COVID Positive Patient

Introduction:The 2019 coronavirus (COVID-19) can cause severe organ dysfunction and death. COVID-19 is associated with a high risk of thrombotic complications such as arterial and venous thrombosis.The proposed mechanism includes systemic inflammation and endothelial damage, both known stroke risk factors. Although there has been prior cases of isolated arterial strokes or venous sinus thrombosis in these patients, here we report a unique case of simultaneous arterial ischemic stroke and dural venous thrombosis as initial presentation in a COVID positive patient(1). Case: A 64 yo female with a past medical history of hypertension presented with left sided hemiparesis, facial drop and SOB. Labs showed hypoxemia, elevated D dimers and a +COVID test. CT Brain demonstrated a large right middle cerebral artery infarct. CT angio head/neck showed a thrombus on the right internal carotid artery bulb and thrombus on the dural venous sinuses. Chest radiograph showed multifocal pneumonia. Discussion: COVID-19 has had a dramatic impact on the health care systems. Coagulopathy in the form of venous and arterial thromboembolism associated with ischemic stroke, is one of the most severe sequela of the disease. Postulated mechanisms include a severe inflammatory response that disrupts the renin-angiotensin system and alters the coagulation cascade. Theoretically, potential treatments include halting viral replication or targeting ACE2 receptors.We highlight the urgent need to understand the pathogenesis of hyper coagulability in the neurology of this pandemic with the aim to find better treatment targets and reduce its morbidity and mortality(2)

Uncommon Implantation Sites of Ectopic Pregnancy: Thinking beyond the Complex Adnexal Mass.

Ectopic pregnancy occurs when implantation of the blastocyst takes place in a site other than the endometrium of the uterine cavity. Uncommon implantation sites of ectopic pregnancy include the cervix, interstitial segment of the fallopian tube, scar from a prior cesarean delivery, uterine myometrium, ovary, and peritoneal cavity. Heterotopic and twin ectopic pregnancies are other rare manifestations. Ultrasonography (US) plays a central role in diagnosis of uncommon ectopic pregnancies. US features of an interstitial ectopic pregnancy include an echogenic interstitial line and abnormal bulging of the myometrial contour. A gestational sac that is located below the internal os of the cervix and that contains an embryo with a fetal heartbeat is indicative of a cervical ectopic pregnancy. In a cesarean scar ectopic pregnancy, the gestational sac is implanted in the anterior lower uterine segment at the site of the cesarean scar, with thinning of the myometrium seen anterior to the gestational sac. An intramural gestational sac implants in the uterine myometrium, separate from the uterine cavity and fallopian tubes. In an ovarian ectopic pregnancy, a gestational sac with a thick hyperechoic circumferential rim is located in or on the ovarian parenchyma. An intraperitoneal gestational sac is present in an abdominal ectopic pregnancy. Intra- and extrauterine gestational sacs are seen in a heterotopic pregnancy. Two adnexal heartbeats suggest a live twin ectopic pregnancy. Recognition of the specific US features will help radiologists diagnose these uncommon types of ectopic pregnancy

A Case of Neuromyelitis Optica Spectrum Disorder

Introduction: We present a case of neuromyelitis optica spectrum disorder (NMOSD), previously known as neuromyelitis optica (NMO) or Devic Disease. NMO was classically described as a triad of optic neuritis, longitudinal myelitis, and a positive anti-AQP4 antibody, however a far wider range of presentations are now recognized and so the term NMOSD is now used. NMOSD is a severe demyelinating disease caused by an autoantibody to the aquaporin-4 water channel. It is a relatively rare disorder with a prevalence ranging from 0.5-10 per 100,000. This case highlights presenting signs/symptoms, imaging findings, and management for NMOSD. Case presentation: A 71-year-old female presented with an episode of right arm weakness and ataxia. The initial stroke workup was negative. Subsequent imaging demonstrated classic findings of NMOSD: a longitudinally extensive spinal cord lesion, optic neuritis, and nonspecific T2/FLAIR white matter hyperintensities in the brain. Furthermore, the patient tested positive for the aquaporin-4 antibody and CSF analysis was negative for oligoclonal bands. The patient was started on a 5-day course of methylprednisolone and transitioned to rituximab for chronic treatment of NMOSD. Discussion and Conclusion: This case report demonstrates a relatively rare disorder that can present under the guise of more common pathologies such as stroke or multiple sclerosis. It also highlights key lab and imaging findings to distinguish it from similar disorders. Despite this being a relatively rare disorder, this case shows a classic presentation, lab values, and imaging findings to help guide the diagnosis and treatment of NMOSD to improve patient outcomes