Clinicoradiological Correlation of Macropsia due to Acute Stroke: A Case Report and Review of the Literature

Dysmetropsia (macropsia, micropsia, teleopsia, or pelopsia) most commonly results from retinal pathologies, epileptic seizure, neoplastic lesions, viral infection, or psychoactive drugs. Vascular lesions are an uncommon cause of dysmetropsia. Vascular hemimicropsia, although rare, has been more frequently described in the literature, whereas hemimacropsia from acute ischemic injury is exceedingly rare. We describe a patient presenting in the emergency room (ER) with visual perception disturbances characterized by a distorted perception of the size of objects, compatible with left hemimacropsia. Magnetic resonance imaging (MRI) of the brain showed an acute occipitotemporal ischemic injury corresponding to the posterior cerebral artery (PCA) territory. The location of the lesion is consistent with previous case reports that suggest that hemimacropsia is associated with the occipitotemporal projection, which plays a decisive role in the visual identification of objects by interconnecting the striate, prestriate, and inferior temporal areas. The difference of our case as compared to previous case reports is that the lesion in our patient spared Brodmann area 17 (calcarine cortex) and therefore did not present symptoms of quadrantanopsia. Instead, the patient presented isolated hemimacropsia, therefore suggesting that the anatomical lesion causing hemimacropsia is located in the ventral portion of the occipitotemporal projection, more specifically Brodmann areas 18 (parastriate) and 19 (peristriate)

Spectrum of intracranial pathology: Tumors versus infections at a tertiary care hospital

Introduction: Aga Khan University Hospital Neurosurgery Department has evolved into a high-volume centre for treatment of neurosurgical diseases. We aimed to compare the relative outcomes of intracranial tumors and CNS infections seen at our facility.Methods: Hospital records of patients admitted under the neurosurgery service between 1994-2003 were evaluated. Cases with a principal diagnosis of an intracranial lesion were identified for further study. Demographic, clinical,and surgical variables were extracted from the medical record. Length of hospital stay, ICU utilization, and in-hospital mortality were the primary outcome indicators. Data were analyzed through descriptive statistics and comparisons of meansand proportions. Results: The mortality rate was 8.7% for intracranial tumors and 18.8% for intracranial infections. Average age for tumor patients was 39.4 years and 26.5 years for patients with infections. Male predominance was seen in the tumor group (55%; p=0.02) and marginally in the infection group (51.6%; p=0.52). Mortality, length of stay and ICU utilization did not decrease significantly in either group over the ten-year period of our study. In both groups, electively admitted patients were associated with better outcomes as compared to emergent admissions. Conclusion: There is a need for better awareness and education among referring physicians to be on the lookout for patients requiring early neurosurgical referral. Careful selection of patients for surgical intervention should be practiced to ensure low mortality rates and more meaningful outcome

Diagnostic yield of transthoracic echocardiography for stroke patients in a developing country

OBJECTIVE: To assess the utility and cost effectiveness of transthoracic echocardiography (TTE) as part of stroke workup in a developing country. METHODS: All patients over the age of 14 years with acute stroke were prospectively enrolled in Aga Khan University stroke databank from August 1999 to May 2001 (22 month period). All patients were evaluated by a consultant neurologist and underwent standard stroke work up such as neuroimaging, TTE, carotid doppler sonography and blood tests e.g. serum glucose, lipid profile, blood urea nitrogen and serum creatinine. For the purpose of this study, patients with ischemic stroke were identified and their echocardiographic data was retrieved and analyzed. TOAST criteria was used to identify findings indicating cardioembolic stroke. RESULTS: Ischaemic stroke was identified in 393 (76%) patients. Of these 278 (71%) patients underwent transthoracic echocardiography as part of stroke workup. Although 199 (73%) patients had abnormal echocardiogram; only 43 (15.5%) had findings suggestive of possible cardioembolism as defined by the TOAST criteria. CONCLUSION: Tranthoracic echocardiography is a valid diagnostic modality for stroke workup. However there is a need to further investigate the specific indications which can be used to prioritize patients for undergoing echocardiography to minimize cost

Limb-shaking transient ischemic attacks: case report and review of literature

BACKGROUND: Limb shaking Transient Ischemic Attack is a rare manifestation of carotid-occlusive disease. The symptoms usually point towards a seizure like activity and misdiagnosed as focal seizures. On careful history the rhythmic seizure like activity reveals no Jacksonian march mainly precipitated by maneuvers which lead to carotid compression. We here present a case of an elderly gentleman who was initially worked up as suffering from epileptic discharge and then later on found to have carotid occlusion. CASE PRESENTATION: Elderly gentleman presented with symptoms of rhythmic jerky movements of the left arm and both the lower limbs. Clinical suspicion of focal epilepsy was made and EEG, MRI-Brain with MRA were done. EEG and MRI-Brain revealed normal findings but the MRA revealed complete occlusion of right internal carotid artery. On a follow-up visit jerky movements of the left arm were precipitated by hyperextension and a tremor of 3–4 Hz was revealed. Based on this the diagnosis of low flow TIA was made the patient was treated conservatively with adjustment of his anti-hypertensive and anti-platelet medications. CONCLUSION: Diagnosis of limb-shaking TIA is important and should be differentiated from other disorders presenting as tremors. Timely diagnosis is important as these patients are shown to benefit from reperfusion procedures either surgical or radiological reducing their risk of stroke