Stroke versus seizure : perfusion computerized tomography in a patient with aphasia

Both stroke and seizures have varied clinical presentations and their differentiation in the acute setting is not always straightforward. We present the case of a patient who presented at the emergency room with acute onset aphasia. Clinically acute ischemic stroke was suspected. Perfusion CT was performed and demonstrated cortical hypervascularity in the left partietotemporal region. Additional MRI and EEG were performed and a final diagnosis of postictal aphasia was made. This case illustrates that perfusion CT is not only a useful tool for acute stroke management, but can also aid in the detection of seizures in patients presenting with stroke-like symptoms

Can fresh frozen heads be used to perform hydraulic pressure measurements during cochlear implant electrode insertion?

Objective: Intracochlear hydraulic pressure change that occurs during cochlear implant surgery is thought to play a role in hearing preservation. Presence of intracochlear air might be a problem when performing pressure measurements in temporal bones. In this study, we aimed to examine if air could enter the cochlea due to decomposition through the opening of the labyrinth and through electrode insertion. Furthermore, the effect of a large amount of insufflated intracochlear air on peak hydraulic pressure during electrode insertion was also examined in fresh frozen heads (FFHs). Methods: Three human FFHs were used. An electrode was inserted three consecutive times, while the peak hydraulic pressure was measured. Air was then insufflated, and a second series of electrode insertions was performed. Computed tomography scans were performed on each FFH before each experiment and after insufflation of air. Volume in mm(3) and location of air were reported. Results: All FFHs had air, especially in the subarachnoid and intravascular space. One FFH had air in both cochleae (3-5 mm(3)). All FFHs showed air near the stapes footplate (1-3 mm(3)) after opening of the labyrinth. Air was present in the vestibule and scala vestibuli (1-23 mm(3)) of all FFHs after the electrode insertions and removal of the pressure sensor. The mean peak hydraulic pressure during electrode insertion decreased with insufflation of air (from 0.68 mmHg (standard deviation [SD] 0.34) to 0.24 mmHg (SD 0.14). Conclusion: Future studies on FFH or temporal bones should consider intracochlear air when performing hydraulic pressure measurements

Microbleed patterns in critical illness and COVID-19

Background: Cerebral microbleeds are increasingly reported in critical ill patients with respiratory failure in need of mechanical ventilation and/or extracorporeal membrane oxygenation (ECMO). Typically, these critical illnessassociated microbleeds involve the juxtacortical white matter and corpus callosum. Recently, this pattern was reported in patients with respiratory failure, suffering from COVID-19. Materials and methods: In this retrospective single-center study, we listed patients from March 11, 2020 to September 2, 2020, with laboratory-confirmed COVID-19, critical illness and cerebral microbleeds. Literature research was conducted through a methodical search on Pubmed databases on critical illness-associated microbleeds and cerebral microbleeds described in patients with COVID-19. Results and discussion: On 279 COVID-19 admissions, two cases of cerebral microbleeds were detected in critical ill patients with respiratory failure due to COVID-19. Based on review of existing literature critical illnessassociated microbleeds tend to predominate in subcortical white matter and corpus callosum. Cerebral microbleeds in patients with COVID-19 tend to follow similar patterns as reported in critical illness-associated microbleeds. Hence, one patient with typical critical illness-associated microbleeds and COVID-19 is reported. However, a new pattern of widespread cortico-juxtacortical microbleeds, predominantly in the anterior vascular territory with relative sparing of deep gray matter, corpus callosum and infratentorial structures is documented in a second case. The possible etiologies of these microbleeds include hypoxia, hemorrhagic diathesis, brain endothelial erythrophagocytosis and/or cytokinopathies. An association with COVID-19 remains to be determined. Conclusion: Further systematic investigation of microbleed patterns in patients with neurological impairment and COVID-19 is necessary

Vestibular schwannoma: natural growth and possible predictive factors

Background: Prediction of vestibular schwannoma (VS) growth would allow for a more differentiated follow-up protocol. Objectives: The natural course of a VS and predictive factors of growth are investigated. Methods: Sixty-two sporadic VS cases diagnosed between 2003 and 2015 were included in this retrospective cohort study. After initial surveillance, active therapy was initiated in 31/62 patients. Regular magnetic resonance images (MRIs) were performed. Two mm/year linear difference was the cut-off value for significant growth. The STROBE guidelines have been implemented. Results: Growth of the tumor was detected in 56% of patients and mainly observed in the first three years of follow-up. Tumor size remained stable in 34% and decreased in 10% of patients. No baseline information, symptom, or sign was found to be predictive for growth. Conclusions: In 56% of the initially conservatively managed VSs growth was observed and active treatment was initiated. Eighty-seven percent of the growing VSs were identified during the first three years of follow-up. The initially larger VSs seemed to grow faster and needed active treatment earlier during follow-up. No predicting factors for growth identified from the literature could be confirmed in the present study. Serial MRI remains the appropriate method to detect tumor growth

Alemtuzumab in multiple sclerosis : a retrospective analysis of occult hemorrhagic magnetic resonance imaging lesions and risk factors

Background and purpose Alemtuzumab, a monoclonal CD52 antibody, is a high-efficacy disease-modifying-therapy in relapsing-remitting multiple sclerosis (RRMS). Recently, intracerebral hemorrhage (ICH) was reported as a possible treatment-related adverse event. Arterial hypertension during infusion was suggested as a potential cause, although platelet or endothelial dysfunction may also contribute. This study aimed to screen for occult hemorrhagic cerebral lesions after alemtuzumab treatment and to further elucidate risk factors. Methods We included 30 RRMS patients who received alemtuzumab treatment at Ghent University Hospital or Sint-Jan Bruges Hospital. Retrospective data concerning vital signs, adverse effects and thrombocyte levels during treatment were collected. The occurrence of occult intracranial hemorrhagic lesions was assessed by magnetic resonance imaging with susceptibility-weighted imaging (SWI). Results The mean (standard deviation [SD]) systolic blood pressure (SBP) during the morning, afternoon and evening was 120 (3.38) mmHg during first administration and 114 (4.40) mmHg during second administration (N = 13). There was no significant increase in SBP when comparing morning, afternoon and evening per day, nor was there a significant difference in daily mean SBP between consecutive administration days. Thrombocyte count during treatment cycles ranged between 107 x 10(9)/L and 398 x 10(9)/L, with a mean (SD) absolute reduction of 59.3 x 10(9)/L (50.65) or a mean (SD) relative reduction of 25.0 (12.84)% (N = 20). No patient had ICH, nor did SWI show any cerebral microbleeds or other hemorrhagic lesions post-treatment (N = 23). Conclusions In our patient population, alemtuzumab treatment was not associated with arterial hypertension, ICH or occult microbleeds. Possible differences in administration regimen (ambulatory vs. in-hospital setting) and patient population (cardiovascular risk) might explain an increased risk in different populations