Acute cerebellitis caused by herpes simplex virus

Case presentation A 29 year-old woman presented to the emergency with gait imbalance and dysarthria. At admission, neurologic examination revealed normal cognition, ataxia, dysarthria, dysmetria on both sides of the body, bilateral vertical nystagmus and loss of the lateral eye movement. Blood examination was notable for a increase in WBC count and demonstrated erythrocyte sedimentation rate of 18 mm/h. Examination of cerebral spinal fluid (CSF) revealed a protein concentration of 166 mg/ dL, a glucose concentration of 56 mg/dL, and pleocytosis. Serum glucose concentration was 126 mg/dL. The patient had no history of immunosuppression or another comorbidity and anti-HIV test was negative Neurological evaluation included a head computed tomography (CT) scan which revealed normal findings. An MRI of the brain revealed bilateral increased signal intensity in the cerebellum on fluid-attenuated inversion recovery images (FLAIR)/T2, without contrast enhancement, suggesting an inflammatory process confined to the cerebellum (Figure 1 and 2). Furthermore, the cerebellar cortex appeared swollen, a finding consistent with diffuse cerebellitis. There were no alterations in the brainstem. Initially, the possibility of bacterial rhomboencephalitis caused by Listeria monocytoges was considered, since it is the most commom cause of rhomboencephalitis. After a few days with antibiotic therapy (ceftriaxone and ampicillin), polymerase chain reaction (PCR) test of the CSF was positive for Herpes Simplex Virus 1/2 (HSV) Bacterial culture of CSF samples showed no growth, and the results of Gram staining of CSF were negative. Anti-Listeria antibody was also negative and ampicillin discontinued. CSF PCR analysis for other herpesviruses (varicella-zoster virus, Epstein-Barr virus, cytomegalovirus, and human herpesvirus types 6–8) and enteroviruses were also negative. Upon treatment with acyclovir (50 mg/kg/day) during 21 days, symptoms improved. One month later after the first MRI, a significantly reduce of imaging abnormalities was detected (Figure 3)

Atypical intracranial calcifications in a conventional Radiographic exam

An 18-year-old male patient of consanguineous parents, delivered at full-term by cesarean section and having no changes in neurodevelopment, presented with skin blisters that evolved to eruptions and scars immediately after birth. In childhood, he developed lesions and diffuse tongue hypertrophy, with cutaneous hyperkeratosis and periods of exacerbation after sun exposure or trauma. In regular outpatient appointments with the medical assistant team, neurological symptoms were not observed. He underwent surgery because of an obstruction of the salivary duct with local abscess. A biopsy of skin lesion was performed and its histological analysis suggested lipoid proteinosis

Stroke and stroke mimics: a case of high grade glioma

The clinical diagnosis of acute stroke is inaccurate approximately 10%-30% of the time, which can lead to unnecessary administration of thrombolytic therapy or delays in appropriate therapy. Rapid and accurate neuroimaging triage is essential to guide therapy and exclude mimics. Although many conditions that mimic stroke clinically have imaging appearances that can overlap acute stroke, these conditions can be differentiated in most cases by using a careful pattern-based approach. We describe a case of 67 yo male patient who had a clinic of wakeup stroke and at the first magnetic resonance image (MRI) it was found that was an acute stroke of middle cerebral artery.The patient did not improve and a second MRI  revelead a two times growth of the lesion, and the MRI findings were compatible with tumor. At the surgery they found a infiltrative lesion and the anatomopathological exam showed that it was a high grade glioma.The diagnosis of ischemic stroke is often straight forward; however, the clinical diagnosis of acute stroke is inaccurate in many cases. Furthermore, many of these conditions, such as encephalitis, mass lesions, seizures, hypoglycemia, transient global amnesia (TGA),demyelinating disease, drug toxicity, and metabolic disturbances, have imaging appearances that can mimic acute or subacute infarction; however, an accurate diagnosis can often be made by using a pattern-based approach.