Superficial siderosis as a rare cause of visual and auditory pseudohallucinations: a case report

Background!#!Superficial siderosis is a rare disease involving hemosiderin deposits on the surface of brain or spinal cord that are thought to cause clinical symptoms, which usually consist of cranial nerve dysfunction, cerebellar ataxia, or myelopathy. Pseudohallucinations have been described as the patient being aware of the nonreality of hallucination-like phenomena. Data on pseudohallucinations of cerebral somatic origin are sparse. We present a case of auditory and visual pseudohallucinations due to superficial siderosis. Siderosis was diagnosed using cerebrospinal fluid analysis and magnetic resonance imaging as part of the clinical routine for newly emerged psychiatric symptoms.!##!Case presentation!#!An 84-year-old white/european female presented to our hospital with no prior history of psychiatric or neurological disease and no history of trauma. She reported seeing things and hearing voices singing to her for some days. She was aware these phenomena were not real (pseudohallucinations). On examination, no relevant abnormalities were detected. Cerebrospinal fluid analysis showed elevated ferritin. Magnetic resonance imaging with susceptibility-weighted sequences revealed diffuse superficial siderosis in several parts of the brain, among other occipital and temporal gyri. The pseudohallucinations resolved with a risperidone regime. The patient was treated with rivaroxaban because of atrial fibrillation. Potentially elevating the risk of further hemorrhage, this therapy was discontinued, and an atrial appendage occlusion device was implanted.!##!Conclusion!#!We report the first case of pseudohallucinations in superficial siderosis. The risk of missing this diagnosis can be reduced by applying a standardized diagnostic pathway for patients presenting with the first episode of psychiatric symptoms. Somatic and potentially treatable causes should not be missed because they might lead to unnecessary treatments, stigmatization, and legal restrictions of self-determination, especially for elderly people

A rare cause of stroke: fail-implanted venous port catheter system – a case report

Background!#!We present the case of a 75-year-old female with acute embolic cerebral infarction caused by a fail-implanted venous port catheter system in the left subclavian artery.!##!Case presentation!#!A 75-year-old woman presented to our emergency room after acute onset of a right-sided hemiparesis and dysarthria. Within 2 days after admission, she developed a left-sided hemiparesis, ataxia with concordant gait disturbance and incoordination of the left upper limb. DWI-MRI showed acute multiple infarcts in both cerebral and cerebellar hemispheres. Laboratory examination, 24-h Holter electrocardiography and transthoracic echocardiography provided no pathological findings. Further examination revealed an arterially fail-implanted port catheter, placed in the left subclavian artery with its tip overlying the ascending aorta, as the source of cerebral embolism.!##!Conclusion!#!This is the first case report of thromboembolic, cerebral infarction due to a misplaced venous port catheter in the subclavian artery, emphasizing the imperative need for a thorough diagnostic workup, when embolism is suspected but cannot be proven at first glance

Evaluation of the middle cerebral artery occlusion techniques in the rat by in-vitro 3-dimensional micro- and nano computed tomography

Abstract Background Animal models of focal cerebral ischemia are widely used in stroke research. The purpose of our study was to evaluate and compare the cerebral macro- and microvascular architecture of rats in two different models of permanent middle cerebral artery occlusion using an innovative quantitative micro- and nano-CT imaging technique. Methods 4h of middle cerebral artery occlusion was performed in rats using the macrosphere method or the suture technique. After contrast perfusion, brains were isolated and scanned en-bloc using micro-CT (8 μm)3 or nano-CT at 500 nm3 voxel size to generate 3D images of the cerebral vasculature. The arterial vascular volume fraction and gray scale attenuation was determined and the significance of differences in measurements was tested with analysis of variance [ANOVA]. Results Micro-CT provided quantitative information on vascular morphology. Micro- and nano-CT proved to visualize and differentiate vascular occlusion territories performed in both models of cerebral ischemia. The suture technique leads to a remarkable decrease in the intravascular volume fraction of the middle cerebral artery perfusion territory. Blocking the medial cerebral artery with macrospheres, the vascular volume fraction of the involved hemisphere decreased significantly (p Conclusion Micro- and Nano-CT imaging is feasible for analysis and differentiation of different models of focal cerebral ischemia in rats.</p

Neuroprotective mechanisms of erythropoietin in a rat stroke model

This study was designed to investigate the indirect neuroprotective properties of recombinant human erythropoietin (rhEPO) pretreatment in a rat model of transient middle cerebral artery occlusion (MCAO)

Visual Hallucinations following Coronary Artery Bypass Grafting: A Prospective Study

Background and Objectives: After major heart surgery, some patients report visual hallucinations that cannot be attributed to psychosis or delirium. This study aimed to investigate the hallucination incidence in patients after coronary artery bypass grafting with (on-pump) and without (off-pump) extracorporeal circulation. Materials and Methods: A total of 184 consecutive patients listed for elective on- or off-pump coronary artery bypass grafting were prospectively enrolled into the study. Preoperative baseline investigations 24&ndash;48 h before surgery (t0) and postoperative follow-up 24&ndash;48 h (t1) and 5&ndash;6 days (t2) after surgery included cognitive testing and a clinical visual acuity test (Landolt rings). Patients reporting visual hallucinations were interviewed using a structured survey to record the type, timing, duration, and frequency of their hallucinations. All the patients received a neurological examination and cranial magnetic resonance imaging if indicated. Results: Of the patients in the sample, 155 patients underwent on-pump bypass surgery, and 29 patients received off-pump surgery. Of these, 25 patients in the on-pump group, but none in the off-pump group, reported transient visual hallucinations (p = 0.020), which could not be attributed to stroke, delirium, psychosis, migraine, or severely impaired vision. Significant correlations were observed for the occurrence of visual hallucinations and the amount of nicotine consumption and aortic clamp/extracorporeal circulation time. Conclusions: Transient visual hallucinations occur in a noticeable proportion of patients after on-pump heart surgery. Knowledge of the phenomenon&rsquo;s benignity is important for patients to prevent anxiety and uncertainty and for treating physicians to avoid unnecessary medication and drug-induced delirium

Combined contrast-enhanced ultrasound and rt-PA treatment is safe and improves impaired microcirculation after reperfusion of middle cerebral artery occlusion

In monitoring of recanalization and in sonothrombolysis, contrast-enhanced ultrasound (CEUS) is applied in extended time protocols. As extended use may increase the probability of unwanted effects, careful safety evaluation is required. We investigated the safety profile and beneficial effects of CEUS in a reperfusion model. Wistar rats were subjected to filament occlusion of the right middle cerebral artery (MCA). Reperfusion was established after 90 minutes, followed by recombinant tissue-type plasminogen activator (rt-PA) treatment and randomization to additional CEUS (contrast agent: SonoVue; 60 minutes). Blinded outcome evaluation consisted of magnetic resonance imaging (MRI), neurologic assessment, and histology and, in separate experiments, quantitative 3D nano-computed tomography (CT) angiography (900 nm3 voxel size). Nano-CT revealed severely compromised microcirculation in untreated animals after MCA reperfusion. The rt-PA partially improved hemispheric perfusion. Impairment was completely reversed in animals receiving rt-PA and CEUS. This combination was more effective than treatment with either CEUS without rt-PA or rt-PA and ultrasound or ultrasound alone. In MRI experiments, CEUS and rt-PA treatment resulted in a significantly reduced ischemic lesion volume and edema formation. No unwanted effects were detected on MRI, histology, and intracranial temperature assessment. This study shows that CEUS and rt-PA is safe in the situation of reperfusion and displays beneficial effects on the level of the microvasculature

Sonothrombolysis with BR38 Microbubbles Improves Microvascular Patency in a Rat Model of Stroke.

Early recanalization of large cerebral vessels in ischemic stroke is associated with improved clinical outcome, however persisting hypoperfusion leads to poor clinical recovery despite large vessel recanalization. Limited experimental sonothrombolysis studies have shown that addition of microbubbles during treatment can improve microvascular patency. We aimed to determine the effect of two different microbubble formulations on microvascular patency in a rat stroke model.We tested BR38 and SonoVue® microbubble-enhanced sonothrombolysis in Wistar rats submitted to 90-minute filament occlusion of the middle cerebral artery. Rats were randomized to treatment (n = 6/group): control, rt-PA, or rt-PA+3-MHz ultrasound insonation with BR38 or SonoVue® at full or 1/3 dose. Treatment duration was 60 minutes, beginning after withdrawal of the filament, and sacrifice was immediately after treatment. Vascular volumes were evaluated with microcomputed tomography.Total vascular volume of the ipsilateral hemisphere was reduced in control and rt-PA groups (p0.1).Microbubble-enhanced sonothrombolysis improves microvascular patency. This effect is not dose- or microbubble formulation-dependent suggesting a class effect of microbubbles promoting microvascular reopening. This study demonstrates that microbubble-enhanced sonothrombolysis may be a therapeutic strategy for patients with persistent hypoperfusion of the ischemic territory

Nano-CT scan of cortex.

<p>Nano-CT images illustrating the “no-reflow phenomenon” in an untreated animal after the withdrawal of the MCA filament (A), and reperfusion of the microvasculature after BR38 (full dose) sonothrombolysis. Scale bar in each image = 100 μm</p

Micro-CT scan for vascular volume.

<p>Representative scans of the 3 mm slice encompassing the MCA territory used for micro-CT analysis from a control (saline treated) (panel A), a BR38 full dose (panel B) and a SonoVue full dose treated rat (panel C). Cortical and striatal regions of interest (ROI) for all animals were analyzed in each hemisphere to quantify vascular volume. Dashed line boxes in panel A have been drawn to demonstrate the ROI chosen for this animal. These scans demonstrate reduced vascular volume in both cortical and striatal regions of the ipsilateral hemisphere of the control rat, while demonstrating normal microvascular perfusion after BR38 or SonoVue microbubble-enhanced sonothrombolysis. Scale bar in each image = 800 μm.</p