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Background Stroke in the setting of three-territory lesion pattern on magnetic resonance-diffusion-weighted imaging "three-territory sign" (TTS) is predominately due to cancer-associated hypercoagulation (CAH). Our goal is to determine the frequency with which "TTS" is overlooked as a diagnostic feature of cancer-associated hypercoagulation stroke. Methods Over a 4-year period (October 2016 to October 2020), stroke admissions with magnetic resonance imaging defined three-territory diffusion-weighted imaging lesions were identified. Patients were prospectively accrued in an observational study from the neurology service at Hartford Hospital, a 938 bed facility with a comprehensive stroke center with 2792 stroke admissions during the study period. Results Twenty-two patients met selection criteria, 4 due to infectious endocarditis, 16 due to stroke from CAH and 2 with no identifiable etiology. Of the 16 CAH patients, 5 were male and 11 female, mean age=72 (range: 47 to 91). Cancer type (biopsy proven unless noted) was cholangiocarcinoma=3, adenocarcinoma of lung=3, adenocarcinoma of breast=1, pancreatic carcinoma=3 (2 biopsy, 1 ultrasound), adenocarcinoma, origin unknown=1, non-small cell carcinoma of lung=2, carcinoid=1, ovarian carcinoma=1, lung mass (not biopsied)=1. Malignancy was known in 7 and occult in 9 at stroke presentation. Consideration of malignancy-related hypercoagulation as the cause of stroke was appreciated in 1 of 16 radiology reports and in 4 of 16 neurology admission notes. Conclusion TTS is a frequently missed diagnostic magnetic resonance feature in cancer-associated hypercoagulation stroke and often heralds occult malignancy.

BackgroundMultiple acute cerebral territory infarcts of undetermined origin are typically attributed to cardioembolism, most frequently atrial fibrillation. However, the importance of 3-territory involvement in association with malignancy is under-recognized. We sought to highlight the “Three Territory Sign” (TTS) (bilateral anterior and posterior circulation acute ischemic diffusion-weighted imaging [DWI] lesions), as a radiographic marker of stroke due to malignancy.MethodsWe conducted a single-center retrospective analysis of patients from January 2014 to January 2016, who suffered an acute ischemic stroke with MRI-DWI at our institution, yielding 64 patients with a known malignancy and 167 patients with atrial fibrillation, excluding patients with both to eliminate bias. All DWI images were reviewed for 3-, 2-, and 1-territory lesions. Chi-square test of proportion was used to test significance between the 2 groups.ResultsWe found an association between the groups (malignancy vs atrial fibrillation) and the number of territory infarcts (p < 0.0001). Pairwise comparisons using the Holm p value adjustment showed no difference between 1- and 2-territory patterns (p = 0.465). However, the TTS was 6 times more likely observed within the malignancy cohort as compared to patients with atrial fibrillation (23.4% [n = 15] vs 3.5% [n = 6]) and was different from both 1-territory (p < 0.0001) and 2-territory patterns (p = 0.0032).ConclusionThe TTS is a highly specific marker and 6 times more frequently observed in malignancy-related ischemic stroke than atrial fibrillation-related ischemic stroke. Evaluation for underlying malignancy in patients with the TTS is reasonable in patients with undetermined etiology.

Diagnostic error is an increasing health care concern. An intravenous drug abuser with chronic meningitis died after a prolonged hospitalization from fungal meningitis diagnosed at autopsy. We examine the diagnostic pitfalls and consider how a computer-assisted diagnostic system may influence the outcome of an otherwise fatal condition.

Background: Multiple cerebral territory infarcts of undetermined origin are typically attributed to cardioembolism; and most frequently atrial fibrillation. However the significance of three territory involvement in association with malignancy is under-recognized. Objective: To highlight the “Three Territory Sign” (bilateral anterior and the posterior circulation DWI lesions), as a radiographic marker of stroke due to malignancy. Methods: We conducted a retrospective analysis of patients at our institution from Jan 2014-Jan 2016 who suffered an acute ischemic stroke with MRI-DWI. We identified all ischemic strokes of undetermined etiology in patients with known malignancy (60 patients) and patients with stroke, atrial fibrillation and no malignancy (167 patients). Patients with both atrial fibrillation and malignancy were excluded. All DWI images were reviewed for 3, 2, and 1 territory lesions. Fisher Exact tests were used to identify statistical significance between the two groups. Statistical significance was set at 0.05. Results: There was a significant association between both cohorts (malignancy vs. atrial fibrillation) and the number of territory infarcts found. While the number of 1 {71.6% (n=43) vs. 79% (n=132)} and 2 territory infarcts {10.0% (n=6) vs. 17. 4% (n=29)} were similar between the two groups, 3 territory infarcts were > 5 times more frequent in malignancy as compared to atrial fibrillation {18.3% (n=11) vs. 3.5% (n=6)} ( p < 0.002 ). Post-hoc pairwise comparisons using the Bonferroni correction for multiple tests support that the 3 territory pattern differs from both 1 territory ( p=0.0033 ) and 2 territory ( p =0.0037 ) patterns. Conclusion: Cerebral territory infarctions involving the bilateral anterior and posterior circulation are 5 times more frequent in malignancy-related ischemic stroke than atrial fibrillation. The “Three territory sign” is a robust marker of malignancy-related stroke and should prompt evaluation for malignancy after exclusion of other known causes.

Background: Imaging studies are an integral part of stroke evaluation and non-contrast head CT is the initial imaging modality. Although critical for assessing acute hemorrhage, ischemic changes may not be visible on CT for up to 24 hours. MRI brain detects ischemic changes within 20 minutes of symptom onset. It is an invaluable tool to confirm an ischemic stroke and determine its etiology. A focused workup for stroke etiology or evaluation for stroke mimics accelerates management strategies and reduces length of stay in the hospital. Early discharge facilitates early rehabilitation and better functional recovery of stroke patients. Current guidelines for management of acute stroke recommend head CT within 25 minutes of presentation. However, to date, a recommendation regarding timeline for MRI brain in stroke evaluation is lacking. Objective of this study was to investigate the correlation between time to MRI & length of hospital stay to functional outcome in stroke patients. Methods: 648 patients (mean age 69±0.5 years; 50.4% women) admitted to Hartford Hospital (Comprehensive Stroke Center) with a focal neurological deficit in the year 2014 and got a CT head and MRI brain were enrolled in the study. Data collection was done via stroke database and retrospective chart review. Patients with any hemorrhage or age Results: There was a significant effect of time from arrival to MRI on length of hospital stay (r=0.27, p Conclusions: Our study indicates that delay in MRI for a suspected stroke increases hospital length of stay. It suggests MRI within 12 hours of admission to be the new standard of care for stroke patients. Ongoing work will assess the correlation of timing to MRI to functional outcomes in stroke patients.

Background Spontaneous convexity SAH in the elderly has heretofore been of uncertain origin until several recent case reports have suggested cerebral amyloid angiopathy (CAA) as the etiology. Objective To better appreciate the relationship of convexity SAH in the elderly to CAA. Method The case histories and MR imaging findings of 4 patients with spontaneous convexity SAH were examined. Results T2*-weighted imaging at the time of symptomatic SAH demonstrated features of prior lobar hemorrhage, microbleeds, and/or superficial hemosiderosis fulfilling diagnostic criteria of CAA in all patients. Conclusions CAA may be the foremost cause of convexity SAH in the elderly.

Selective insult to brain deep gray matter nuclei is uncommon, may be congenital or acquired, acute or chronic, and varied in etiology. Determining the etiology relies on history, clinical presentation, laboratory investigations, and lesion pattern on Neuroimaging.We review the differential diagnosis and clinical, laboratory and neuroimaging pattern of conditions that manifest with lesions of deep gray matter nuclei in the context of representative case studies.While presentations may vary in individual patients, the essentials of history, clinical examination, laboratory evaluation,and neuroimaging lesion pattern can be efficiently directed to differentiate the various etiologies of deep gray matter nuclei lesions. In this review we focus on the etiologic classification and diagnostic approach to acute and chronic conditions that manifest on neuroimaging with bilateral symmetric lesions of deep gray matter nuclei.

A 48-year-old man presented with progressive spastic paraparesis and diffuse white matter involvement on neuroimaging that suggested a primary demyelinating disease. Brain biopsy 3 years after onset of symptoms demonstrated idiopathic granulomatous angiitis. In patients with MRI features of diffuse white matter disease of uncertain etiology, open brain biopsy of leptomeninges and parenchyma should be considered to exclude idiopathic granulomatous angiitis of the CNS.

Hemorrhage complicating acute carbon monoxide poisoning is usually confined to the basal ganglia. The authors report three people with acute carbon monoxide poisoning manifesting selective or prominent white matter involvement complicated by hemorrhagic infarction on CT and MRI in one and by subcortical T2*-weighted MRI abnormality in all three.

Lakhan et al.1 should be praised for their account of the role of electronic media in neurology education. They balanced the progress with the pitfalls, which is always both welcome and wise. However, the article does not quite do justice to the myriad types of e-learning resources that are available, the roles that they can play, and the speed of change in this area. In the past, it may …

A 65-year-old man with a 3-year history of difficulty seeing had normal ophthalmologic and neurologic examinations except for impaired visual spatial and perceptual function. Brain MRI failed to disclose any structural abnormalities, but positron emission tomography (PET) performed 2 weeks later showed prominent hypometabolism in the parieto-occipital regions bilaterally. These findings were considered consistent with the visual variant of Alzheimer disease (VVAD). Although the dissociation between normal structural and abnormal functional imaging has been reported before in VVAD, this patient is a reminder that PET may be useful to confirm the diagnosis before the disease becomes advanced.

Sequelae following hypoglycemic coma are rare, dependent on the severity and duration of hypoglycemia, and include profound memory loss, persistent vegetative state, and death in 2 to 4% of cases. MRI reports are limited and characterized by lesions that involve cerebral cortex, hippocampus, and basal ganglia.1-3⇓⇓ Diffusion-weighted MRI (DWI) detects change in water diffusion with cellular dysfunction and primarily identifies early ischemic changes in stroke.4 We here report DWI in association with hypoglycemic coma and consider its prognostic importance. A 53-year-old man with insulin-dependent diabetes mellitus and HIV infection was taken to the Hartford Hospital emergency department after being found unresponsive at home. A friend found the patient “sleeping” and gave him his morning insulin dose; when he failed to awaken after several hours, emergency medical services was called. On arrival they found the patient unresponsive with pinpoint pupils, shallow respirations, and hypotension. Blood glucose was 23 mg/dL and the patient was given 1 mg of glucagon and 1.4 mg of naloxone hydrochloride IM without improvement. Medical …

Symmetric pallidal necrosis from a variety of causes is well appreciated pathologically. Corresponding computed tomographic (CT) changes have only infrequently been reported and on no occasion have the lesions been hemorrhagic. We describe the CT correlate of a previous neuropathologic observation of bilateral hemorrhagic infarction of the globus pallidus in association with acute renal failure. Factors predisposing to these changes are considered.

Article abstract—Intravenous edrophonium chloride promptly stopped a sustained high frequency abduction nystagmus, supporting a diagnosis of myasthenia gravis in a patient with hyperthyroidism. Myasthenia gravis should be considered in the differential diagnosis of any acquired, isolated, and sustained abduction nystagmus, and this possibility should be ruled out by intravenous edrophonium chloride.