Search

Introduction: The differential diagnosis of Primary Central Nervous System Angiitis (PACNS) is complex and includes several inflammatory and non-inflammatory conditions. Among the first ones, post-infectious CNS vasculitides represent a relevant topic and they are often underdiagnosed., Aims: The main aim of this review is to summarize the clinical and neuroimaging features of post-infectious vasculitides, highlighting the diagnostic clues and the need to carefully consider them in the differential diagnosis of PACNS., Findings: Several infectious agents (viruses, bacteria, fungi and parasites) can be involved in documented post-infectious vasculitides, often with a pathological confirmation. Post-infectious vasculitides involve not only immunocompromised hosts but also immunocompetent people and the diagnosis might be complicated by the lack of close time relationship between infections and neuro-logical symptoms, as in Varicella Zoster Virus (VZV) related vasculopathy in adults. Several complications may occur, ranging from ischemic to hemorrhagic stroke, from arterial to venous thrombosis, from large to small vessel involvement, often simultaneously., Conclusions: Post-infectious vasculitides are caused by a broad spectrum of microorganisms and they should be carefully considered in the differential diagnosis of some neurological pictures and neuroradiologicals findings in immunocompetent adults too., Competing Interests: Declarations. Ethical approval: Not applicable. Competing interests: The authors have no competing interests to declare that are relevant to the content of this article., (© 2024. Fondazione Società Italiana di Neurologia.)

Introduction: Large artery atherosclerosis is a relevant cause of ischemic stroke. Beyond carotid artery stenosis ≥ 50%, causative in etiological classification of stroke, non-stenosing plaques are an increasingly reported cause of stroke with embolic pattern., Methods: We are presenting the case of a 56 years old woman presenting with a first symptomatic multifocal ischemic stroke in the right internal carotid artery (ICA) territory on 2018 and a finding of asymptomatic past vascular injury in the same vascular territory on neuroimaging studies. Extended etiological search, including extra- and intracranial vascular investigations, cardiological studies with prolonged heart rhythm monitoring, screening for acquired and genetic prothrombotic conditions failed to reveal any cause. In 2021, the patient went again for a recurrent symptomatic stroke in right ICA territory and Computed Tomography Angiography (CTA) found a huge floating thrombus on a very small plaque at the right ICA, already known from the previous CTA. Treatment with low-molecular-weight-heparin at anticoagulant dosage was started until documentation of thrombus resolution and finally the patient underwent stenting. The clinical and neuroradiological follow-up until now did not show changes., Discussion: Even very small carotid plaques might be associated with stroke and the putative mechanism of artery-to artery embolism from superimposed thrombus is often hypothesized but seldom imaged. This could lead to a misclassification of stroke etiology and to a non-negligible rate of atherothrombotic embolic stroke of undetermined source (ESUS) with higher risk of recurrence., Conclusions: Atherothrombotic stroke may come from non-stenosing plaques and artery-to artery embolism is a common mechanism., Competing Interests: Declarations. Ethics statement: Not applicable. Disclosure: The authors have no relevant financial or non-financial interests to disclose. Competing interests: The authors have no competing interests to declare that are relevant to the content of this article., (© 2024. Fondazione Società Italiana di Neurologia.)

Introduction: Pregnancy and postpartum are phases in the women's life where the thrombotic risk is increased both on the venous and on the arterial side., Methods: We are presenting the case of a young woman at the third pregnancy, carried out without complications until delivery, whose postpartum was characterized by the occurrence of headache. Neuroimaging studies were performed, firstly brain computed tomography (CT) with CT Angiography and after brain Magnetic Resonance Imaging (MRI) with MR Angiography. The main finding was the simultaneous presence of two cerebrovascular vascular diseases, i.e. cerebral venous thrombosis (CVT) and left carotid dissection, without stroke. The neuroimaging features of both the diseases were analyzed and both CVT and dissection had neuroimaging markers of acute timing. After starting heparin therapy at anticoagulant dose the clinical symptoms disappeared within a few days., Discussion: CVT is a rare event with a peak in the late pregnancy and puerperium, but other arterial cerebrovascular events, as spontaneous dissection, have not an increased incidence in the postpartum. Headache is one of the main symptoms for all these cerebrovascular diseases, but usually stroke is the accompanying event. This is not always true and the presented case illustrates this unexpected occurrence., Conclusions: Headache is a nonspecific and highly prevalent symptom and in the postpartum period it could raise the suspicion of CVT. Sometimes several different causes are found for the same symptom and concurrent acute cerebrovascular diseases might be considered. Neuroimaging investigations may help for diagnosis and timing concurrent thrombotic diseases, particularly DWI-MRI., Competing Interests: Declarations. Competing interests: The authors have no competing interests to declare that are relevant to the content of this article. Ethics statement: Not applicable. The authors have no relevant financial or non-financial interests to disclose., (© 2024. Fondazione Società Italiana di Neurologia.)

Introduction: As detailed in the first part of this review, post-infectious vasculitides are a wide and complex category, including several clinical, microbiological and neuroradiological patterns. In order to raise the suspicion for diagnosis, the knowledge of two different neuroradiological issues is needed, i.e. the knowledge of neuroimaging pattern of infections and the one of neuroimaging pattern of vasculitis., Aims: The main aim of this second part is to summarize the neuroradiological features of post-infectious vasculitides focusing on imaging of vessels and consequences of vessel involvement, continuing the discussion proposed in the first part about neuroimaging of infections. In some cases, the two neuroradiological issues are both simultaneously present in the same patient, but in other cases only the second one can be depicted due to the latency between infection and vasculitis., Findings: Beyond general features of cerebral vascular involvement in post-infectious vasculitides, some well-studied and homogenous diseases, as treponemal vasculitis, Varicella Zoster Virus (VZV) arteriopathy, neuroborreliosis, SARS-CoV2-related endotheliopathy are described in detail, being not rare and sometimes underdiagnosed. The main clinical and neuroradiological features of these conditions are deeply addressed, providing diagnostic clues and pictorial examples., Conclusions: Although some general features are common in clinical presentation and neuroimaging of post-infectious vasculitides, there are few neuroimaging clues pointing out a specific microbial agent as causative. The main step is to raise the diagnostic suspicion in order to start the dedicated investigation pathway and treatment., Competing Interests: Declarations. Ethical approval: Not applicable. Competing interests: The authors have no competing interests to declare that are relevant to the content of this article., (© 2024. Fondazione Società Italiana di Neurologia.)

Background: Intravenous thrombolysis (IVT) and/or endovascular therapy (EVT) are currently considered best practices in acute stroke patients. Data regarding the efficacy and safety of reperfusion therapies in patients with atrial fibrillation (AF) are conflicting as regards haemorrhagic transformation, mortality, and functional outcome. This study sought to investigate for any differences, in terms of safety and effectiveness, between AF patients with acute ischaemic stroke (AIS) treated and untreated with reperfusion therapies., Methods: Data from two multicenter cohort studies (RAF and RAF-NOACs) on consecutive patients with AF and AIS were analyzed to compare patients treated and not treated with reperfusion therapies (IVT and/or EVT). Multivariable logistic regression analysis was performed to identify independent predictors for outcome events: 90-day good functional outcome and mortality. A propensity score matching (PSM) analysis compared treated and untreated patients., Results: Overall, 441 (25.4%) were included in the reperfusion-treated group and 1,295 (74.6%) in the untreated group. The multivariable model suggested that reperfusion therapies were significantly associated with good functional outcome. Rates of mortality and disability were higher in patients not treated, especially in the case of higher NIHSS scores. In the PSM comparison, 173/250 patients (69.2%) who had received reperfusion therapies had good functional outcome at 90 days, compared to 146/250 (58.4%) untreated patients (p = 0.009, OR: 1.60, 95% CI:1.11-2.31)., Conclusions: Patients with AF and AIS treated with reperfusion therapies had a significantly higher rate of good functional outcome and lower rates of mortality compared to those patients with AF and AIS who had undergone conservative treatment., (© 2024. The Author(s).)

Cerebellar mutism syndrome (CMS) is a frequent complication of surgical intervention on posterior fossa in children. It has been only occasionally reported in adults and its features have not been fully characterized. In children and in young adults, medulloblastoma is the main reason for neurosurgery. A single case of postsurgical CMS is presented in an adult patient with a cerebellar hemorrhage and a systematic review of the published individual cases of CMS in adults was done. Literature review of individual cases found 30 patients, 18/30 (60%) males, from 20 to 71 years at diagnosis. All but one case was post-surgical, but in one of the post-surgical cases iatrogenic basilar artery occlusion was proposed as cause for CMS. The causes were: primary tumors of the posterior fossa in 16/22 (72.7%) metastasis in 3/30 (10%), ischemia in 3/30 (10%) cerebellar hemorrhage in 3/30 (10%), and benign lesions in 2/30 (6.7%) patients. 8/30 patients (26.7%) were reported as having persistent or incomplete resolution of CMS within 12 months. CMS is a rare occurrence in adults and spontaneous cerebellar hemorrhage has been reported in 3/30 (10%) adult patients. The generally accepted hypothesis is that CMS results from bilateral damage to the dentate nucleus or the dentate-rubro-thalamic tract, leading to cerebro-cerebellar diaschisis. Several causes might contribute in adults. The prognosis of CMS is slightly worse in adults than in children, but two thirds of cases show a complete resolution within 6 months., (© 2024. Fondazione Società Italiana di Neurologia.)

Introduction: Calcified arterial cerebral embolism is a rare occurrence among large and medium vessel occlusions causing ischemic stroke and its diagnosis and treatment is a challenge. The sources of calcified embolism might be a calcific atheroma from the aortic arch and carotid artery, but also heart valve disease has been reported in the literature. Calcified embolism is frequently simultaneous on multiple vascular territories. The prognosis of patients is usually poor, including patients treated by using endovascular thrombectomy (EVT) and this diagnosis could be easily missed in the acute phase. In addition, the optimal secondary prevention has not been yet fully stated., Methods: We are presenting two cases of acute stroke due to calcified embolism in the middle cerebral artery (MCA) coming from a complicated carotid atheroma, non-stenosing in the first case (a 49 years old man) and stenosing in the second case (a 71 years old man) without clinical indications to intravenous thrombolysis and/or EVT, extensively investigated in the acute phase and followed-up for over 12 months with a favorable clinical course and the persisting steno-occlusion in the involved MCA. In both cases, antiplatelet treatment and targeting of vascular risk factors were done without recurrences in the follow-up period., Discussion: Cerebral calcified embolism has been reported in 5.9% of cases of acute ischemic stroke in a single center series and only in 1.2% of a large retrospective cohort of EVT-treated patients. In both series the prognosis was poor and only one third of EVT-treated patients had functional independence at 3-months follow-up. The natural history of these subtype of ischemic stroke is relatively poorly understood and both etiological diagnosis and treatment have not yet defined. It is possible that some cases might be underdiagnosed and underreported., Conclusions: Calcified cerebral embolism is a rare cause of stroke, but it is largely underreported and both acute phase and secondary preventive treatment have to be defined., (© 2024. Fondazione Società Italiana di Neurologia.)

Introduction: Posterior reversible encephalopathy syndrome (PRES) is a rare and complex disorder with variable clinical presentation and a typical magnetic resonance imaging (MRI) pattern of vasogenic edema with typical and atypical locations. It is often triggered by other diseases and drugs and the most prototypical association is with persistently elevated arterial pressure values. Among the potential cerebrovascular complications, intracranial bleeding has been described, but ischemic stroke is uncommonly reported., Methods: We are presenting a case of a male patient with prolonged and sustained arterial hypertension acutely presenting with lacunar ischemic stroke involving the right corona radiata and composite MRI findings with the association of chronic small vessel disease (SVD) markers, acute symptomatic lacunar stroke, and atypical, central variant, posterior fossa dominant PRES. In the MRI follow-up, the white matter hyperintensities in T2-fluid attenuated inversion recovery (FLAIR sequences) due to PRES., Discussion: The pathophysiology of PRES is not yet fully known, but the association with markedly increased values of arterial pressure is typical. In this context, ischemic stroke has not been considered in the clinical and neuroradiological manifestations of PRES and it has been only occasionally reported in the literature. In this case, the main hypothesis is that sustained hypertension may have triggered both manifestations, PRES, and ischemic stroke and the last one allowed to diagnose the first one., Conclusions: Atypical variants of PRES are not so rare and it may also occur in typical triggering situations. The association with ischemic stroke is even rarer and it may add some clues to the pathomechanisms of PRES., (© 2023. Fondazione Società Italiana di Neurologia.)

Introduction: Secondary neurodegeneration after stroke is a complex phenomenon affecting remote and synaptically linked cerebral areas. The involvement of the substantia nigra in this process has been rarely described in infarcts involving the striatum., Methods: We are presenting a case of ischemic stroke involving the right striatum due to atrial fibrillation and associated in a few days with the neuroimaging finding of hyperintensity of the ipsilateral substantia nigra and striatonigral tract on T2-fluid attenuated inversion recovery and diffusion-weighted imaging sequences of brain magnetic resonance imaging. This finding was not related to clinical manifestations and substantially disappeared within 3 months from stroke onset., Discussion: The pathophysiology of secondary degeneration of the substantia nigra is poorly understood and it relies on animal models and autoptic studies. The main putative mechanism is not ischemic but excitotoxic with a different role of the internal and external globus pallidus and a different effect on the pars compacta and pars reticularis of the substantia nigra. In animal models, inflammatory mechanisms seem play a role only in the late phase. The main studies on humans were presented in detail., Conclusions: A better understanding of the secondary degeneration of the substantia nigra has the potentiality to offer a chance for neuroprotection in acute stroke, but further studies are needed., (© 2023. Fondazione Società Italiana di Neurologia.)

Background: There is no evidence in the current literature about the best treatment option in sacral fracture with or without neurological impairment., Materials and Methods: The Italian Pelvic Trauma Association (A.I.P.) decided to organize a consensus to define the best treatment for traumatic and insufficiency fractures according to neurological impairment., Results: Consensus has been reached for the following statements: When complete neurological examination cannot be performed, pelvic X-rays, CT scan, hip and pelvis MRI, lumbosacral MRI, and lower extremities evoked potentials are useful. Lower extremities EMG should not be used in an acute setting; a patient with cauda equina syndrome associated with a sacral fracture represents an absolute indication for sacral reduction and the correct timing for reduction is "as early as possible". An isolated and incomplete radicular neurological deficit of the lower limbs does not represent an indication for laminectomy after reduction in the case of a displaced sacral fracture in a high-energy trauma, while a worsening and progressive radicular neurological deficit represents an indication. In the case of a displaced sacral fracture and neurological deficit with imaging showing no evidence of nerve root compression, a laminectomy after reduction is not indicated. In a patient who was not initially investigated from a neurological point of view, if a clinical investigation conducted after 72 h identifies a neurological deficit in the presence of a displaced sacral fracture with nerve compression on MRI, a laminectomy after reduction may be indicated. In the case of an indication to perform a sacral decompression, a first attempt with closed reduction through external manoeuvres is not mandatory. Transcondylar traction does not represent a valid method for performing a closed decompression. Following a sacral decompression, a sacral fixation (e.g. sacroiliac screw, triangular osteosynthesis, lumbopelvic fixation) should be performed. An isolated and complete radicular neurological deficit of the lower limbs represents an indication for laminectomy after reduction in the case of a displaced sacral fracture in a low-energy trauma associated with imaging suggestive of root compression. An isolated and incomplete radicular neurological deficit of the lower limbs does not represent an absolute indication. A worsening and progressive radicular neurological deficit of the lower limbs represents an indication for laminectomy after reduction in the case of a displaced sacral fracture in a low-energy trauma associated with imaging suggestive of root compression. In the case of a displaced sacral fracture and neurological deficit in a low-energy trauma, sacral decompression followed by surgical fixation is indicated., Conclusions: This consensus collects expert opinion about this topic and may guide the surgeon in choosing the best treatment for these patients., Level of Evidence: IV., Trial Registration: not applicable (consensus paper)., (© 2023. Societa Italiana di Ortopedia e Traumatologia (Italian Society of Orthopaedics and Traumatology SIOT).)

Background: Posterior wall fracture is the most common acetabular fracture. Comminuted fractures with an impacted segment represent a subtype of this injury. The subchondral bone of the articular zone is compressed and causes a bone defect. The impacted fragment should be isolated, mobilized, and then reduced. A bone graft should be used to fill the gap. The other fragments are fixed following the reduction of the impacted segment., Materials and Methods: Ten patients with comminuted fractures and impacted segments with bone defects were enrolled in our study, from January 2010 to July 2012. Autogenous bone grafts from the greater trochanter were used to fill the gap in all patients. The reduction was achieved through the insertion of the graft above the impacted fracture, and plate fixation was performed subsequently. Merle d'Aubigne and Postel scoring, modified by Matta, was applied to evaluate the patients during follow-up. The mean follow-up was 12 months., Results: The clinical results included one "excellent", four "very good", four "good" and one "poor". Pain in the zone of graft harvesting was not detected in any patient. Femoral head necrosis was observed in one case. No other severe complications were detected., Conclusions: Using an autogenous bone graft to fill the bone defect supplies excellent mechanical stability without any severe complications at the donor site. This surgical technique seems to be effective and safe in treating a comminuted fracture of the posterior wall in association with an impacted segment., Level of Evidence: Level IV.

Surgical treatment of a unusual acetabular fracture is described. This fracture was characterized by impaction and breaking down of the posterior articular surface and comminution of lamina quadrilatera lower portion, without cortical fracture of both columns. The fracture was treated surgically through the Kocher-Langenbeck approach. A small hole was created in the acetabulum posterior wall, the impacted fragment was reduced, and the bone defect was filled with autologous bone from the greater trochanter. A plate was shaped in order to fix both bone graft and fractured fragment.