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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.

Magnetic resonance (MR) is an effective imaging modality in the evaluation of infectious brain disease, yet findings are often nonspecific. The presence of a diagnostic feature can facilitate early treatment, particularly where mortality is high. We highlight MR apparent diffusion coefficient/T2-weighted target sign in the diagnosis of cerebral aspergillosis.

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.

Postoperative visual loss is rare and most often due to posterior ischemic optic neuropathy. We describe optic nerve MR imaging of a 37-year-old man with postoperative visual loss due to posterior ischemic optic neuropathy after complicated aortic aneurysm surgery. MR demonstrated restricted diffusion and focal enhancement of both optic nerves. Combined restricted diffusion and focal enhancement is a unique MR imaging feature with postoperative vision loss.

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.

The vast majority of restricted-diffusion abnormalities result from acute stroke, and as such, the diagnosis may be problematic when this MRI feature results from other causes. Distinct patterns of restricted diffusion seen with various disease conditions can play an important diagnostic role. The association of certain diseases with a given restricted-diffusion pattern allows for a focused assessment to determine a specific etiology.

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.

As acute symmetric lesions of deep gray nuclei are often associated with an impaired level of consciousness and neuroimaging by itself cannot distinguish between etiologies, diagnosis may be problematic. Appreciation of the cause of the various neuroimaging patterns in conjunction with the history, examination and laboratory investigations allows for accurate diagnosis in the vast majority of cases. Given the metabolic vulnerability of deep gray nuclei, other than bi-thalamic infarction, it follows that toxic-metabolic and hypoxic-ischemic events account for the majority of cases. Nevertheless, the differential diagnosis is broad and diverse. We here describe two cases of bilateral pallidal hemorrhage in AIDS-associated toxoplasmosis, and review conditions recently described with acute symmetric deep gray nuclei lesions on neuroimaging.

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.

Magnetic resonance imaging (MRI) findings associated with chronic liver disease are characterized by cerebral atrophy and bilateral, symmetric hyperintensities of the globus pallidus on T1-weighted images without corresponding signal intensities in T2-weighted images. Recently, distinct MRI changes of acute hepatic encephalopathy have been described which may be misinterpreted given their resemblance to hypoxic-ischemic injury imaging changes as well as their limited description in the neurologic literature. We describe 3 cases of acute hyperammonemic encephalopathy primarily characterized by restricted diffusion involving the insular and cingulate cortices and thalamus bilaterally.

Considering computers are more efficient at processing large amounts of information than the human brain, speaks to the need to explore more intelligent computer-assisted diagnostic approaches. Two diagnostic checklist programs, one for single key term entry (NeurologyINDEX), and another, with more advanced algorithms to process multiple key terms and perform additional functions (NeurologicDx) are discussed. Both programs are internet based, access the same database, and are designed to generate diagnostic checklists and disease profiles accessible with hand-held or other computer device. The development of systems that use "smart algorithms" to generate valid diagnostic checklists is the goal.

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.

Background Magnetic resonance (MR) imaging of posterior cerebral artery infarction with hemiparesis (PCAH) is limited to case reports with T2-weighted lesions involving the cerebral peduncle. Objective We sought to extend the MR imaging correlate of PCAH. Methods The case histories and MR/MR angiography findings of 4 patients with PCAH were examined. Results Distinct from previously described MR imaging findings with PCAH, diffusion-weighted imaging and/or FLAIR changes were noted in the thalamogeniculate artery (TGA) territory in one patient; in the distribution of the TGA and lateral posterior choroidal artery (PChA) in two patients; and in the TGA and lateral PChA combined with the peduncular perforating arteries of the cerebral peduncle in one patient. Conclusion Diffusion-weighted imaging changes of infarction in the distribution of the TGA alone or combined with lateral PChA involvement with or without cerebral peduncle infarction correlate with PCAH.

Summary This paper describes a diabetic dialysis patient presenting two episodes of symmetric basal ganglia lesions occurring 18 months apart, and discusses the MR imaging findings and the pathogenesis of this condition.

Catheter angiography is performed to exclude aneurysm as the cause of subarachnoid hemorrhage (SAH). Certain categories of SAH however are for the most part nonaneurysmal and the risk of catheter angiography not justified. Primary convexity SAH may be nonaneurysmal and adequately investigated noninvasively. Determine if primary convexity SAH is nonaneurysmal in origin. Five new cases with primary convexity SAH and seven from the literature are reviewed for etiology, diagnostic studies, and outcome. Diagnostic investigations included catheter angiography in 6 patients, MR in 11 patients, computed tomography (CT) in 10 patients, magnetic resonance angiography/magnetic resonance venography in 7 patients, CT angiography in 1 patient, and outcome of the 12 patients was benign without subsequent hemorrhage. No case of primary convexity SAH was caused by aneurysm and outcome was benign in all patients, suggesting a noninvasive evaluation is adequate to investigate this condition.

To correlate prognosis of hypoxic-ischemic white-matter injury with magnetic resonance imaging (MRI). In a retrospective review at an urban medical center, three adult and three pediatric patients with predominant white-matter involvement caused by hypoxic-ischemic injury were evaluated over a 15-month period. Five patients with MRI-defined hypoxic-ischemic leukoencephalopathy had a favorable outcome, and one with associated diffusion-weighted abnormality of deep gray structures died. The prognosis of hypoxic-ischemic leukoencephalopathy is more favorable than previously reported, and diffusion-weighted imaging abnormality of deep gray structures was associated with a poor outcome.

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.

This study describes a series of cases and reviews the literature on cases of ring lesion on diffusion-weighted imaging to better appreciate the spectrum of disease associated with this neuroimaging finding. We retrospectively reviewed the MR studies of 15 patients with ring pattern lesions on diffusion-weighted imaging from an inpatient Neurology service of a tertiary care center seen over a ten-year period, and reviewed cases in the literature. Thirty-one cases, including 15 new patients, comprise the study group. Immunocompromised patients accounted for 38% of patients with ring lesions on diffusion-weighted imaging with cerebral aspergillosis in five patients, progressive multifocal leukoencephalopathy in three, primary CNS lymphoma in two, cerebral toxoplasmosis in one, and resolving cerebral hematoma in one. In the immunocompetent group demyelinating lesions including multiple sclerosis, acute disseminated encephalomyelitis, Balo's concentric sclerosis and acute necrotizing encephalitis, were seen in 11 patients, vascular etiology in four and neoplastic in three patients, two primary and one metastatic and pyogenic brain abscess in one. Ring lesions on diffusion-weighted imaging are associated with a spectrum of disease not previously considered. Immunocompromised patients accounted for almost one-half while demyelinating conditions in the immunocompetent patients were most common overall.

Isolated acute sphenoid sinusitis is an uncommon sinus infection, frequently misdiagnosed and not usually considered in the differential diagnosis of acute severe headache, with the potential of serious neurologic complications.To describe two patients with acute sphenoid sinusitis who presented with acute onset of severe headache and consider the role of surgical management.Case report.Tertiary care hospital.Patient 1 developed right cavernous sinus thrombosis and permanent visual loss in one eye, requiring sphenoidotomy following failure of medical treatment. Patient 2 experienced failure of the medical treatment. However, sphenoidotomy abated all his symptoms without any neurologic sequelae.It is important to be aware of acute sphenoid sinusitis in the setting of new onset severe headache, when imaging studies are unrevealing for intracranial pathology. Considering the serious consequences of failed medical treatment vis-à-vis the safety and efficacy of sphenoidotomy we propose surgical intervention at the time of diagnosis.

Lymphoproliferative disorders are known to complicate immunosuppressive therapy and two cases of primary lymphoma of CNS (PCNSL) have previously been described in association with mycophenolate mofetil (MMF) treatment. We report the third case of PCNSL in a patient with lupus nephropathy while on MMF treatment. PCNSL may be seen more frequently considering the increased use of MMF in immunosuppressant responsive conditions.

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.

Notably absent from current practice guidelines for common neurologic diseases as stroke and seizure is the revised Centers for Disease Control (CDC) recommendation for human immunodeficiency virus (HIV) testing of all clinical encounters. During a 9-month period 2 patients with treatable stroke mimics related to HIV type 1 infection were misdiagnosed resulting in delay in beginning antiretroviral therapy and increased cost and morbidity. This study was conducted to determine the frequency of HIV-1 screening in our stroke center population and consider the implications of such testing on neurologic disease. We surveyed our stroke center database to determine the frequency of HIV screening in ischemic strokes from January 2005 through May 2011. Of 2806 ischemic strokes, 27 (0.96%) patients were HIV-tested during the 6.5-year study period. We suggest that incorporating the CDC recommendations for HIV screening into neurology practice guidelines can impact diagnosis and treatment of unsuspected HIV-related neurologic disease with reduction in cost of care and morbidity.

The neurologic presentation of limbic encephalitis is variable and when it occurs due to a rare cause the diagnosis may be problematic. We present a case of autoimmune limbic encephalitis due to glutamic acid decarboxylase antibody and consider the magnetic resonance imaging and antineural antibody screening aspects in the diagnosis of this entity.

A rare syndrome of acute symmetrical bilateral basal ganglia lesions in diabetic dialysis patients that manifests clinically with headache, dysarthria, and gait and movement disorder has been described almost exclusively in patients of Asian descent. The pathophysiology of this condition has not been established. Of the 28 cases reported, 3 patients have been from North America. In the context of magnetic resonance imaging showing dramatic resolution of lesions of the basal ganglia, this report describes a fourth case from North America of a 47-year-old Hispanic woman with diabetes on dialysis therapy who presented with headache, unsteady gait, and slurred speech. We also consider presymptomatic metabolic abnormalities in the pathogenesis of this disease.

A 27-year-old woman was transferred to our hospital for further evaluation of progressive gait difficulty, slurred speech, right hand tremor, and temporal lobe lesion. She was in her usual state of good health until 1 year earlier when she developed right hand weakness and tremor and slurred speech. Her symptoms gradually worsened over the next 6 months and significant dysarthria and right hand weakness and intention tremor was noted. Her penmanship was illegible, tandem gait was impaired, and rapid alternating movements with the right hand were slow compared to the left. A dilated left pupil was diagnosed as an Adie tonic pupil. MRI showed a small area of increased signal on fluid-attenuated inversion recovery (FLAIR) sequence in the right temporal lobe. She was readmitted because of falls, progressive cognitive impairment, gait ataxia, dysarthria, and right hand tremor. On gait testing, she could only walk with the assistance of 2 aides. Because of increased size of the right temporal lobe lesion on repeat MRI, she was transferred to our hospital for consideration of brain biopsy.

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 …

Background/purpose Target lesions on diffusion-weighted imaging are uncommon and their significance not well appreciated. To assess the diagnostic value of this neuroimaging finding, a case of cerebral aspergillosis is presented and the literature reviewed. Methods The diffusion-weighted magnetic resonance imaging features of target lesions in a case of cerebral aspergillosis with neuropathologic correlate is presented and 8 other cases manifesting this neuroimaging finding are reviewed for etiology, patient immune status, lesion number, enhancement, and location. Results The etiologies included cerebral aspergillosis, Balo concentric sclerosis, and acute necrotizing encephalopathy. The cerebral aspergillosis cases were immunocompromised with multiple lesions in 4 of 5 patients. The acute necrotizing encephalopathy and Balo concentric sclerosis patients were immunocompetent with bilateral thalamic lesions in the former and multiple random or solitary lesions in the later. Enhancement was seen in 5 patients. Conclusion Target lesions on diffusion-weighted imaging are compelling for a diagnosis of cerebral aspergillosis in immunocompromised patients and for acute necrotizing encephalopathy in immunocompetent patients when lesions are bilateral thalamic and Balo concentric sclerosis when white matter is involved.

To assess the efficacy of a product containing isoflavones and other plant extracts (BIO) on whole menopausal symptomatology and plasma lipids profile.Multicentre, randomized, double blind, placebo controlled clinical investigation on 125 menopausal women randomly assigned to two groups treated for 6 months with placebo or one tablet daily of an herbal product containing 72 mg/dose of isoflavones of different plants origin and other plant extracts (BIO). Primary end-point: Kupperman Menopause Index (KI) variations; secondary end-point: activity on plasma lipids profile and clinical global impression (CGI) on efficacy and tolerability by investigators and patients. The usual parametric test (paired Student t test) was performed to evaluate the significance. In case of non-applicability of parametric tests, the non-parametric Mann-Whitney U test was used. The differences where considered significant at p0.05 level.At the end of treatment in both groups KI showed a significant decrease (p0.001). However, in the BIO group the KI reduction was significantly higher (p=0.0265) than in the placebo group after 4 and 6 months of treatment. In the BIO treated patients the LDL cholesterol showed a borderline but not significant reduction compared to placebo (p=0.0608) and triglyceride (TG) a significant (p=0.0151) decrease compared to placebo. The investigator's and patient's CGI on BIO group where superior as compared to placebo. Clinical tolerability was good in booth groups.On the basis of positive effects on KI and lipids profile as well as of good clinical tolerability, BIO can be considered one of the possible alternative therapy for conventional HRT.

A 48 year old woman, status post renal transplantation six years earlier, died after a two week illness characterised by fever, recurrent seizures, and coma. Widespread abnormalities were seen on neuroimaging. A diagnosis of septic encephalopathy was established on postmortem. We describe the magnetic resonance imaging findings of bilateral basal ganglia, thalamic, cerebellar, brainstem, and cerebral abnormalities in this patient, which correlate with the pathophysiology of septic encephalopathy.

In the clinical setting of ankle edema, headache, proteinuria, and elevated blood pressure, a 33-year-old woman developed a postpartum subarachnoid hemorrhage that was seen on computed tomography and magnetic resonance imaging. Angiography demonstrated diffuse cerebral vasospasm without other underlying pathology. Subarachnoid hemorrhage with vasospasm in pre-eclampsia, not previously documented in the absence of associated systemic or cerebral abnormality, is described.

Background Cerebral venous thrombosis is a rare complication of polycythemia. To our knowledge, epoetin alfa–induced polycythemia has not previously been reported in association with cerebral venous thrombosis. Case Description A 37-year-old patient who was receiving peritoneal dialysis and epoetin alfa (Epogen) therapy presented with a several-day history of worsening headache, and a neuroimaging scan demonstrated thrombosis of the sagittal and transverse sinus. Epoetin alfa therapy, which had been initiated 3 months earlier according to an institutional protocol, was associated with a problematic increase in hematocrit values. Conclusions Headache should raise the suspicion of cerebral venous thrombosis in patients who are being treated with epoetin alfa, particularly in the presence of elevated hematocrit values. Monitoring hematocrit parameters in accordance with "standard guidelines" is recommended.

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.

Multiple simultaneous intracerebral hemorrhages are rare and varied in etiology. In the absence of known risk factors or obvious underlying disease, determining the cause may be problematic. We outline a diagnostic approach to multiple simultaneous intracerebral hemorrhages in the context of three case studies. We conclude that when there are no apparent risk factors, neuroimaging and identification of underlying diseases are central to determining the cause of multiple simultaneous intracerebral hemorrhage.

Lymphomatous meningitis (LM) occurs in about 10% of patients with non-Hodgkins lymphoma (NHL) and usually in the setting of known systemic lymphoma and often in association with progression of the tumor. [1] In about 5% of patients however, LM is the initial manifestation of this lymphoma. [2] Although neuro-ophthalmologic features as papilledema, optic atrophy, ptosis, ophthalmoplegia, visual loss, and pupillary abnormality not uncommonly accompany LM, as an initial event they are rare and usually unilateral and with other disease-related features. [3-6] We describe a patient with non-Hodgkins lymphoma in whom illness began as bilateral ptosis and ophthalmoplegia in the absence of other neurologic signs or evidence of systemic illness. A 54-year-old woman presented with a 3-week history of progressive ptosis and diplopia. She was treated with 30 mg of prednisone for several days by her family physician for presumed myasthenia gravis and because of increasing swallowing and breathing difficulty, admitted to hospital. Her medical history was significant for asthma and a positive PPD 3 months prior, for which INH and vitamin B6 was administered, and an 8-10-pound weight loss over the last 6 months. …

Sudden headache, confusion, and hemiparesis followed within minutes of late-morning sexual intercourse in a 39-year-old man. Imaging studies revealed hemorrhage into a vascular malformation. Sexual intercourse and circadian rhythm independently elevate blood pressure, and their concurrence may predispose to cerebral hemorrhage in the presence of a vascular malformation.