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Intraparenchymal hemorrhage (IPH) is a debilitating and highly morbid type of stroke with limited effective treatment modalities. Minimally invasive evacuation with tissue plasminogen activator (rt-PA) has demonstrated promise for mortality/functional improvements with adequate clot volume reduction. In this study, we report 2 cases of continuous rt-PA infusion using a closed circuit, dual lumen catheter, and irrigation system (IRRAflow) for IPH treatment.A 55-year-old man was admitted for acute onset left hemiparesis; he was found to have right basal ganglia IPH. He was treated with continuous rt-PA irrigation using the IRRAflow device, at a rate of 30 mL/h for 119 hours, with a total volume reduction of 87.8 mL and post-treatment volume of 1.2 mL. At 3-month follow-up, he exhibited a modified Rankin score of 4 and improved hemiparesis. A 39-year-old woman was admitted for acute onset left facial droop, left hemianopsia, and left hemiparesis; she was diagnosed with a right basal ganglia IPH. She was treated with drainage and continuous rt-PA irrigation at 30 mL/h for 24 hours, with a total hematoma volume reduction of 41 mL and with a final post-treatment volume of 9.1 mL. At 3-month follow-up, she exhibited a modified Rankin score of 3 with some improvement in left hemiparesis.Continuous rt-PA infusion using a minimally invasive catheter with saline irrigation was feasible and resulted in successful volume reduction in 2 patients with IPH. This technique is similar to the Minimally Invasive Surgery Plus rt-PA for Intracerebral Hemorrhage Evacuation (MISTIE) approach but offers the potential advantages of less breaks in the sterile circuit, continuous intracranial pressure monitoring, and may provide more efficient clot lysis compared with intermittent bolusing.

Introduction Wake-up strokes are challenging to manage due to unknown time of onset. Recently, the wake-up trial demonstrated that recombinant tissue plasminogen activator (rtPA) could be administered based on the magnetic resonance imaging (MRI)- diffusion weighted imaging/fluid attenuated inversion recovery mismatch. Many still doubt the safety results due to the higher rate of hemorrhagic conversion reported. Although it was statistically insignificant, the study was terminated early. Furthermore, Corona virus disease-19 is associated with coagulopathy and a higher risk of hemorrhagic conversion. Case report A 46-year-old fully functioning male presented with a wake-up right hemiparesis, right facial droop, and expressive aphasia. His National Institute of Health Stroke Scale was 4 upon arrival. Last known well state was >4.5 hours. He tested positive for SARS-CoV-2 viral infection. He had left distal-M2 occlusion. He was deemed not a candidate for rtPA. Hyperacute-MRI protocol showed diffusion weighted imaging/fluid attenuated inversion recovery mismatch. The patient received rtPA at 6.5 hours from the last knwn well state. Follow-up MRI-susceptibility weighted imaging revealed fragmented clot. The stroke burden was less than that shown on the initial computed tomography-perfusion scans implying saved penumbra. There was no hemorrhagic conversion despite low fibrinogen levels. Conclusion The hyperacute-MRI protocol for wake-up COVID-19 associated strokes might be a safe option.

Background: Psoriasis is a chronic inflammatory dermatological disease with a strong genetic predisposition and autoimmune pathogenic traits. The hallmark of psoriasis is sustained inflammation that leads to uncontrolled keratinocyte proliferation and dysfunctional differentiation. Objective: The aim of this study was to evaluate serum level of paraoxonase-1 in psoriasis patients compared to control group. Patients and methods: This research included 50 psoriasis patients and 40 healthy controls that were comparable in age and sex to the cases category. They were chosen at random from the Outpatient Clinic of Dermatology Department, Mansoura University Hospitals. Results: Psoriasis group showed significantly lower level of paraoxonase-1 when compared to control group (median=35.6 versus 54.5; p < 0.001). Additionally, median paraoxonase-1 level decreased gradually with increased psoriasis grades (p < 0.001). No significant associations were found regarding paraoxonase-1 level according to gender, smoking, and FH in psoriasis group (p > 0.05 for each). Paraoxonase-1 level showed significant negative correlation with PASI score (p < 0.001), but not with age, onset, or duration (p > 0.05 for each). Lower paraoxonase-1 level was considered as independent predictor of psoriasis development. Lower paraoxonase-1 level was considered as independent predictor of psoriasis severity (p < 0.001). Conclusion: Paraoxonase-1 level in psoriasis patients had substantially lower levels than healthy controls. Paraoxonase1 level showed significant negative correlations with PASI score. Lower baseline paraoxonase-1 level was suggested to be independent risk predictor for psoriasis occurrence and severity.

Background Hyperbaric oxygen therapy (HBOT) for the treatment of acute stroke has been under the radar for a long time. Previous studies have not been able to prove efficacy. Several factors might have contributed to such inconsistent results. The timing of delivering the hyperbaric oxygen in relation to the stage of stroke evolution may be an important factor. This was not taken into account in the previous studies as there was no feasible and standardized method to assess the penumbra in the acute phase. Now with the perfusion scan appearing as a key player in the acute stroke management, precise stroke patient selection for hyperbaric oxygen therapy deserves a second chance similar to mechanical thrombectomy. Case presentation A 62-year-old female patient who presented with acute large vessel stroke was not eligible for chemical or mechanical thrombectomy. There was a large penumbra on imaging. She got treated with several sessions of hyperbaric oxygen over a 2-week period immediately after stroke. The patient showed significant improvement on the follow-up perfusion imaging as well as some clinical improvement. The more impressive radiological improvement was probably due to the presence of relatively large core infarction at baseline affecting functional brain areas. The patient continued to improve clinically on her 6-month follow up visit. Conclusion Our case demonstrates immediate stroke-related penumbra improvement associated with HBOT. Based on that, we anticipate a potential role for HBOT in acute stroke management considering precise patient selection. Future randomized controlled trials are needed and should take that in consideration.

Longitudinally extensive transverse myelitis (TM) or TM with inconclusive CSF findings should raise concern for prion disease (also known as Creutzfeldt-Jacob disease [CJD]) especially in the setting of associated cognitive impairment.

Background and Purpose The computed tomography angiographic (CTA) spot sign has been shown to predict hematoma expansion in patients with intracranial hemorrhage (ICH), but the significance of the spot sign density (SSD) and the spot sign ratio (SSR) has not yet been explored. Methods Using the institutional Neurocritical care and Stroke registry, we retrospectively reviewed patients with ICH from January-2013 to June-2017. We selected patients who had baseline CT-head (CTH), CTA with positive-spot sign within 6 hours of last known well and at least one follow-up CTH within 24 hours. Baseline demographics and variables known to affect hematoma-volume were collected. Hematoma-volumes and SSR were calculated using computer-assisted 3D-volumetric measurement and the average of the surrounding hematoma density divided by the SSD, respectively. The 2-sample t test and the area-under-the-curve (receiver operating characteristic) were used to detect the association between hematoma expansion and outcome at discharge. Results A total of 320 patients were reviewed; 22 met the inclusion criteria. Significant hematoma expansion (volume expansion ≥12.5 cc or ≥33% compared to baseline) was noted in 14 (64%) subjects. SSD was significantly higher in subjects with hematoma expansion (216 ± 66) than those without (155 ± 52, P = .036). With a cut-off SSD of ≥150 HU, we had sensitivity of 86% and specificity of 75%. For SSR, lower ratios suggested a trend toward hematoma expansion, although it was not statistically significant (P = .12). There was no significant correlation between SSD or SSR and modified ranking scale at discharge and after 3-6 months. Conclusion SSD might be a good predictor of hematoma growth. Although SSR showed a trend toward expansion, results were not statistically significant.

Background: Respiratory centers are known to be present in the central medulla oblongata and pons. There are multiple complex respiratory networks involving these centers. The midbrain periaqueductal grey is believed to act as a regulator of the respiratory function. The effect of brain-stem strokes on respiration remains understudied. There is a lack of clear understanding of the anatomical influence of such strokes on respiration. We attempted to identify brain-stem locations with the highest liability for respiratory failure in case of stroke. Methods: We included all ischemic and hemorrhagic brain-stem strokes from our stroke-registry between 2016 and 2018 then performed univariate/multivariate regression-analyses on variables that might predict respiratory failure and the need for intubation. The brain stem was divided into nine locations (right lateral, central, left lateral in each of the midbrain, pons, and medulla oblongata). Results: Out of 128 brain-stem strokes of different sizes and etiologies, central midbrain strokes were the only significant and independent affected location associated with respiratory failure and endotracheal intubation (coefficient= 0.1256, 95%-CI= 0.0175, 0.2338, p= 0.023). R-squared was equal to 15% when only central midbrain strokes stayed in the model. Conclusions: While one might assume that central medullary and pontine strokes have the most impact on respiration; our results show that central midbrain is the most impactful, accounting for about 15% of respiratory instability associated with brain-stem strokes. This can be explained by the adaptive nature of respiratory circuits within the medulla and pons. Central periaqueductal grey within the midbrain controls the rate and depth of respiration and might not have the same flexibility present elsewhere.

Introduction The vocal cord is innervated by the recurrent laryngeal nerve and the superior laryngeal nerve, which are branches of the vagus nerve. The nucleus ambiguous is a motor nucleus of the vagus nerve and it is located in the medulla. It receives supratentorial upper motor regulatory fibers. Commonly, this regulation is bilaterally represented in the brain. Less commonly, it is contralaterally represented. This case describes a rare presentation. Case presentation We present a female patient in her early sixties with a past medical history significant for hypertension who presented with acute right-sided weakness and expressive aphasia (National Institutes of Health Stroke Scale = 20). Computed tomography (CT)-head was unremarkable but she was outside the window for chemical thrombolytic therapy. CT-angiogram revealed occlusion of the left extracranial and intracranial internal carotid artery and, thus, she was deemed not a candidate for mechanical thrombectomy. CT-perfusion scans (Rapid software) showed a large penumbra within the respective vascular territory affected including the operculum and the insula. The core infarction was relatively small and located in the left basal ganglia. After inducing therapeutic hypertension, the patient's aphasia improved. Surprisingly, this unmasked a moderate to severe hypophonic voice. The patient underwent flexible fiberoptic laryngoscopy which showed a paralyzed left vocal cord but without signs of inflammation. Conclusion Our case is a rare case of transient ipsilateral vocal cord paralysis associated with anterior unilateral cerebral ischemia. The paralysis resolved with improvement of the cerebral ischemic penumbra.

Introduction: Presence of functional leptomeningeal collaterals has been found to be one of the key determinants of good outcomes. We evaluated the effects of certain environmental and physical factors in cerebral collateral circulation. Methods: After IRB approval, data was collected from prospective institutional Neurocritical Care and Stroke Registry. Stroke patients presenting with acute anterior circulation large vessel occlusion between May 2013 and August 2018 were included. Collaterals were graded based on CT-Angiogram and CT-Perfusion images obtained on presentation, by a blinded Neuroradiologist as good (grade 3-4) and poor (grades 0-2). Ohio air pollution data (2013-2018) were obtained from the US EPA and summarized as a single mean concentration by monitor. Strokes were geocoded and linked with the closest monitor. Odds of good (vs. poor) collateral grade were compared using BMI (linear), smoking status, antiplatelet medication use, and mean PM 2.5 concentration (cubic). Sensitivity analyses assessed additional adjustment by sex and change in NIHSS (admission to discharge). Results: A total of 73 strokes were analyzed with 48% male, mean BMI of 30.4 (SD=7.2), and 22% with good collateral grade. For each kg/m 2 greater BMI, the odds of having good collaterals (vs. poor) were 11% higher (OR: 1.11; 95%CI:1.01-1.22; p =0.029). Higher PM 2.5 concentrations were suggestive of lower odds of good collaterals ( p =0.124). Antiplatelet medication use (OR: 2.10; 95%CI:0.59-7.45) and smoking status (OR: 1.35; 95%CI:0.73-13.9) were not associated with the odds of having good collateral grade. After controlling for change in NIHSS and sex, higher BMI remained associated with good collateral grade (fig.1). Conclusions: Higher BMI was independently associated with higher odds of good collateral grade; this association needs to be explored in larger population taking other factors like age and medical comorbidities into account.

The presence of the spot sign on computed tomography angiogram (CTA) is considered a sign of active bleeding, and studies have shown it can predict hematoma expansion in intraparenchymal hemorrhage (IPH). The spot sign in intraventricular hemorrhage (IVH) has not been explored yet. The purpose of this study is to estimate the prevalence of the intraventricular-spot sign, and its prediction of hematoma expansion and clinical outcomes. We retrieved data of hemorrhagic stroke patients seen at our medical center from January 2013 to January 2018. A total of 321 subjects were filtered for the prevalence analysis (PA). We further excluded 114 subjects without a follow-up CT-head for the hematoma expansion analysis (HEA). Patients were grouped based on the location of hemorrhage into three groups: isolated IPH with the spot sign always in IPH (i-IPH), isolated IVH with the spot sign always in IVH (i-IVH), and combined IPH and IVH which would be further sub-grouped according to the location of the spot sign: in IPH only (IPH+/IVH) and in IVH only (IPH/IVH+). The prevalence, demographics, and incidence of hematoma expansion were compared between the groups using Pearson’s chi-square test and Student’s t test. The prevalence of the spot sign was 8, 20, 17, 5% in (i-IPH), (i-IVH), (IPH+/IVH), and (IPH/IVH+) groups, respectively. The rate of hematoma expansion were (42 vs. 13%), (33 vs. 31%), (80 vs. 22%), and (25 vs. 22%) in spot sign positive vs. negative subjects in each group, respectively (p values = 0.023, = 1

Background Cerebellopontine angle represents a complex anatomical area of the brain. A cerebellopontine angle lesion could be a vestibular schwannoma, meningioma, epidermoid cyst, or less likely, arachnoid cyst, metastasis, lower cranial nerves schwannoma, lipoma, hemangioma, paraganglioma, or vertebra-basilar dolichoectasia. Primary meningeal melanocytoma is a rare neoplasm, especially when it occurs at the cerebellopontine angle. Nevus of Ota (aka oculodermal melanocytosis) is a hyperpigmentation along the distribution of the ophthalmic and maxillary branches of trigeminal nerve; it occurs due to entrapment of melanocytes at the upper third of the dermis. It may not present at birth and may show up at puberty. Case description We describe a case of primary meningeal melanocytoma of the cerebellopontine angle associated with nevus of Ota in a 46-year-old male patient presented with 7-day history of left arm weakness and vertigo. Computed tomography and MRI showed right-sided cerebellopontine angle mass, which was resected. Histopathology confirmed the meningeal melanocytic lesion and revealed its nature. Conclusion Primary meningeal melanocytoma of the brain is a rare but benign tumor; the association between meningeal melanocytoma and nevus of Ota is also rare and possibly explained by their common embryonic origin from neural crest cells. There are six cases reported so far in literature including our case for meningeal melanocytoma associated with nevus of Ota.

Uncertainty regarding reperfusion of mildly-symptomatic (minor) large vessel occlusion (LVO)-strokes exists. Recently, benefits from reperfusion were suggested. However, there is still no strong data to support this. Furthermore, a proportion of those patients don't improve even after non-hemorrhagic reperfusion. Our study evaluated whether or not non-perfusion factors account for such persistent deconditioning.Patients with identified minor LVO-strokes (NIHSS ≤ 8) from our stroke alert registry between January-2016 and May-2018 were included. Variables/ predictors of outcome were tested using univariate/multivariate logistic and linear regression analyses. Three month-modified ranking scale (mRS) was used to differentiate between favorable (mRS = 0-2) and unfavorable outcomes (mRS = 3-6).Eighty-one patients were included. Significant differences between the two outcome groups regarding admission-NIHSS and discharge-NIHSS existed (OR = 0.47, 0.49 / p = 0.0005,0.0001 respectively).The two groups had matching perfusion measures. In the poor outcome group, discharge-NIHSS was unchanged from the admission-NIHSS while in the good outcome group, discharge-NIHSS significantly improved.Admission and discharge NIHSS are independent predictors of outcome in patients with minor-LVO strokes. Unchanged discharge-NIHSS predicts worse outcomes while improved discharge-NIHSS predicts good outcomes. Unchanged NIHSS in the poor outcome group was independent of the perfusion parameters. In literature, complement activation and pro-inflammatory responses to ischemia might account for the progression of stroke symptoms in major-strokes. Our study concludes similar phenomena might be present in minor-strokes. Therefore, discharge-NIHSS may be useful as a clinical marker for future therapies.