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A 52-year-old woman with cystic fibrosis presented to the emergency department with expressive aphasia and right-sided hemiparesis. CT scan of the brain revealed a left middle cerebral artery territory infarct. A diagnosis of cerebral paradoxical embolisation associated with patent foramen ovale and a history of deep venous thrombosis was made. The patient underwent endovascular thrombectomy and percutaneous closure of patent foramen ovale. Current literature, including five published case reports, pertaining to the subject is discussed. The unique aspects of the case are highlighted, including the particular risk of cerebral paradoxical embolisation in patients with cystic fibrosis. The result of this case report, in context to previously reported literature, suggests that clinicians should be aware of paradoxical embolisation in patients with cystic fibrosis via an intracardiac shunt, particularly with implanted vascular access devices and a history of deep venous thrombosis.

Phlegmasia cerulea dolens is a rare presentation of deep venous thrombus treated with catheter directed thrombolysis and pharmacomechanical thrombectomy. This is the case of a 78-year-old woman who underwent catheter directed thrombolysis to treat phlegmasia cerulea dolens and subsequently developed left-sided hemiplegia and expressive aphasia in the setting of an international normalized ratio of 2.0. Further imaging revealed a lacunar infarct in the right thalamus with a middle cerebral artery distribution. Further workup revealed a patent foramen ovale. We highlight the unexpected enigmatic consequence from multimodal endovascular intervention, the consequence of long-term inferior vena cava filters.

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.

Intravascular papillary endothelial hyperplasia (IPEH), commonly known as Masson’s tumor, is a benign lesion that manifests as an excessive proliferation of endothelial cells within a vessel wall. IPEH is extremely rare in the brain, with only 36 intracranial cases previously described in the literature. It is commonly mistaken for more malignant pathologies, such as angiosarcoma. Careful histopathological examination is required for diagnosis, as no clinical or radiographic features are characteristic of this lesion. In this first published case of intracranial IPEH presenting during pregnancy, the authors describe a 32-year-old female with a left frontal intraparenchymal hemorrhage resulting in complete expressive aphasia at 28 weeks 6 days’ gestation. An MRI scan obtained at a local hospital demonstrated an area of enhancement within the hemorrhage. The patient underwent a left frontoparietal craniotomy for hematoma evacuation and gross-total resection (GTR) of an underlying hemorrhagic mass at 29 weeks’ gestation. This case illustrates the importance of multidisciplinary patient care and the feasibility of intervention in the early third trimester with subsequent term delivery. While GTR of IPEH is typically curative, the decision to proceed with surgical treatment of any intracranial lesion in pregnancy must balance maternal stability, gestational age, and suspected pathology.

An 11-year-old girl with no relevant medical history experienced acute-onset confusion and speech arrest without loss of consciousness, eye deviation, tonic stiffening, or convulsion. At an outside emergency department, her examination included expressive aphasia, right lower facial droop, and right-sided hemiparesis. Noncontrast head CT was negative for acute intracranial pathology, CT angiogram showed patent vasculature, and CT perfusion showed no areas of perfusion mismatch. The patient was transferred to our institution for further management.

Although spirituality has been discussed extensively in the healthcare literature in general in the last twenty years, there is a paucity of speech and language therapy literature related to the subject. Spiritual concerns may be brought to the fore and need to be expressed after serious illness. However, following stroke, some patients may present with difficulties in their communication, such as aphasia. This research asks the following research question: what is it like to express your spirituality when you have aphasia?\ud \ud Eight people with aphasia were interviewed about their spirituality using a phenomenological approach. The interviews were transcribed and analyzed using a flexible analytic approach, and themes common to several participants were identified.\ud \ud Participants were able to express ideas of spirituality and life-meaning using a variety of communication methods. Speech and language therapists need to be mindful of their patients’ spiritual concerns if therapy is not to become superficial.

Background/Objective Delirium is a common complication in critically ill patients with a negative impact on hospital length of stay, morbidity, and mortality. Little is known on how neurological deficits affect the outcome of commonly used delirium screening tools such as the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) in neurocritical care patients. Methods Over a period of 1 month, all patients admitted to a neurocritical care and stroke unit at a single academic center were prospectively screened for delirium using both CAM-ICU and ICDSC. Tool-based delirium screening was compared with delirium evaluation by the treating clinical team. Additionally, ICD-10 delirium criteria were assessed. Results One hundred twenty-three patients with a total of 644 daily screenings were included. Twenty-three patients (18.7%) were diagnosed with delirium according to the clinical evaluation. Delirium incidence amounted to 23.6% (CAM-ICU) and 26.8% (ICDSC). Sensitivity and specificity of both screening tools were 66.9% and 93.3% for CAM-ICU and 69.9% and 93.9% for ICDSC, respectively. Patients identified with delirium by either CAM-ICU or ICDSC presented a higher proportion of neurological deficits such as impaired consciousness, expressive aphasia, impaired language comprehension, and hemineglect. Subsequently, generalized estimating equations identified a significant association between impaired consciousness (as indexed by Richmond Agitation and Sedation Scale) and a positive delirium assessment with both CAM-ICU and ICDSC, while impaired language comprehension and hemineglect were only associated with a positive CAM-ICU result. Conclusions A positive delirium screening with both CAM-ICU and ICDSC in neurocritical care and stroke unit patients was found to be significantly associated with the presence of neurological deficits. These findings underline the need for a more specific delirium screening tool in neurocritical care patients.

Background Chronic subdural hematoma (cSDH) is an intracranial pathology most commonly affecting elderly patients. Patients may present with worsening headache, seizures, weakness, balance and gait problems, and memory deficits. Even in patients undergoing hematoma evacuation, there is a substantial risk for recurrence. The authors present the first use of an irrigating external ventricular drain in the United States in the perioperative management of a patient with cSDH treated with craniotomy (IRRAS, Stockholm, Sweden). Case Description An 82-year-old male presented with right-sided weakness, confusion, and right-sided neglect with expressive aphasia. He was found to have a large 2.5-cm cSDH with a 9-mm left-to-right midline shift. The patient was treated with a minicraniotomy to evacuate the hematoma and placement of an irrigating drain in the subdural space. The patient was discharged home on postoperative day 3 without complication. He was at neurologic baseline 2 weeks later on follow-up. Conclusions The use of an irrigating drain for perioperative management of cSDH is a novel means to prevent recurrence and warrants further exploration.

Background Intracerebral hemorrhage (ICH) is associated with a significant mortality of up to 50%, with almost all survivors suffering from debilitating functional compromise. In most cases, open craniotomy has failed to yield significant survival benefit. However, emerging evidence suggests that minimally invasive surgery (MIS) may yield clinically significant improvements in patient survival and quality of life in cases where open craniotomy has not shown benefit. Case presentation We report the first documented usage of a side-cutting-aspiration device via an endoscopic approach for the evacuation of a 56cc hematoma, which was a technical modification on previous MIS techniques. The patient is a 50-yr-old female who was transferred emergently to our center with a National Institutes of Health Stroke Scale score of 27 and found to have a large hematoma involving her left basal ganglia. A minimally-invasive approach was elected due to evidence on the risks and suboptimal outcomes of open craniotomy in ICH evacuation. Neuronavigation was used to plan the surgical trajectory for ICH access. Evacuation took place in three main steps: 1) beginning at the center of the clot to remove bulk; 2) mobilizing clots from parenchymal walls to a safe zone via aspiration, followed by clot homogenization; and 3) re-expansion of the cavity via continuous irrigation to allow visualization of further clots. A final inspection was performed to ensure removal of all clots that could be safely removed. The dual functionalities of the device, namely, suction only and suction plus side-cutting functions, enabled key maneuvers, such as clot homogenization and controlled aspiration strength, to be safely performed. A near-total evacuation of the hematoma was achieved without damage to surrounding parenchyma. The patient experienced a rapid clinical course from comatose to discharge-ready in 5 d. At 30-d follow-up, the patient had residual expressive aphasia and was able to ambulate with the assistance of a quad cane. There are no radiographical signs of recurrent hemorrhage or parenchymal injury. Clinical follow-up with this patient is ongoing. Conclusion This is the first ICH evacuation with a side-cutting-aspiration device via an endoscopic approach. In our patient, this technique proved to be safe and efficacious, suggesting that this technique may be a promising addition to the armamentarium of MIS for ICH evacuation.

Expressive aphasia (non-fluent aphasia) is characterized by the inability to produce words or sentences. The most common cause of expressive aphasia is stroke, usually due to thrombus or emboli in the middle cerebellar artery or internal carotid artery affecting Broca's area. We present an important, reversible, and previously undescribed cause of a purely expressive aphasia secondary to steroid use. A case of a steroid-induced expressive aphasia has not yet been described in the medical literature. Recognition of this presentation is critical to appropriate therapy and excess morbidity, particularly as steroid (dexamethasone) utilization has increased since the COVID-19 pandemic.

Author(s): Gray, Matthew; Ernst, Jacob; Ashworth, Simeon; Patel, Ronak; Couperus, Kyle | Abstract: Introduction: Bilingual aphasia is an atypical stroke presentation in the multilingual patient where an isolated aphasia occurs in one language while the other remains unaffected.Case Report: A multilingual male presented to the emergency department with expressive aphasia to English but who was still able to speak fluently in French. Receptive English was preserved. While his National Institute of Health Stroke Scale score was technically zero, his pure aphasia component qualified him as an exception. He regained some repetitive English, so fibrinolyitic therapy was not initiated.Conclusion: Bilingual aphasia is an indication for fibrinolysis given the impact that a pure aphasic stroke has on quality of life.

Subcortical band heterotopia (SBH) is a rare neurodevelopmental disorder due to mutation in the DCX or LIS1 gene. It is predominantly a disease of females. Its presentation varied widely, ranging from mild epilepsy and mental retardation to refractory epilepsy and severe mental retardation. Here, a case of a 22-year-old lady with refractory seizure is reported. She also had expressive aphasia which had reversed after adjustment of the anti-epileptic drugs and control of the seizure. Her MRI of the brain revealed a band of complete gray matter deep to the pachygyric cortex and an electroencephalogram (EEG) revealed bi-frontal slow waves.

BACKGROUND Providing the standard of care to patients with glioblastoma (GBM) during the novel coronavirus of 2019 (COVID-19) pandemic is a challenge, particularly if a patient tests positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Further difficulties occur in eloquent cortex tumors because awake speech mapping can theoretically aerosolize viral particles and expose staff. Moreover, microscopic neurosurgery has become difficult because the use of airborne-level personal protective equipment (PPE) crowds the space between the surgeon and the eyepiece. However, delivering substandard care will inevitably lead to disease progression and poor outcomes. OBSERVATIONS A 60-year-old man with a left insular and frontal operculum GBM was found to be COVID-19 positive. Treatment was postponed pending a negative SARS-CoV-2 result, but in the interim, he developed intratumoral hemorrhage with progressive expressive aphasia. Because the tumor was causing dominant hemisphere language symptomatology, an awake craniotomy was the recommended surgical approach. With the use of airborne-level PPE and a surgical drape to protect the surgeon from the direction of potential aerosolization, near-total gross resection was achieved. LESSONS Delaying the treatment of patients with GBM who test positive for COVID-19 will lead to further neurological deterioration. Optimal and timely treatment such as awake speech mapping for COVID-19–positive patients with GBM can be provided safely.

Inclusion of brain tumour patients in oncological protocols may be hampered by their neurological impairment. The goal of this study was to assess the reliability of Karnofsky Performance Scale (KPS) and WHO Performance Scale (WHO-PS) scores in this population. A cross-sectional survey was conducted through the Association des Neuro-Oncologues d‘Expression Francaise (ANOCEF) and European Neuro-Oncology Association (EANO) networks. Clinicians were asked to write a text defining their operative definition of a patient with ≥ 70 KPS and to assess KPS and WHO-PS in six different clinical case vignettes. Two hundred seventy-six clinicians sent a response. The operative definition mentioned a normal life (89%), what patients were able (26%) or unable (29%) to do, normal cognitive processing (8%) and caregivers (6%). Older physicians mentioned more often what patients were unable to do (p = 0.005). The two scales were homogeneous in less severely handicapped patients only. More patients were excluded for hemiplegia than for expressive aphasia. Older physicians significantly excluded more patients for KPS and WHO-PS. Speciality of the physician significantly influenced scoring. On multivariable analysis, age and speciality of the physicians were correlated with KPS and WHO-PS rating even if adjusted on cases. Discordant scoring increased with severity of the deficit: in nearly all cases, the KPS would have denied, while WHO-PS would have allowed, access to a trial. Performance scores assigned to brain tumour patients are clinician and score dependant. WHO-PS would allow more access to a trial. Specific criteria should be developed for patients with neurological deficits to facilitate their access to trials.

Pneumocephalus is air in the cranium commonly seen in postcraniotomy and in head injury patients. When this air causes an increase in intracranial pressure leading to neurological deterioration, it is called tension pneumocephalus. Similarly, intraventricular air causing compression on vital centers and increasing intracranial pressure is called tension pneumoventricle, and this causes expressive aphasia, which is rarely described in the literature. This study reported a case of a traumatic cerebrospinal fluid (CSF) leak leading to tension pneumoventricle and aphasia. Case: A young male patient sustained severe head injury and had extradural hematoma (EDH) and multiple skull and skull base fractures. EDH was drained, and he recovered and was discharged with a Glasgow coma scale score of 15. He presented to neurosurgical outpatient with CSF leak, aphasia, and loss of bowel and bladder control for a duration of three days. Computed tomography brain scan showed tension pneumoventricles, and he was started on conservative management. His general condition deteriorated, and the next day, his pupils became unequal, and Glasgow coma scale (GCS) dropped to 8/15. He was immediately taken to theater, and the air was aspirated from the ventricles, and an external ventricular drain was inserted. The patient woke up in the immediate postoperative period and started talking normally by day four. Conclusion: Tension pneumoventricles should be considered a cause of aphasia. Immediate intervention and reduction of intracranial pressure are crucial to reverse neurological abnormality and improve patient's outcome.

The objectives of this study were to test (i) If stroke patients with expressive Aphasia could learn to up-regulate the Blood Oxygenation Level Dependent (BOLD) signal in language areas of the brain, namely Inferior Frontal Gyrus (Broca's area) and Superior Temporal Gyrus (Wernicke's area), with real-time fMRI based neurofeedback of the BOLD activation and functional connectivity between the language areas; and (ii) acquired up-regulation could lead to an improvement in expression of language. The study was performed on three groups: Group 1 (n = 4) of Test patients and group 2 (n = 4) of healthy volunteers underwent the neurofeedback training, whereas group 3 (n = 4) of Control patients underwent treatment as usual. Language performance and recovery were assessed using western aphasia battery and picture naming tasks, before and after the neurofeedback training. Results show that the Test group had significant increase in activation of the Broca's area and its right homologue, while the Normal group achieved the greatest activation during neurofeedback. For the Test group both perilesional and contralateral activations were observed. The improvement in language ability of the test patients was not significantly greater than that of the control patients. Neurofeedback training in Aphasia patients induced significant activation of the Broca's area, Wernicke's area and their right homologues, although healthy individuals achieved greater activations in these regions than the patient groups. Training also activated perilesional areas of Rolandic operculum, precentral gyrus and postcentral gyrus for the Test patients significantly. However, lack of behavioral and symptom modifications in the Test group calls for improvements in the efficacy of the approach.

Six children with anti-NMDAR encephalitis were followed-up for 6 to 24 months. They presented with seizures, neuropsychiatric symptoms and movement disorder, particularly orofacial dyskinesia and choreoathetosis. Immunosuppressive therapy resulted in varying degrees of improvement; none relapsed. Expressive aphasia was the last symptom to regress.

Introduction Epidermoid cysts within the sylvian fissure are extremely rare. Expressive aphasia and neurocognitive dysfunction because of mass effect have never been reported previously. Case Presentation We discuss the case of a 53-year-old male who presented with an acute episode of expressive aphasia and vision changes along with progressive headaches and cognitive slowing over the 2.5 years prior to presentation. A detailed neurologic examination revealed subtle conductive aphasia, as well as mild short-term memory dysfunction. Magnetic resonance imaging revealed a cystic mass consistent with epidermoid cyst within the left sylvian fissure. High-definition fiber tractography showed that the arcuate fasciculus was stretched by the tumor. A left frontotemporal craniotomy allowed for near-total excision of the cyst and led to rapid and complete resolution of symptoms. Conclusion Although rare, epidermoid cysts of the dominant sylvian fissure can present with progressive aphasia due to mass effect on the arcuate fasciculus. Despite the long-standing symptoms, surgical resection can lead to their complete resolution.

A 16-year-old female patient presented with subacute onset of headaches, changes in acute mental status, expressive aphasia and auditory hallucinations. New oedema and enhancement of the temporal lobe were seen on brain MRI, with correlating subclinical seizures seen on electroencephalogram. Simultaneously, our patient was diagnosed with new-onset type 1 diabetes mellitus, with positive anti-glutamic acid decarboxylase (anti-GAD-65) antibodies in the serum. Cerebrospinal fluid studies remained negative, including anti-GAD-65 antibodies. Clinical remission was achieved with corticosteroids and intravenous immunoglobulins.

Glioblastoma multiforme (GM) is the most common type of aggressive malignant glioma in the brain or spinal cord and represents 15% of all primary brain tumors among adults. Although ischemic strokes in the setting of an underlying glioma is a rare occurrence, its diagnosis is usually challenging due to the overlapping neurological manifestations with the underlying brain tumor. We report a case of a 58-year-old white male who presented with subacute worsening symptoms of expressive aphasia with focal neurological symptoms, including right-sided extremity motor weakness and intermittent vision spots. Magnetic resonance imaging (MRI) of brain revealed a large 9.5 cm infiltrating mass in the left frontal and temporal lobes, strongly indicative of a primary glioma. The patient underwent resection to confirm diagnosis and remove part of the tumor mass. Pathological examination revealed GM. Expressive aphasia was markedly improved following the surgery; however, on postoperative day 3, the patient developed acute onset of right-sided weakness and sensory deficit. MRI revealed acute left posterior, frontal, and parietal infarct. Unfortunately, recent brain surgery would not allow for intravenous thrombolysis, and, therefore, he was discharged with a plan for outpatient radiation treatment and oral temozolomide chemotherapy.

Patient: Female, 7-year-old Final Diagnosis: Stroke Symptoms: Aphasia Medication:— Clinical Procedure: — Specialty: Neurology Objective: Rare disease Background: Ischemic stroke can have a tremendously negative impact on the fitness and well-being of a child. Because endovascular interventions may be of benefit in the adult stroke population, many investigators have recently evaluated the safety and benefits of pharmacological and non-pharmacological options in the pediatric stroke population and compared pediatric patients to their adult counterparts. Some of these trials have had promising results, showing the positive effects of endovascular treatment in children with arterial acute ischemic stroke due to large-vessel occlusion (LVO). The 2015 American Heart Association/American Stroke Association guidelines suggest that mechanical thrombectomy with stent retrievers may be a consideration in some patients who are younger than 18 years and have severe LVO, when treatment (groin puncture) is initiated within 6 h of symptom onset. However, the method remains under-studied in this age group. Case Report: A 7-year-old girl presented with migraine-like headache, right arm and facial weakness, and expressive aphasia 9.5 h after symptom onset. Her PEDS-NIH stroke scale score was 4. Upon further investigations, she was found to have a left middle cerebral artery cryptogenic stroke with a distal left M1 clot, which was successfully treated with mechanical thrombectomy. Huge improvement was noticed during her subsequent physical examination. Conclusions: Endovascular therapy offers an exciting treatment option for the management of pediatric stroke. The extent of safety of mechanical thrombectomy among children who present with large-vessel occlusion over an extended time window remains unknown and warrants further investigations.

This study examines an 11-year-old boy with a known history of a large previously asymptomatic arachnoid cyst (AC) presenting with acute onset of right facial droop, hemiplegia, and expressive aphasia. Shortly after arrival to the emergency department, the patient exhibited complete resolution of right-sided hemiplegia but developed headache and had persistent word-finding difficulties. Prior to symptom onset while in class at school, there was an absence of reported jerking movements, headache, photophobia, fever, or trauma. At the time of neurology consultation, the physical exam showed mildly delayed cognitive processing but was otherwise unremarkable. The patient underwent MRI scanning of the brain, which revealed left convexity subdural hematohygroma and perirolandic cortex edema resulting from ruptured left frontoparietal AC. He was evaluated by neurosurgery and managed expectantly. He recovered uneventfully and was discharged two days after presentation remaining asymptomatic on subsequent outpatient visits. The family express concerns regarding increased anxiety and mild memory loss since hospitalization.

A 28-year-old male presented after gunshot injury to his right side from a shotgun. He had no prior history of gunshot injury and no neurologic deficits on presentation. Initially, non-contrast computed tomography (CT) scans of the head, face, chest, abdomen, and pelvis demonstrated multiple pellets lodged in the patient's right upper extremity, face, abdomen, and right hemithorax which penetrated the right lung. A shotgun pellet was also found in the region of the left middle cerebral artery (MCA) on the head CT without contrast with no skull fracture or intracerebral hemorrhage. The patient subsequently developed right hemiplegia and expressive aphasia approximately 48 hours after the trauma. CT angiography (CTA) of the head and neck with perfusion at that time demonstrated ischemic penumbra and the location of the pellet to be in the distal left M1 branch. No intervention was performed given the location. The patient clinically improved without intervention. This is an uncommon injury and outcome for embolization of a foreign body.

Introduction: Neurological manifestations are emerging as relatively frequent complications of corona virus disease 2019 (COVID-19), including stroke and encephalopathy. Clinical characteristics of the latter are heterogeneous and not yet fully elucidated, while the pathogenesis appears related to neuroinflammation in a subset of patients. Case: A middle-aged man presented with acute language disturbance at the emergency department. Examination revealed expressive aphasia, mild ideomotor slowing, and severe hypocapnic hypoxemia. Multimodal CT assessment and electroencephalogram (EEG) did not reveal any abnormalities. COVID-19 was diagnosed based on chest CT findings and positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) reverse transcription PCR (RT-PCR) on nasopharyngeal swab. The following day, neurological symptoms progressed to agitated delirium and respiratory status worsened, requiring admission to the ICU and mechanical ventilation. Brain MRI and cerebrospinal fluid (CSF) studies were unremarkable. RT-PCR for SARS-CoV-2 on CSF was negative. He received supportive treatment and intravenous low-dose steroids. His neurological and respiratory status resolved completely within 2 weeks. Conclusions: We report a patient with reversible COVID-19-related encephalopathy presenting as acute aphasia, mimicking stroke or status epilepticus, eventually evolving into delirium. Although large-vessel stroke is frequently encountered in COVID-19, our case suggests that focal neurological deficits may occur as the earliest feature of encephalopathy. Neurological status reversibility and the absence of abnormalities on brain MRI are consistent with a functional rather than a structural neuronal network impairment.

A 29-year-old G6P3023, left-handed woman presented with acute onset left-sided weakness and expressive aphasia. She was in her normal state of health while driving home from work when her mother noted symptom onset. She was taken immediately to the emergency department for further evaluation. On presentation, she was afebrile with blood pressure 136/99 mm Hg, regular heart and respiratory rates, and oxygen saturation 88% on room air. Neurologic examination was notable for left-sided hemiparesis and sensory disturbance. The aphasia had resolved. Emergent head CT did not demonstrate any abnormalities.

Objectives This study aimed to investigate the epidemiology of intravenous midazolam-induced postoperative expressive aphasia (EA). Methods The incidence rate, risk ratio, and contributing factors to intravenous midazolam-induced postoperative EA were analyzed retrospectively in 6756 orthopedic patients. A telephone interview was conducted with patients with EA after surgery. Results Patients were allocated to either the midazolam group (n = 6178) or no-midazolam group (n = 578). Twelve patients developed EA in the midazolam group, with an incidence of 0.19%, and no patient developed EA in the no-midazolam group. The mean age of EA patients was 70 years, and 92% were women. Among them, 75% received general anesthesia, and the mean dose of midazolam was 1.8 mg. EA was reversed in nine of 12 (75%) patients within 4 minutes of flumazenil administration, and >60 minutes were required to reverse EA in the other three patients (25%). Conclusion Intravenous midazolam administration for preoperative sedation caused transient EA in 0.19% of patients, especially elderly women who received general anesthesia, and EA could be reversed by flumazenil.

An 87-year-old male with expressive aphasia, weakness in the right upper extremity, and inability to write as normal. Carotid Doppler suggested a high-grade lesion of left common Carotid Artery that was confirmed by Carotid angiogram.

Patients with chronic stroke have currently little hope for motor improvement towards regaining independent activities of daily living; stem cell treatments offer a new treatment option and needs to be developed. Patients with chronic stroke (more than 3 months prior to stem cell treatment, mean 21.2 months post-stroke) were treated with CD271+ stem cells, 7 patients received autologous and 1 allogeneic cells from first degree relative; administration was intravenous in 1 and intrathecal in 7 patients. Each patient received a single treatment consisting of 2-5x106 cells/kg and they were followed up for up to 12 months. There were significant improvements in expressive aphasia (2/3 patients) spasticity (5/5, of which 2 were transient), and small improvements in motor function (2/8 patients). Although motor improvements were minor in our chronic stroke patients, improvements in aphasia and spasticity were significant and in the context of good safety we are advocating further administration and clinical studies of CD271+ stem cells not only in chronic stroke patients, but also for spastic paresis/plegia; a different, yet unexplored application is pulmonary emphysema.

Encephalopathy is emerging as a recurrent complication of COVID-19 yet remains poorly characterized. We report the case of a middle-aged woman with COVID-19-related encephalopathy presenting as expressive aphasia and inattentiveness, subsequently progressing to agitation and marked confusion. Brain MRI and CSF analysis were unremarkable, while EEG showed slowing with frontal sharp waves. Neuropsychiatric symptoms resolved following treatment with tocilizumab. CNS involvement in COVID-19 may present as a subacute encephalopathy characterized by prominent frontal lobe dysfunction, with language disturbances as first neurological manifestation. Future studies should further investigate the role of tocilizumab in treating COVID-19-related encephalopathy., Graphical abstract Unlabelled Image, Highlights • CNS involvement in COVID-19 may present as a subacute encephalopathy. • COVID-19-related encephalopathy may present with early language disturbances. • Cytokine-mediated neuroinflammation has been suggested as the underlying mechanism. • Tocilizumab has shown efficacy in treating cytokine release syndrome. • In our patient, neuropsychiatric symptoms resolved following tocilizumab therapy.

A 23-year-old woman with a medical history of migraines and tobacco use was brought to the emergency department with a 2-hour history of acute onset, right-sided hemiplegia and expressive aphasia. The patient had never experienced similar symptoms in the past. Her migraines occurred 3 times weekly, lasted 1–2 days, and were characterized by photophobia along with bilateral headache of a right-sided predominance. She took acetaminophen and ibuprofen for pain relief. Her family history was significant for a sister with glucose-6-phosphate dehydrogenase deficiency.

A 77-year-old white man presented to the emergency department with a 1-week history of episodic expressive aphasia, lasting between 3 and 30 minutes and increasing in frequency. He denied any associated symptoms with the aphasia and between episodes returned to baseline. His medical history included psoriatic arthritis, remote biopsy-confirmed giant cell arteritis (GCA), and metastatic urothelial adenocarcinoma for which he was being treated with programmed death ligand 1 (PD-L1) checkpoint inhibitor therapy.

Background and importance Cerebral hyperperfusion syndrome (CHS) is a well-known complication of superficial temporal artery (STA) to middle cerebral artery (MCA) bypass for ischemic cerebrovascular disease. While this argues against "low flow" in the bypass construct, flow rates in the graft have not been previously quantified in the setting of CHS. Clinical presentation A 58-yr-old man presented with recurrent left hemispheric ischemic strokes and fluctuating right hemiparesis and aphasia. Vascular imaging revealed left cervical internal carotid artery occlusion and perfusion imaging confirmed left hemispheric hypoperfusion. After failing to respond to maximal medical therapy, the patient underwent single-barrel STA-MCA bypass. Postoperatively, his symptoms resolved and blood pressure (BP) was strictly controlled within normal range. However, 2 d later, he developed severe expressive aphasia. CTA demonstrated a patent bypass graft and SPECT showed focal hyperperfusion in Broca's speech area. Seizure activity was ruled out. A high graft flow rate of 52 mL/min was documented by quantitative magnetic resonance angiography (MRA). Thus, the diagnosis of CHS was made and managed with strict BP control. The patient exhibited complete recovery of speech over a period of days and was discharged home. Repeat SPECT at 4 mo showed resolution of hyperperfusion and quantitative MRA demonstrated reduction of graft flow rate to 34 mL/min. Conclusion This is the first case of perfusion imaging-proven CHS after STA-MCA bypass, where high graft flow rates are objectively documented. Our observations constitute irrefutable evidence challenging the classic belief that the STA-MCA bypass is a low-flow construct.

Background: Aphasia affects 0.37% of South Africans. Expressive aphasic patients’ ability to react appropriately to the environment contributes to their hospital experience, and ultimately their mental health and recovery. The challenge of communication for these patients makes it important to anticipate their experiences. Objectives: The purpose of the present study was to explore the patterns of patient experiences in relation to expressive aphasia following brain injuries in order to identify helpful recommendations for alternative communication and for promoting mental health and well-being.Methods: A qualitative case series study was completed with the participation of seven adults who had recovered from expressive aphasia. Participants had received their acute care at Worcester Provincial Hospital, South Africa and at the time of the study were able to communicate effectively concerning their experiences and perspectives. Interviews were transcribed and transcripts analysed by two independent researchers. A thematic analysis method, within a constructionist framework, and at a latent level, was applied.Results: Participants were generally satisfied with the services of health professionals. All participants described their families as being supportive. However, even though most participants had attempted to initiate alternative forms of communication, their families had not reciprocated this. Participants experienced sadness, frustration and anger following the onset of expressive aphasia. They reported gaining insight into the way their lives might change in the near future, such as their roles within the community, as well as into their experiences of introspection and self-reflection. Conclusions: Persons with new onset expressive aphasia during acute care at a large South African hospital experience negative emotions (such as feelings of frustration, entrapment and sadness) as well as inadequate responses to their desire to use alternative forms of communication. Anticipation of such negative experiences may substantially help communication. Formal training in this regard is recommended for health care professionals. Also, visitors to patients with expressive aphasia require basic instruction on the use of alternative communication.

A 72-year-old female status post renal transplant presenting with right hemiparesis, expressive aphasia, and weight loss was found to have a left frontal ring-enhancing lesion with associated vasogenic edema. Imaging was most concerning for high-grade glioma, gliomatosis cerebri with anaplastic transformation, vs solitary metastasis and less concerning for evolving intraparenchymal hemorrhage, abscess, tuberculoma, or fungal granuloma. Maximal safe resection was not feasible. Awaiting stereotactic biopsy results, plans for palliative chemoradiotherapy for presumed glioblastoma were initiated. Frozen pathology review suggested high-grade glioma but ultimate diagnosis of cerebral toxoplasmosis was made. Patient started sulfadiazine, pyrimethamine, and leucovorin. This case identifies an uncommon presentation of cerebral toxoplasmosis whose definitive pathological diagnosis was indispensable to preservation of life. It serves as a critical example of the importance of maintaining a wide differential, as a patient with presumed aggressive terminal cancer was diagnosed with a treatable parasitic infection. We share perspectives from neurosurgery, medical-oncology, radiation-oncology, and infectious disease specialists regarding diagnosis and management. We highlight atypical presentations of cerebral toxoplasmosis, emphasize differential diagnoses, and promote obtaining tissue diagnosis in guiding medical decision making of ring enhancing lesions.

It is because of the distribution of the MCA that isolated aphasia is uncommon. This case reminds us of the risk of stroke in illicit drug use while highlighting another cause of stroke with isolated aphasia.We present a 50 year old male with no prior medical history, who presented because his wife noted he was unable to speak. When seen, his physical examination revealed expressive aphasia and agraphia without any other focal neurological deficits. A brain CT showed a large area of loss of gray-white differentiation to the left frontal lobe including the insular cortex with associated sulcal effacement. An MRA confirmed subacute ischemic injury involving the left MCA distribution with focal narrowing of an M2 branch within the sylvian fissure. Carotid artery doppler, echocardiogram, lipid profile, and thrombophilia workup were negative. His cause of stroke was therefore assumed to be secondary to illicit drug abuse.Isolated aphasia is usually secondary an embolic event. As illicit drug related vasculopathy is an accepted proposed mechanism for ischemia, it should be highlighted that illicit drugs can also be a cause of this uncommon presentation of stroke. Keywords: Aphasia, Isolated aphasia, Stroke, Cocaine, Marijuana

Background Polycythemia is a rare but important preventable cause of stroke with potential for recurrence when not identified and appropriately managed. Case Presentation This is a case of a 55-year-old Ghanaian who presented to our tertiary facility after a 2-month delay with a history of sudden onset of right-sided hemiparesis and expressive aphasia. He had suffered a previous stroke with left hemiparesis 2 years previously where hypertension and polycythemia were identified and treatment initiated. However, patient defaulted treatment for 18 months prior to the onset of recurrent stroke. A cranial CT scan revealed chronic right and subacute left middle cerebral artery territorial infarcts. Presenting hematocrit was 71%. Treatments initiated included high dose hydroxyurea, venesections, and dual antiplatelet therapy of Aspirin and Clopidogrel. He has since been discharged and remains stable under follow-up with moderate functional deficits– Modified Rankin score of 3/6 and the hematocrit of 54% at 3 months postdischarge. Conclusions Default of therapy for polycythemia is associated with a profound risk of recurrent strokes requiring patient education and support to prevent the devastating consequence of this modifiable but rare cause of stroke. This case report highlights the challenges of instituting secondary prevention for stroke in resource-limited settings.