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1/18. basilar artery occlusion due to spontaneous basilar artery dissection in a child.

    basilar artery occlusion (BAO) causing brainstem infarction occurred in a 7-year-old boy without any basic disorders. A diagnosis of BAO due to basilar artery dissection (BAD) was suspected at angiography, and this was confirmed by gadolinium-enhanced magnetic resonance imaging (MRI). These investigations clearly showed all the typical diagnostic signs such as a pseudolumen, double lumen and intimal flap, and a pseudolumen in resolution. The spontaneous healing of the dissection was clearly demonstrated during 10 months of follow-up. We stress that BAD can occur in young children and that combined diagnosis with gadolinium-enhanced MRI and angiography is conclusive for diagnosis of dissecting aneurysms. Wider use of these combined diagnostic methods will allow the detection of less severe basilar artery dissection, thus extending the spectrum of presentation and prognosis.
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2/18. Intracerebral thrombosis. Case report and brief clinical review.

    A 29-yr-old writer presented with seizures and left hemiparesis 8 days post-partum. Studies revealed right parietal hemorrhagic infarction secondary to superior sagittal sinus thrombosis. An anticoagulant was given for clot extension associated with increasing cerebral edema and coma. Inpatient rehabilitation was undertaken for residual left hemiparesis, most severe in the leg. Left arm strength rapidly returned to normal. Significant improvement in left leg strength occurred but was delayed for many months. Intracerebral thrombosis is an uncommon but significant cause of stroke in young adults. It frequently occurs in the puerperium and may be associated with unilateral or bilateral neurologic deficits. Treatment with anticoagulants is controversial because of the risk of hemorrhagic cerebral infarction, but may be beneficial in some cases. Recovery may be delayed for several months pending recanalization of the sinus or the development of collateral circulation. The overall prognosis for neurologic and functional recovery in survivors of intracerebral thrombosis is good.
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3/18. Clinical features of vascular thrombosis following varicella.

    OBJECTIVE--To define the clinical characteristics, neuroimaging features, and outcome of five patients with post-primary varicella zoster virus infection hemiparesis and to offer a hypothesis to explain the predilection for the involvement of the cerebral vasculature in this condition. DESIGN--Patient series. SETTING--Five patients were treated during a 14-month period in a private pediatric neurology practice in a medium-size southwestern city. INTERVENTIONS--steroids (two patients) and antiplatelet drugs (two patients). No observed effects of therapy. RESULTS--The onset of the hemiparesis occurred several weeks (mean, 5.4 weeks) following an episode of the chickenpox. Magnetic resonance imaging was more sensitive than computed tomography or angiography in demonstrating the area of involvement deep in the cerebral hemispheres. The prognosis was good regardless of the therapy administered, as all patients recovered completely or nearly completely. CONCLUSIONS--Primary varicella zoster virus infection with delayed-onset hemiparesis typically occurs approximately 6 weeks after primary varicella zoster virus infection. magnetic resonance imaging is the most sensitive neuroimaging tool in these children. The prognosis is good, with recovery of function and no recurrences in our patients. The innervation of the carotid artery and the characteristics of the varicella zoster virus itself together provide the local and systemic factors that may trigger the vasculopathy responsible for this syndrome.
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4/18. mucorales and deferoxamine: from saprophytic to pathogenic state.

    Rhinocerebral mucormycosis can be a rapidly fatal course disease if the institution of treatment is delayed. We describe a case of a long-term dialysis patient in which the role of a siderophore such as deferoxamine in promoting mucormycosis is discussed. The frequent lack of early diagnosis, itself subsequent to a break away from the standard diagnostic tools (apart from biopsy and culture) makes the survival prognosis particularly critical.
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5/18. Cerebral venous thrombosis: new causes for an old syndrome?

    The range of disorders affecting the cerebral veins and sinuses is increasing and now includes blood disorders, abnormalities in the patterns of blood flow, and infiltrative or inflammatory conditions, all of which may promote thrombosis. We describe 10 patients with cerebral venous thrombosis: two had protein s deficiency, one had protein c deficiency, one was in early pregnancy, and there was a single case of each of the following: dural arteriovenous malformation, intracerebral arteriovenous malformation, bilateral glomus tumours, systemic lupus erythematosus, Wegener's granulomatosis, non-Hodgkin's lymphoma. The recognition of such diverse aetiology may be importance since clinical features are non-specific, and may consist only of raised intracranial pressure, allowing confusion with 'benign intracranial hypertension'. The existence of effective treatment both for the thrombosis and for many of the underlying disorders makes early diagnosis essential. The prognosis of treated patients may be favourable.
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6/18. brain function in patients with cerebral fat embolism evaluated using somatosensory and brain-stem auditory evoked potentials.

    In two victims of traffic accidents with broken bones and fat embolism, serial recordings of somatosensory evoked potentials (SEPs) and brain-stem auditory evoked potentials (BAEPs) were examined to assess brain function. Initial SEPs and BAEPs revealed normal subcortical components, while the late cortical components of SEPs were abolished, findings indicative of diffuse dysfunction of grey rather than of white matter. As the neurological functions became normal, the late components appeared. It is concluded that while absent late components of SEPs do reflect cortical dysfunction, they are not necessarily associated with a poor prognosis. Repetitive recordings of SEPs appear to be a useful tool for assessing the neurological condition and the prognosis of patients with cerebral fat embolism.
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7/18. The unilateral hyperdense middle cerebral artery: an early CT-sign of embolism or thrombosis.

    In four patients with acute neurologic deficits non-enhanced CT on admission showed a hyperdense segment of one middle cerebral artery. These patients eventually turned out to have complete infarctions of the middle cerebral artery territory, the high density representing an intravascular clot. Three patients died within a few days and one survived with disabling deficits, so this visualisation of emboli on CT may be considered to be a sign of a poor prognosis.
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8/18. Left atrial myxoma with cerebral emboli.

    Infarction of the central nervous system secondary to embolism from left atrial myxoma is a recognized phenomenon. However, myxoma as the source of an embolus may be overlooked if an index of suspicion is not present during the evaluation of the patient with a stroke without a known cause. We present a case report that illustrates some of the pitfalls and characteristic findings present in the evaluation of these patients. The magnetic resonance image of multiple cerebral aneurysms and infarction associated with this condition is presented along with a unique, arteriographically proven resolution of a fusiform cerebral aneurysm after the removal of the cardiac tumor. A review of published case reports suggests that, if the cardiac tumor is recognized and treated quickly, the ultimate prognosis, while uncertain, is usually good. However, because the potential exists for recurrence of the cardiac tumor, for enlargement of the cerebral lesions, or for late development of cerebral lesions, long term follow-up is mandatory and a vigorous work-up must be pursued if the patient again becomes symptomatic or develops central nervous system manifestations for the first time.
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9/18. The role of continuous-wave Doppler sonography in the diagnosis and management of basilar and vertebral artery occlusions, with special reference to its application during local fibrinolysis ("Vertebrobasilar disease. time for a new strategy." Louis R. Caplan, 1981).

    In general, the prognosis of bilateral vertebral or basilar artery occlusions is very poor. No satisfactory management of this condition is known; in addition, the early diagnosis of severe lesions of the "intradural vertebrobasilar artery" on the basis of clinical signs and symptoms alone is difficult and regularly requires invasive procedures. Continuous-wave Doppler sonography has proved to be of great value in the primary diagnosis of vertebrobasilar thrombosis. In two cases, in whom bilateral intracranial vertebral artery lesions and basilar thrombosis were successfully treated with the help of local intraarterial fibrinolysis, Doppler sonography proved to be a reliable diagnostic tool for the evaluation and the non-invasive follow-up of thrombolysis. Clinical, Doppler sonographic and angiographic findings are presented and correlated.
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10/18. The benign lateral medullary syndrome.

    Four young, otherwise healthy men developed the signs and symptoms of lateral medullary ischemia following extraordinary outdoor exercise. The syndrome was short-lived, with excellent long-term prognosis. We suggest that the designation "benign lateral medullary syndrome" is appropriate for this transient nonrecurring state.
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