In order to find a subtle hemiparesis of the arms and legs, so called “Barré’s test” has been routinely used in clinical practice. This eponym has been questioned by several neurologists. To clarify this, I searched and found the original paper by Giovanni Mingazzini, reported in Revue Neurologique in 1913. He showed arm drift test with his original photo, as asking the patient to stretch his arms in front, hands in the same horizontal plane with the manner of swearing and the fingers spread. The eyes are closed. The examiner observes downward drift of the hand after one half to a minute. He described a similar test for the legs in this article. The patient in supine position raises the legs in a 45 degree angle from the bed. If the leg drops downward too early, an organic hemiparesis could be present. Barré described a new leg drift test in 1919 with a patient lying on the abdomen. He also presented the Mingazzini’s arm and leg tests with photos as carried by his patient-models in his article of 1937. He did not quote the original article of Mingazzini as a reference. These brought us incorrect information to consider the presence of Barré’s arm test.
A 21-year-old right-handed woman was admitted to our hospital with fever, headache, and seizures. On admission, she showed anterograde and retrograde amnesia. These features, together with mild pleocytosis in the cerebrospinal fluid, led to the diagnosis of encephalitis. Brain MRI was normal. EEG revealed small spike waves in the left temporal lobe. There were no recurrent convulsions. Five days later, she stated she had hyperfamiliarity for faces of people she had never met before. She reported that many people appeared familiar regardless of age, sex, and profession; however, feelings of likes and dislikes did not accompany these symptoms. This symptom lasted for 20 days. Her ability to recognize known faces was normal, and prosopagnosia was not present. Neuropsychological tests indicated that her verbal memory was impaired. The retrograde amnesia remained until discharge. Considering the psychological findings attributable to left temporal lobe dysfunction, as well as previous reports on similar cases, our case suggests a possible relationship between lesions of the left temporal lobe and hyperfamiliarity for faces.
A 78-year-old woman noticed that people’s eyes and the right nasal foramens located in her left visual field looked smaller than those observed in the right. The woman reported no change in shape regarding facial outlines or scenic objects. Magnetic resonance imaging revealed an acute infarction of the right side of the splenium of the corpus callosum. Close examination revealed that her metamorphopsia affected the left side of her visual field, especially influencing facial components, particularly the eye. The woman had similar reactions to photographs of several kinds of animals, realistic portraits of humans, and caricatured humans. Meanwhile, presentings caricature human face at a 90° rotation elicited metamorphopsia in eyebrows located on the left side of a picture, but not the eyes. She also reported a change of shape or color tone for geometric objects. The patient’s only symptom was metamorphopsia, and she did not show any other neurological defects such as callosal disconnection syndrome. Furthermore, objects that were affected by the patient’s metamorphopsia (e.g. facial component especially the eye, and simple geometric figures) may be easy images to use in order to detect this type of distorted vision.
Central nervous system (CNS) aspergillosis with stroke has a high mortality and poor prognosis generally. We report a 78-years-old woman with diabetes mellitus, who developed invasive paranasal sinus aspergillosis with the orbital apex syndrome on the right side and cerebral infarction caused by intracranial occlusion of the right internal carotid artery. Based on the presence of a mass lesion in the ethmoid sinus extending to the orbital apex on the right side with cranial CT, the mass lesion was surgically removed and the pathological examination of the surgical specimen revealed aspergillus mold. Immediately after surgery, we initiated treatment with voriconazole 200 mg × 2/day intravenously for 38 days, and then via feeding tube for 86 days until the galactomannan-aspergillus antigen level in the cerebrospinal fluid became negative at 132 days. She is alive now for almost two years without relapse of aspergillosis. There is no definitive guideline for management of patients with CNS aspergillosis concerning the length of drug treatment and the method for monitoring the response for treatment. We believe that measurement of the galactomannan-aspergillus antigen level in the cerebrospinal fluid might be a useful way of monitoring the efficacy of treatment for CNS aspergillosis.
A 81-year-old man with rheumatoid vasculitis presented with total aphasia followed by right hemiplegia. The NIHSS score was 24. Diffusion weighted magnetic resonance imaging (DWI) demonstrated an acute infarct in the left middle cerebral artery (MCA) territory, and magnetic resonance angiogram (MRA) revealed left MCA M1 occlusion. We administrated recombinant tissue plasminogen activator (rt-PA) at 132 min after symptom onset, but symptom was not improved. Emergency neuroendovascular recanalization was conducted with Penumbra® system. After MCA was recanalized partially, extravasations appeared on left lenticulostriate arteries territory at 376 min from symptom onset. Multiple extravasations spread over perforating branches, and ventricular rupture recognized angiographically. After the procedure, head CT demonstrated hematoma on left basal ganglia territory with intraventricular bleeding. Rheumatoid vasculitis might affect hemorrhagic infarction in emergency neuroendovascular recanalization procedure, and careful choice of treatment would be required.
The present report describes a 54-year-old woman with cavernous sinus thrombosis (CST) presenting with fever, and marked periorbital swelling. There is a history of untreated periodontal disease. On initial examination, periorbital pain associated with bilateral blephaloptosis, chemosis, and disturbed eye movement was present. The laboratory evaluation showed significant elevations in inflammatory and fibrinolytic markers. Diffusion-weighted MRI revealed high signal intensities in the bilateral superior ophthalmic veins (SOV). Contrast-enhanced computed tomography (CT) of the cranium showed an enlarged right SOV and a non-enhancing lesion within the right SOV and bilateral cavernous sinus, indicating cavernous sinus thrombosis with diffuse SOV thrombosis. Blood culture performed on admission showed bacterial infection by intraoral resident flora; therefore, the CST was attributed to untreated periodontal disease. Contrast-enhanced CT of the case also revealed the presence of thrombosis in the jugular vein associated with micropulmonary embolus, indicating co-occurrence of Lemierre’s syndrome. Antibiotic and anticoagulant treatment were initiated, and the tooth decay was treated; all clinical symptoms and signs subsequently improved. Additional neuroimaging showed that the thrombus was absent from both SOV and the cavernous sinus. Infectious CST is life threatening; therefore, laboratory and imaging examination should be performed quickly, and antibiotic and anticoagulant therapy administrated immediately.
Two patients presented with chronic intracerebral hemorrhage (CIH) in the basal ganglia. A 48-year-old man (Case 1) was admitted to our hospital because of hypertensive right putaminal hemorrhage. On day 14, his hematoma surrounding the edema had grown without re-bleeding as seen on head CT, which was then removed endoscopically on day 28. Biopsied specimen of the hematoma capsule showed granulomatous tissue with vascularity. A 54-year-old man (Case 2) was admitted to our hospital because of bilateral intracerebral hemorrhage in the basal ganglia of the right putamen and left thalamus. On head CT, both hematomas were found to be enlarged without change in his symptoms on the 11th day after onset. His symptoms and signs subsided with medical treatment for 4 weeks. Cerebral angiography showed no abnormality of cerebral vessels. The patient had intracerebral hemorrhage in the basal ganglia or cerebral lobes 5 times in the past 10 years. Although no arterial or venous abnormality was detected by cerebral angiography and MRI/MRA, the abnormality of vessels including capillaries was strongly suggested. CIH should be considered a possibility when the symptom or hematoma does not improve even 2 weeks after the onset. The prevalence of CIH in our hospital was 0.08% of total intracerebral hemorrhages and 0.15% of hemorrhages in the basal ganglia.
A 52-year-old man developed sudden occipital headache followed by vomiting and vertigo. On admission, he displayed right Horner syndrome with ipsilateral reduced facial sensation to pain and temperature that crossed in the body, affecting the left limbs. In addition, he had right hemiparesis. Diffusion weighted magnetic resonance images showed a high intensity lesion localized in the lower and right lateral medulla oblongata. Magnetic resonance angiography showed severe luminal stenosis in the right vertebral artery and T2-weighted sampling perfection with application optimized contrasts using different flip angle evolution (SPACE) showed arterial wall expansion. T1-weighted SPACE showed subacute intramural hematoma at that point, suggesting arterial dissection. First described in 1946, Opalski syndrome is considered a variant of Wallenberg syndrome with ipsilateral hemiparesis. This motor impairment is considered as a result of extension of the ischemia from the lateral medulla to the upper cervical cord involving corticospinal fibers caudal to pyramidal decussation. This case adds information regarding the anatomy of the pyramidal decussation.
This report describes a 9-year-old boy with an internal carotid artery (ICA) injury caused by a fall with the blunt edge of a toothbrush held in the mouth. The initial injury appeared trivial, but 2 weeks later, generalized convulsion and left hemiparesis occurred. Magnetic resonance imaging and magnetic resonance angiography revealed an infarction of the right striatum, right ICA occlusion, and stenosis of the right middle cerebral artery, which were caused by the dissection or intimal damage of the ICA due to the blunt trauma. For children, intraoral blunt trauma sometimes causes ICA occlusion and consecutive strokes after the latent interval of days to weeks. Therefore, a careful clinical observation is essential to prevent overlooking strokes. This patient was an unique case with a long latent interval among the past literatures.