Citations

We report a unique case and presentation of a 77-year-old man with atrial fibrillation who presented with complex imaging features, including bifrontal cerebral hematomas that progressed to multifocal macro- and microhemorrhages, vasogenic edema, and cortical/meningeal enhancement. Cerebrospinal fluid analysis was only remarkable for a protein elevation of 65 mg/dL. Leptomeningeal vessel biopsy failed to demonstrate evidence of amyloid angiopathy but did show concentric obstructive intimal fibroplasia, suggestive of chronic venous congestion. Conventional cerebral angiography showed a Cognard type IV dural arteriovenous fistulae fed by bilateral ethmoidal arteries draining directly into ectatic cortical veins. A chronic occlusion of the anterior third of the superior sagittal sinus was also noted. The fistula was successfully surgically obliterated via an uncomplicated left frontal craniotomy approach. After rehabilitation therapy, he was discharged home with a modified Rankin Scale score of 3. Because effective treatment exists, this case underscores the importance of identifying this rare etiology of intracerebral hemorrhage and pursuing adequate workup.

Abstract Introduction: The endocannabinoid system (ECS) regulates functions throughout human physiology, including neuropsychiatric, cardiovascular, autonomic, metabolic, and inflammatory states. The complex cellular interactions regulated by the ECS suggest a potential for vascular disease and stroke prevention by augmenting central nervous and immune cell endocannabinoid signaling. Discussion: The endocannabinoid N-arachidonoylethanolamine (anandamide) plays a central role in augmenting these processes in cerebrovascular and neurometabolic disease. Furthermore, cannabidiol (CBD), a nonpsychoactive constituent of Cannabis , is an immediate therapeutic candidate both for potentiating endocannabinoid signaling and for acting at multiple pharmacological targets. Conclusion: This speculative synthesis explores the current state of knowledge of the ECS and suggests CBD as a therapeutic candidate for stroke prevention by exerting favorable augmentation of the homeostatic effects of the ECS and, in turn, improving the metabolic syndrome, while simultaneously stalling the development of atherosclerosis.

Endovascular management of acute ischemic stroke secondary to septic emboli from bacterial endocarditis is case-specific and outside established guidelines. We report three new cases of an acute ischemic stroke secondary to septic embolus from two different centers. All cases reported here were large vessel occlusions of the middle cerebral artery in anticoagulated patients. In one case the embolus was noted to be firm and aspiration thrombectomy was attempted in lieu of stent retrieval. Thrombolysis in Cerebral Ischemia (TICI) 3 recanalization was achieved and the patient experienced a good outcome with resolution of deficits. In this case, pathologic analysis of the embolus was available. These additional three cases from two centers add to the small but growing literature for interventional management of acute ischemic stroke in bacterial endocarditis.

This case report describes a rare presentation of ischemic stroke secondary to an extensive internal carotid artery thrombus, subsequent therapeutic dilemma, and clinical management. A 58-year-old man was administered intravenous (IV) thrombolysis for right middle cerebral artery territory ischemic stroke symptoms. A computed tomography angiogram of the head and neck following thrombolysis showed a longitudinally extensive internal carotid artery thrombus originating at the region of high-grade calcific stenosis. Mechanical embolectomy was deferred because of risk of clot dislodgement and mild neurological symptoms. Recumbency and hemodynamic augmentation were used acutely to support cerebral perfusion. Anticoagulation was started 24 hours after thrombolysis. Carotid endarterectomy was completed successfully within 1 week of presentation. Clinical outcome was satisfactory with discharge modified Rankin Scale score 0. A longitudinally extensive carotid artery thrombus poses a risk of dislodgement and hemispheric stroke. Optimal management in these cases is not known with certainty. In our case, IV thrombolysis, hemodynamic augmentation, delayed anticoagulation, and carotid endarterectomy resulted in a favorable clinical outcome.