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We report the case of a young male patient who presented to our emergency department complaining of a transient headache and a feeling of motor impairment in his right lower limb, both of which completely resolved spontaneously. After a few minutes of his arrival, he developed a locked-in sensation with anxiety and agitation, followed by a rapid onset of left facio-brachio-crural hemisyndrome. Contrast-enhanced CT of the brain and neck showed the occlusion of the proximal-intermediate basilar artery. Acute basilar artery occlusion (BAO) is a rare life-threatening stroke that requires prompt diagnosis and appropriate treatment to avoid rapid fatal complications (coma and death). The prognosis is poor, with long-lasting sequelae in the survivors. The diagnosis is often difficult since BAO accounts for only 1% of all strokes, and the prodromal symptoms are often very mild, transient, and non-specific, such as nausea, dizziness, headache, confusion, and vertigo. In the presence of convulsion-like symptoms or an unexplained altered level of consciousness, emergency physicians should always consider BAO in the differential diagnosis.

Spinal cord injury without radiographic abnormality (SCIWORA) is a rare post-traumatic myelopathy, more frequently seen in paediatric population and elderly. Clinical manifestation can range from transient isolated paraesthesia to quadriplegia. Due to its rarity in adults and the broad spectrum of neurological manifestations, SCIWORA actually represents a challenge for emergency physicians. Early diagnosis and timely intervention are crucial for the patient’s prognosis avoiding permanent neurological deficits. Magnetic resonance imaging (MRI) plays a pivotal role in the diagnosis, management and prognosis of SCIWORA, being the golden standard technique to identify spinal cord injuries. To highlight the importance of in-depth neurological examination and early diagnosis of SCIWORA, we describe the case of a 53-year-old woman who presented to our emergency department following a forward fall down the stairs with a minor head injury.

We report the case of a 32-year-old Italian man admitted to our emergency room for visual disturbances with blurred vision, anisocoria and temporal headache suddenly occurred in absence of other neurological symptoms. A diagnosis of Datura stramoniuminduced anticholinergic toxicity was done. With our work, we want to highlight the importance of a meticulous clinical examination, including papillary diameter and reflexes, combined with a detailed history of the patient in the emergency room. Anticholinergic toxicity is a medical emergency. The diagnosis is always clinical, and it can represent a challenge for the emergency clinicians because it can mimic several neurological diseases, including acute stroke and seizures, but early diagnosis is crucial to avoid severe complications and management errors.

Literature on antiepileptic induced iatrogenic hypoglycemia is scanty. Due to its broad spectrum of activity and mechanisms of action, valproic acid (VPA), a fatty acid, is the most widely prescribed epilepsy treatment worldwide. Herein, we describe an adult epileptic patient, where persistent, otherwise unexplained hypoglycemia, was most likely induced by VPA, as suggested by the VPA time course and glucose blood levels. Indeed, no further hypoglycemic episodes occurred after VPA discontinuation and the diagnostic work-up ruled out other possible causes of hypoglycemia. This case supports the hypothesis that VPA may induce hypoglycemia, due to still not well-defined metabolic mechanisms of action. Moreover, it emphasizes the fact that an iatrogenic pathogenesis should be considered if an apparently unexplained hypoglycemia occurs in a patient on chronic therapy with antiepileptics, even at a therapeutical dosage.

Novel biomarkers are advocated to manage carotid plaques. Therefore, we aimed to test the association between textural features of carotid plaque at computed tomography angiography (CTA) and unfavorable outcome after carotid artery stenting (CAS). Between January 2010 and January 2021, were selected 172 patients (median age, 77 years; 112/172, 65% men) who underwent CAS with CTA of the supra-aortic vessels performed within prior 6 months. Standard descriptors of the density histogram were derived by open-source software automated analysis obtained by CTA plaque segmentation. Multiple logistic regression analysis, receiver operating characteristic (ROC) curve analysis and the area under the ROC (AUC) were used to identify potential prognostic variables and to assess the model performance for predicting unfavorable outcome (periprocedural death or myocardial infarction and any ipsilateral acute neurological event). Unfavorable outcome occurred in 17/172 (10%) patients (median age, 79 years; 12/17, 70% men). Kurtosis was an independent predictor of unfavorable outcome (odds ratio, 0.79; confidence interval, 0.65–0.97; p = 0.029). The predictive model for unfavorable outcome including CTA textural features outperformed the model without textural features (AUC 0.789 vs. 0.695, p = 0.004). In patients with stenotic carotid plaque, kurtosis derived by CTA density histogram analysis is an independent predictor of unfavorable outcome after CAS.