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INTRODUCTION: Pituitary apoplexy has historically been considered an emergent condition that necessitates surgical intervention when there is acute symptomatic onset. This potentially serious condition often occurs in the setting of an underlying adenoma, cystic lesion, or other sellar mass. When these mass lesions hemorrhage within the confined space of the sella turcica, the pituitary gland is subjected to hemorrhagic ischemia. Furthermore, critical neurovasculature in close proximity to the sella can sustain collateral damage. In the present study, we investigate whether early versus delayed surgical intervention (in terms of three timelines: before versus after 48 h, 72 h, and 7 days, respectively) results in differences in visual outcomes for patients experiencing pituitary apoplexy with acute onset neurological and/or neuro-opthalmic symptoms. Furthermore, we compare the efficacy of surgical decompression versus expectant management of this condition. METHODS: Accordingly, we queried the PubMed, Scopus, and Embase databases in adherence to PRISMA guidelines. Quantitative meta-analysis was performed according to the Mantel-Haenszel method and forest plots were generated using Review Manager v5.4. P-values  0.05). CONCLUSION: In the present study, timing of surgical intervention for pituitary apoplexy was predictive of visual function recovery only at the 7-day timepoint, as has been reported by previous studies. Ultimately, this suggests that pituitary apoplexy involving severe visual deficits or altered mental status is best addressed within the first seven days post-presentation, and that both surgery and conservative management can offer similar outcomes. When apoplexy is suspected, IV corticosteroids should be administered independent of acuity or severity to prevent secondary adrenal crisis. Subsequently, for patients presenting without severe visual or other neurological deficits, expectant management is recommended. Management should be patient-specific and dependent upon the severity of symptoms present at onset.

Cerebrovascular disease is a common cause of death and the general histopathologist will often be responsible for the post mortem examination of stroke-related death. The pathological findings vary depending on the type of stroke, its location and aetiology. The underlying pathology is variable and includes atherosclerosis, cardiogenic embolism and small vessel disease alongside many rarer causes. The adequate post mortem examination of stroke is essential to usefully inform clinical teams, coronial services and relatives and requires proper preparation, familiarity with the range of underlying pathological processes, careful gross examination and judicious use of histology. [ABSTRACT FROM AUTHOR]

Introduction: Traumatic extradural haematoma (EDH) is one of the neurosurgical emergencies in the paediatric population. One of the rare complications of extradural haematoma is adjacent parenchymal infarct from the compressive effect of haematoma leading to further morbidity. We aimed to evaluate the incidence and outcomes of this rare complication in paediatric trauma patients. Methods: We undertook a retrospective review of all operative extradural haematoma cases in single centre paediatric neurosurgical unit between the years 2008 and 2024. Cases with postoperative imaging were analysed for demographics, age, sex, dimensions of haematoma and underlying infarct, pre-operative GCS and pupillary abnormality and time interval from scan to surgery. Infarct was defined as well-defined parenchymal hypodensity corresponding to vascular territory and not attributable to contusions on postoperative CT head performed at 24–72 h. All patients suspected of stroke had further MRI brain for evaluation. Statistical analysis was then performed comparing groups with and without infarct. Results: Overall, 115 cases of extradural haematoma were identified during the study period. Eighty cases had adequate postoperative imaging to allow assessment for infarcts; 7.5% demonstrated evidence of infarct underlying extradural haematoma. Mean age in the infarct group was 1.8 years (M:F ratio 2:1) with mean EDH dimensions of 77 mm × 31.4 mm × 79.7 mm). Mean age in the non-infarct group was 8.6 years (M:F ratio 2:1) with mean EDH dimensions of (57.5 mm × 19.6 mm × 62.6 mm). Children with infarcts were significantly younger with larger haematoma dimensions and had a higher proportion of pupillary abnormalities. There was no significant difference in pre-operative GCS and scan-to-surgery time-lapse between the groups with and without infarct. Conclusion: Compressive effect of EDH can lead to underlying parenchymal infarct. Children with extradural haematoma-related infarct were younger with larger haematoma size and a higher proportion of pupillary abnormalities. [ABSTRACT FROM AUTHOR]

Vaishnavi Kundel,1 Kavya Devarakonda,1 Samira Khan,1 Mayte Suarez-Farinas,1 Oren Cohen,1 Carlos Santos-Gallego,1 Mark A Menegus,2 Annapoorna Kini,1 Yuliya Vengrenyuk,1 Naotaka Okamoto,1 Hiroshi Ueda,1 Umesh Gidwani,1 Jorge R Kizer,3 Susan Redline,4 Robert Kaplan,2,5 Neomi Shah1 1Icahn School of Medicine at Mount Sinai, New York, NY, USA; 2Albert Einstein College of Medicine, Bronx, NY, USA; 3Cardiology Section, San Francisco Veterans Affairs Health Care System and Departments of Medicine, Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA; 4Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA; 5Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USACorrespondence: Vaishnavi Kundel, Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1232, New York, NY, 10029, USA, Tel +1-212-241-1967, Email Vaishnavi.kundel@mssm.eduPurpose: We designed a study investigating the cardioprotective role of sleep apnea (SA) in patients with acute myocardial infarction (AMI), focusing on its association with infarct size and coronary collateral circulation.Methods: We recruited adults with AMI, who underwent Level-III SA testing during hospitalization. Delayed-enhancement cardiac magnetic resonance (CMR) imaging was performed to quantify AMI size (percent-infarcted myocardium). Rentrop Score quantified coronary collateralization (scores 0– 3, higher scores indicating augmented collaterals). Group differences in Rentrop grade and infarct size were compared using the Wilcoxon Rank-Sum test and Fisher’s Exact test as appropriate, with a significance threshold set at p < 0.05.Results: Among 33 adults, mean age was 54.4± 11.5 and mean BMI was 28.4± 5.9. 8 patients (24%) had no SA, and 25 (76%) had SA (mild n=10, moderate n=8, severe n=7). 66% (n=22) underwent CMR, and all patients had Rentrop scores. Median infarct size in the no-SA group was 22% versus 28% in the SA group (p=0.79). While we did not find statistically significant differences, moderate SA had a trend toward a smaller infarct size (median 15.5%; IQR 9.23) compared to the other groups (no SA [22.0%; 16.8,31.8], mild SA [27%; 23.8,32.5], and severe SA [34%; 31.53], p=0.12). A higher proportion of moderate SA patients had a Rentrop grade > 0, with a trend toward significance (moderate SA versus other groups: 62.5% versus 28%, p=0.08).Conclusion: Our study did not find statistically significant differences in cardiac infarct size and the presence of coronary collaterals by sleep apnea severity among patients with AMI. However, our results are hypothesis-generating, and suggest that moderate SA may potentially offer cardioprotective benefits through enhanced coronary collaterals. These insights call for future research to explore the heterogeneity in ischemic preconditioning by SA severity and hypoxic burden to guide tailored clinical strategies for SA management in patients with AMI.Keywords: sleep apnea, MI, myocardial infarction, cardiac MRI, Rentrop, ischemic preconditioning

Introduction: Skull infarction is an uncommonly reported complication of sickle cell disease. We aimed to characterize the clinical and imaging features of skull infarction in pediatric patients with sickle cell disease. Methods: We searched the PubMed database for case reports on skull bone infarction in pediatric patients with sickle cell disease. Out of 67 records retrieved, 15 met inclusion criteria, and a 16th case reported by the senior author was included. We extracted and analyzed clinical and imaging data. Results: The most common symptom at onset was headache (88%). Bilateral skull infarction (50%) and parietal bone involvement (82%) were frequent imaging findings. Epidural hematoma developed in 65% of the cases, 30% of patients required drainage, and exchange infusion was reported in 18%. No fatal outcomes were reported. Conclusions: Skull infarction is a potentially severe complication of sickle cell disease presenting unique clinical challenges. Acute headaches should raise suspicion for this condition and may require additional investigation. [ABSTRACT FROM AUTHOR]

Dunbar syndrome is an underdiagnosed condition, first reported in 1963 and confirmed through imaging methods until 1972. It presents clinically with epigastric pain, caused by compression of the celiac trunk by the median arcuate ligament, which can be due to a low insertion of the ligament or a high origin of the celiac trunk. This stenosis persists even with changes in the position of the diaphragm during the respiratory cycle. In this article, two imaging methods, namely angiotomography and spectral Doppler ultrasound, were employed. Key data were obtained from each of these modalities, and their integration is crucial for establishing the diagnosis. [ABSTRACT FROM AUTHOR]

Objectives: The few voxel-wise lesion-symptom mapping (VLSM) studies aimed at identifying the anatomy of executive function are limited by the absence of a model and by small populations. Using Trail Making Test (TMT) and verbal fluency and a model of their architectures, our objective was to identify the key structures underlying two major executive processes, set-shifting and strategic word search. Methods: We applied a validated VLSM analysis to harmonized cognitive and imaging data from 2009 ischemic stroke patients as a part of the Meta VCI Map consortium. All contrast analyses used an adjusted threshold with 2000 Freedman–Lane permutations (p ≤ 0.05). Results: The TMT parts A and B were associated with structures involved in visual-spatial processing, the motor system, the frontal lobes, and their subcortical connections. Set-shifting depended on the left dorsomedial frontal region. Both semantic and phonemic fluency tests depended on verbal output abilities and processing speed with similar slopes in different languages. The strategic search process depended on Broca's area, F2 and related tracts, temporal and deep regions. Lastly, the lesion map of set-shifting did not overlap with those of strategic word search processes. Interpretation: Our results identify the anatomical substrates of two main executive processes, revealing that they represent only a specific subpart of previously reported structures. Finally, our results indicate that executive functions depend on several specific, anatomically separable executive processes mainly operating in various parts of the frontal lobes. [ABSTRACT FROM AUTHOR]

ABSTRACT: Dengue infection can take on many different forms, ranging from no symptoms to a mild fever, all the way to a severe condition known as dengue shock syndrome. Although the typical symptoms of dengue are well known, the virus can also cause rare neurological complications. Dengue encephalitis is a severe form of neuroinvasive dengue that can be fatal as the virus directly affects the central nervous system. This case series provides a comprehensive overview of dengue, its clinical spectrum, and the potential for severe neurological complications such as dengue encephalitis. It highlights the importance of considering dengue as a possible diagnosis in patients with encephalitis, particularly during a dengue epidemic. [ABSTRACT FROM AUTHOR]

Background: This multicenter study examines the contemporary management of penetrating carotid artery injury (PCAI) to identify trends in management, outcomes, and to determine prognostic factors for stroke and death. Methods: Data from three large urban trauma centers in South Africa were retrospectively reviewed for patients who presented with PCAI from 2012 to 2020. Results: Of 149 identified patients, 137 actively managed patients were included. Twenty‐four patients (17.9%) presented in coma and 12 (9.0%) with localizing signs (LS). CT angiography was performed on admission for 120 (87.6%) patients. Thirty patients (21.9%) underwent nonoperative management, 87 (63.5%) open surgery, and 20 (14.6%) endovascular stenting. Eighteen patients (13.1%) died, and 15 (12.6%) surviving patients had strokes. Ligation was significantly related to death and reperfusion to survival. A mechanism of gunshot wound, occlusive injuries, a threatened airway, a systolic blood pressure <90 mmHg, hard signs of vascular injury, a low GCS, coma, a CT brain demonstrating infarct, a high injury severity score and shock index, a low pH or HCO3, and an elevated lactate were significant independent prognostic factors for death. Ligation was unsurvivable in all patients with severe neurological deficits, whereas reperfusion procedures resulted in survival in 63% (12/19) patients with coma and 78% (7/9) with LS although with high stroke rates (coma: 25.0%, LS: 85.7%). Conclusions: Outcomes in PCAI, including patients with severe neurological deficit and stroke, are better when reperfused. Reperfusion holds the best promise of survival and ligation should be reserved for technically inaccessible bleeding injuries. [ABSTRACT FROM AUTHOR]

BackgroundSignificant advances have been made in our understanding of the endolysosomal cycle. Disruption of this cycle leads to cell death. The objective of this study aims to investigate the role of disrupted endolysosomal cycle in brain ischemia-reperfusion injury.MethodsA total of 57 mice were randomly assigned into four experimental groups: (i) wildtype (wt) sham control; (ii) wt middle cerebral artery occlusion (MCAO); (iii) cathepsin B (CTSB) knockout (KO) sham control; and (iv) CTSB KO MCAO. Mice were subjected either to 0 min (sham) or 40 min of MCAO, followed by reperfusion for 1 or 7 days. Physical and behavioral examinations were conducted in the 7-day reperfusion group for 7 consecutive days after MCAO. Confocal microscopy was used to assess the levels, redistributions, and co-localizations of key endolysosomal cycle-related proteins. Histopathology was examined by light microscopy.ResultsConfocal microscopy revealed a significant accumulation of CTSB in post-ischemic penumbral neurons relative to those in the sham group. In addition, N-ethylmaleimide sensitive factor ATPase (NSF) was irreversibly depleted in these neurons. Furthermore, CTSB-immunostained structures were enlarged and diffusely distributed in both the cytoplasm and extracellular space, indicating the release of CTSB from post-ischemic neurons. Compared to wt mice, CTSB KO mice showed a significant decrease in hippocampal injury area, a significant increase in the number of survival neurons in the striatal core area, and a significant improvement in physical and functional performance in post-MCAO mice.ConclusionBrain ischemia leads to a cascade of events leading to inactivation of NSF, disruption of the endolysosomal cycle, endolysosomal structural buildup and damage, and the release of CTSB, eventually resulting in brain ischemia reperfusion injury. CTSB KO in mice protected the brain from ischemia-reperfusion injury.

Early detection of fetal intracranial hemorrhage and infarct during pregnancy is crucial for preventing lethal and debilitating complications in neonatal life. Every radiologist must be aware of the imaging features of these conditions to refer patients to specialists. Sonographic and MRI features of fetal intracranial hemorrhage and infarct have been discussed in many previous articles. The aim of this article is to organize and categorize these findings into a practical guideline for improved application in diagnosing these diseases. The use of MRI sequences, such as DWI and multiplanar EPI should be developed for suspected prenatal infarct and intracranial hemorrhage and can serve as additional tools for early detection. In this review article, we first explain possible etiologic factors contributing to the development of fetal IVH and infarct. Then we discuss the different imaging features of these disorders on sonography and MRI separately, as well as their differential diagnosis. Finally, the mortality and morbidity associated with these two concerning fetal abnormalities will be addressed.

Long insular artery (LIA) infarct can occur after insular glioma surgery. LIA infarct after extracranial-intracranial (EC-IC) bypass is very rare, and so far, it is not reported in EC-IC bypass. Here, we report a case of high-flow EC-IC bypass, where postoperatively, the patient developed isolated LIA infarct. A 65-year-old female presented with recurrent severe headache along with altered sensorium. Computed tomography (CT) scan and CT angiography (CTA) of the brain showed ruptured large left internal carotid artery (ICA) fusiform aneurysm. She underwent left-sided, high-flow EC-IC bypass involving upper trunk of left middle cerebral artery (MCA) and ICA ligation at neck at its origin. Postoperatively, the patient developed right sided hemiplegia. Postoperative MRI of the brain showed left-sided external capsular infarct, extending up to the corona radiata resulted from LIA infarct. By the end of 6 months after operation, she could walk with support but her left upper limb remained more severely affected and magnetic resonance angiogram (MRA) showed almost disappearance of aneurysm with functioning bypass.

OBJECTIVE To investigate an association between pancreatitis and chronic kidney disease (CKD) in cats. ANIMALS 154 client-owned cats: 77 cats with pancreatitis and 77 control cats with no evidence of pancreatitis. METHODS Retrospective record review from October 1, 2017, to October 1, 2022, including cats with gastrointestinal clinical signs, pancreatic lipase immunoreactivity (PLI) 28.8 jig/L or PLI 4,5 to 8.7 µ/L with sonographic evidence of pancreatitis. Control cats had a PLI 5 4.4 µ/L with no sonographic evidence of pancreatitis. RESULTS Cats with pancreatitis had significantly higher International Renal Interest Society CKD stages than controls (P < 001; OR, 13 [95% Cl, 6.3 to 31]), and mean creatinine was on average 0.79 mg/dL (95% Cl, 0.56 to 1.0) higher than controls (P < .001; age covariate ANCOVA, P = .003). Odds of CKD in cats with pancreatitis compared to controls increased significantly with age (P = .002). Cats aged 10 to < 15 years and 15 to 20 years with pancreatitis had significantly higher prevalence of CKD stage 2 to 4 compared to controls (P < .001; OR, 10.9 [95% Cl, 3.4 to 44]; and P = .001; OR, 66 [95% Cl, 4.6 to > 1,000], respectively). Cats with pancreatitis had significantly more sonographic renal infarcts (P = .004; OR, 6.9 [95% Cl, 1.8 to 46]) and concurrent diabetes mellitus (P = .002; OR, 6 [95% Cl, 1.9 to 27]). Cats with pancreatitis were fed more exclusively dry-food diets compared to controls (P = .014). CLINICAL RELEVANCE Pancreatitis is associated with CKD in cats. Investigating and treating these diseases concurrently early in the disease process may reduce morbidity and mortality due to progressive disease and expensive hospitalizations. Renal infarcts may be associated with pancreatitis in cats without overt cardiac disease. [ABSTRACT FROM AUTHOR]

Abstract Background Cerebrovascular accidents (CVAs) in dogs are diagnosed using magnetic resonance imaging (MRI). This modality is sometimes unavailable, and CVAs can resemble other lesions on MRI. D‐dimer concentration and thromboelastography (TEG) are utilized in human medicine in addition to diagnostic imaging to support diagnosis of CVAs, but their use in veterinary patients has not been assessed. Objective Assess utility of blood D‐dimer concentration and TEG in supporting the imaging diagnosis of CVAs in dogs. Animals Sixty‐eight client‐owned dogs with neurologic signs that had brain MRI and D‐dimer concentration or TEG performed. Methods Multicenter, retrospective study. The incidence of abnormal D‐dimer concentration or TEG was compared between patients with MRI evidence of CVA and a control population. Analysis methods included Fisher's exact test or Chi‐squared test for association and comparison of independent proportions. Results Neither D‐dimer concentration nor TEG was significantly associated with a CVA (P = .38 and .2, respectively). D‐dimer testing was performed in a low‐risk population and showed low sensitivity (30.8%; 95% confidence interval [CI], 10%‐61%) and high specificity (86.4%; 95% CI, 64%‐96%) for CVA diagnosis. Thromboelastography was performed in a high‐risk population and showed moderate sensitivity (64.3%; 95% CI, 44%‐81%) and specificity (66.7%; 95% CI, 24%‐94%) for CVA diagnosis. Abnormal D‐dimer concentration or TEG were not helpful in differentiating hemorrhagic from ischemic stroke (P = .43 and .41, respectively). Conclusions Although blood D‐dimer concentration or TEG alone are not diagnostic of CVAs in dogs, a positive D‐dimer result supports additional testing for CVA.

Background: Cerebrovascular accidents (CVAs) in dogs are diagnosed using magnetic resonance imaging (MRI). This modality is sometimes unavailable, and CVAs can resemble other lesions on MRI. D‐dimer concentration and thromboelastography (TEG) are utilized in human medicine in addition to diagnostic imaging to support diagnosis of CVAs, but their use in veterinary patients has not been assessed. Objective: Assess utility of blood D‐dimer concentration and TEG in supporting the imaging diagnosis of CVAs in dogs. Animals: Sixty‐eight client‐owned dogs with neurologic signs that had brain MRI and D‐dimer concentration or TEG performed. Methods: Multicenter, retrospective study. The incidence of abnormal D‐dimer concentration or TEG was compared between patients with MRI evidence of CVA and a control population. Analysis methods included Fisher's exact test or Chi‐squared test for association and comparison of independent proportions. Results: Neither D‐dimer concentration nor TEG was significantly associated with a CVA (P =.38 and.2, respectively). D‐dimer testing was performed in a low‐risk population and showed low sensitivity (30.8%; 95% confidence interval [CI], 10%‐61%) and high specificity (86.4%; 95% CI, 64%‐96%) for CVA diagnosis. Thromboelastography was performed in a high‐risk population and showed moderate sensitivity (64.3%; 95% CI, 44%‐81%) and specificity (66.7%; 95% CI, 24%‐94%) for CVA diagnosis. Abnormal D‐dimer concentration or TEG were not helpful in differentiating hemorrhagic from ischemic stroke (P =.43 and.41, respectively). Conclusions: Although blood D‐dimer concentration or TEG alone are not diagnostic of CVAs in dogs, a positive D‐dimer result supports additional testing for CVA. [ABSTRACT FROM AUTHOR]

H2S-donors are cardioprotective in ischemia/reperfusion (I/R) injury. Some H2S-donors exert their beneficial effects in a nitric oxide (NO)-dependent manner, while others act using NO-independent pathways. The aims of the present study were to (i) evaluate whether H2S-donors with distinct pharmacodynamic properties act synergistically in I/R injury and (ii) determine if H2S-donors remain cardioprotective in obese mice. C57BL/6 mice were subjected to 30 min of ischemia followed by 120 min of reperfusion. Donors were administered intravenously at the end of ischemia (Na2S: 1 μmol/kg, GYY4137: 25 μmol/kg, AP39: 0,25 μmol/kg), while the 3-mercaptopyruvate sulfurtransferase (10 mg/kg) inhibitor was given intraperitonially 1 h prior to ischemia. Infarct size was estimated by 2,3,5-triphenyltetrazolium staining, while the area at risk was calculated using Evans blue. All three donors reduced infarct size when administered as a sole treatment. Co-administration of Na2S/GYY4137, as well as Na2S/AP39 reduced further the I/R injury, beyond what was observed with each individual donor. Since inhibition of the H2S-producing enzyme 3-mercaptopyruvate sulfurtransferase is known to reduce infarct size, we co-administered C3 with Na2S to determine possible additive effects between the two agents. In this case, combination of C3 with Na2S did not yield superior results compared to the individual treatments. Similarly, to what was observed in healthy mice, administration of a H2S-donor (Na2S or AP39) reduced I/R injury in mice rendered obese by consumption of a high fat diet. We conclude that combining a NO-dependent with a NO-independent H2S-donor leads to enhanced cardioprotection and that H2S-donors remain effective in obese animals. [ABSTRACT FROM AUTHOR]

Long insular artery (LIA) infarct can occur after insular glioma surgery. LIA infarct after extracranial-intracranial (EC-IC) bypass is very rare, and so far, it is not reported in EC-IC bypass. Here, we report a case of high-flow EC-IC bypass, where postoperatively, the patient developed isolated LIA infarct. A 65-year-old female presented with recurrent severe headache along with altered sensorium. Computed tomography (CT) scan and CT angiography (CTA) of the brain showed ruptured large left internal carotid artery (ICA) fusiform aneurysm. She underwent left-sided, high-flow EC-IC bypass involving upper trunk of left middle cerebral artery (MCA) and ICA ligation at neck at its origin. Postoperatively, the patient developed right sided hemiplegia. Postoperative MRI of the brain showed left-sided external capsular infarct, extending up to the corona radiata resulted from LIA infarct. By the end of 6 months after operation, she could walk with support but her left upper limb remained more severely affected and magnetic resonance angiogram (MRA) showed almost disappearance of aneurysm with functioning bypass. [ABSTRACT FROM AUTHOR]

Objectives: Cerebellar infarction is an ischemic or hemorrhagic type episode involving the three main cerebellar arteries. An infarction in each of these arteries causes different but common symptoms, requiring a particularly important contribution of physiotherapy to its treatment. This overview aimed to investigate the effectiveness of physiotherapy programs on the symptoms of patients with cerebellar infarction. Methods: A literature search was performed using eight databases and the keywords, including physiotherapy, physical therapy, rehabilitation, therapeutic exercise, exercise, cerebellar infarct, cerebellar infarction, and cerebellar blockage. The selection process of the final studies was carried out after setting inclusion and exclusion criteria and separately by two reviewers. Results: Out of 1477 initial records, six studies met the inclusion criteria for this overview. Interventions focused on a balance training program and walking training, as opposed to a treadmill training program, seem to improve symptoms in these patients. Also, task-oriented approach was a promising method of rehabilitation. Discussion: Physiotherapy has a beneficial effect on the symptoms of patients with cerebellar infarction and should be considered for the overall recovery of the patient. However, future research is needed due to the small number of studies and to find therapeutically proven forms of intervention. Coresponding author: Georgios Marios Kyriakatis, E-mail: georgemarioskiriakatis2000@gmail.com You can also search for this author in: PubMed, Google Scholar

Abstract Background Capsular warning syndrome (CWS) is a rare clinical syndrome characterised by recurrent and transient episodes of focal neurological deficits with high risk of infarction. The exact physiological mechanism of CWS remains unclear but is most commonly believed to be a result of haemodynamic insufficiency in diseased, small penetrating vessels. There are no defined treatment guidelines or established effective therapy. Case presentation We describe the case of a 65-year-old man who presented to the emergency department with recurrent episodes of dysarthria coupled with right facial droop and right-sided weakness. Symptoms recurred a total of ten times within a span of 3 h. He had new onset atrial fibrillation. An initial cerebral angiogram showed mild intracranial atherosclerotic disease with no proximal large vessel occlusion or acute infarct. Magnetic resonance imaging 1 h later demonstrated an infarct in the left corona radiata. Conclusions This case illustrates an uncommon etiology of CWS. We will also discuss the lack of consensus in treatment options for CWS to mitigate a complete stroke.

Central Nervous System (CNS) is one of the major system involved in HIV and HCV infected individuals. There are various mechanisms through which virus enters into the brain tissue and activates immunological response to cause damage to brain tissue. Consequences can ranges from minor cognitive motor impairment to life threatening secondary opportunistic infections like progressive multifocal leukoencephalopathy, toxoplasmosis, cryptococcosis and mycobacterial infection e.g. tubercular meningitis and tuberculoma. Stroke is also one of the rare complication which can be seen as a sequelae of vasculitis. Previous studies have shown significant association between HIV and HCV pathogenesis to involve central nervous system. In this case series, ten cases are discussed in which CNS manifestations of individuals affected with co-infection with HIV and HCV. All these individuals presented at younger age showing its significant association to cause the CNS manifestations. [ABSTRACT FROM AUTHOR]

Background and aim: Imaging of patients with COVID-19 has provided unique insights into the pathophysiology of the infection. Cysts are a rare manifestation of the disease in the lung. The aim of this research was to compare COVID-19-positive patients with cysts on CT to patients without cysts and propose a mechanism for cyst formation in this patient population based on radiographic observations. Materials and Methods: Our HIPAA-compliant IRB-approved research project involved a retrospective review of 219 chest CT scans identified in COVID-19-positive inpatients and emergency room patients at Columbia University Irving Medical Center from February 27, 2020 to July 17, 2020. A thoracic radiologist with over 20 years of experience reviewed the images on lung window settings and identified the presence of cysts, their distribution (central or pleural based), and if there was an accompanying pneumothorax. The extent of consolidation of the entire lung on a scale of 0-16 and the presence of fibrosis were also documented. Results: Cysts were identified in 10 of the 219 patients. CT scans with cysts were obtained on average on day 57 of symptoms (range 16-115 days) compared to CT scans of those without cysts that were obtained on average on day 19 (range 0-89 days). The distribution of cysts was heterogeneous; six patients had multiple cysts while four were isolated. Seven cysts were peripheral in distribution while three were central. Two patients with cysts developed a subsequent pneumothorax. Fifty percent of those with cysts had been intubated. Conclusions: Patients with COVID-19 develop cystic lung lesions for at least two reasons; pleuralbased lesions are more likely areas of infarction and central lesions with surrounding ground glass are more likely related to infection and/or mechanical ventilation. [ABSTRACT FROM AUTHOR]

Background: Left atrial volume index (LAVI) is one marker of atrial myopathy, which is increasingly being recognized as a cause of cardioembolic stroke even in the absence of atrial fibrillation. Cardiac embolism is associated with larger strokes than other stroke mechanisms. The purpose of this study was to examine the association between LAVI and total brain infarct volume in patients with ischemic stroke. Methods: This was a retrospective study of 545 patients prospectively enrolled in the Cornell ActuE Stroke Academic Registry (CAESAR), which includes all acute ischemic stroke patients admitted to our hospital since 2011. LAVI measurements were obtained from our echocardiography image store system (Xclera, Philips Healthcare). Brain infarcts on diffusion-weighted images (DWI) were manually segmented and infarct volume was obtained on 3D Slicer. We used multiple linear regressionmodels adjusted for age, sex, race, and vascular comorbidities including atrial fibrillation. Results: Among 2,945 CAESAR patients, 545 patients had both total infarct volume and LAVI measured. We found an association between LAVI and log-transformed total brain infarct volume in both unadjusted (β = 0.018; p = 0.002) and adjusted (β = 0.024; p = 0.001) models. Conclusion: We found that larger left atrial volume was associated with larger brain infarcts. This association was independent of known cardioembolic risk factors such as atrial fibrillation and heart failure. These findings support the concept that atrial myopathy may be a source of cardiac embolism even in the absence of traditionally recognized mechanisms such as atrial fibrillation. [ABSTRACT FROM AUTHOR]

Abstract Background Endometrial carcinosarcomas are rare and carry a very poor prognosis. They usually present with extensive lymphatic spread. An acute presentation of a stroke may reveal the underlying diagnosis. Case presentation A woman in her 50s with no reported medical history presented to the emergency department as a code stroke. She was found during the evening by her sister leaving the bathroom disheveled. At that time, she was found to be mute, not following commands, with left gaze deviation and right hemiparesis. Computed tomography (CT) imaging showed an acute infarct in the left middle cerebral artery M2 branch or frontoparietal territory consistent with acute stroke. Upon further review, the sister states that she has had significant vaginal bleeding and never had menopause. On admission, she had significant anemia. CT of the abdomen and pelvis showed a large right adnexal mass, endometrial thickening, diffuse lymphadenopathy, omental nodularity, and a pulmonary nodule concerning for gynecologic malignancy with metastasis. Surgical pathology showed high grade endometrial carcinosarcoma. She was outside of the tPA window, and neurology determined her not to be a candidate for thrombectomy. She was managed medically with antiplatelet agents, high dose atorvastatin, and blood transfusions. Conclusions Endometrial carcinosarcoma can present with severe anemia and irregular menstrual bleeding. In patients without routine gynecologic care, endometrial carcinosarcoma can go unnoticed and only be identified after workup for another condition such as acute stroke. Endometrial biopsy for diagnosis may be challenging in a patient with severe anemia. Alternatively, transvaginal ultrasonography with Doppler study and magnetic resonance imaging may be used to support the diagnosis. Furthermore, endometrial carcinosarcoma can complicate ischemic stroke management as it can present with bleeding and make it difficult to use anticoagulating agents.

BackgroundLeft atrial volume index (LAVI) is one marker of atrial myopathy, which is increasingly being recognized as a cause of cardioembolic stroke even in the absence of atrial fibrillation. Cardiac embolism is associated with larger strokes than other stroke mechanisms. The purpose of this study was to examine the association between LAVI and total brain infarct volume in patients with ischemic stroke.MethodsThis was a retrospective study of 545 patients prospectively enrolled in the Cornell ActuE Stroke Academic Registry (CAESAR), which includes all acute ischemic stroke patients admitted to our hospital since 2011. LAVI measurements were obtained from our echocardiography image store system (Xclera, Philips Healthcare). Brain infarcts on diffusion-weighted images (DWI) were manually segmented and infarct volume was obtained on 3D Slicer. We used multiple linear regression models adjusted for age, sex, race, and vascular comorbidities including atrial fibrillation.ResultsAmong 2,945 CAESAR patients, 545 patients had both total infarct volume and LAVI measured. We found an association between LAVI and log-transformed total brain infarct volume in both unadjusted (β = 0.018; p = 0.002) and adjusted (β = 0.024; p = 0.001) models.ConclusionWe found that larger left atrial volume was associated with larger brain infarcts. This association was independent of known cardioembolic risk factors such as atrial fibrillation and heart failure. These findings support the concept that atrial myopathy may be a source of cardiac embolism even in the absence of traditionally recognized mechanisms such as atrial fibrillation.

Introduction: Neurocognitive symptoms and dysfunction of various severities have become increasingly recognized as potential consequences of SARS-CoV-2 infection. Although there are numerous observational and subjective survey- reporting studies of neurological symptoms, by contrast, those studies describing imaging abnormalities are fewer in number. Methods: This study conducted a metanalysis of 32 studies to determine the incidence of the common neurological abnormalities using magnetic resonance imaging (MRI) in patients with COVID-19. Results: We also present the common clinical findings associated with MRI abnormalities. We report the incidence of any MRI abnormality to be 55% in COVID-19 patients with perfusion abnormalities (53%) and SWI abnormalities (44%) being the most commonly reported injuries. Cognitive impairment, ICU admission and/or mechanical ventilation status, older age, and hospitalization or longer length of hospital stay were the most common clinical findings associated with brain injury in COVID-19 patients. Discussion: Overall, the presentation of brain injury in this study was diverse with no substantial pattern of injury emerging, yet most injuries appear to be of vascular origin. Moreover, analysis of the association between MRI abnormalities and clinical findings suggests that there are likely many mechanisms, both direct and indirect, by which brain injury occurs in COVID-19 patients. [ABSTRACT FROM AUTHOR]

Background and purpose: Computed tomography perfusion (CTP) has successfully extended the time window for reperfusion therapies in ischemic stroke. However, the published perfusion parameters and thresholds vary between studies. Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses of Diagnostic Test Accuracy Studies (PRISMA-DTA) guidelines, we conducted a systematic review to investigate the accuracy of parameters and thresholds for identifying core and penumbra in adult stroke patients. Methods: We searched Medline, Embase, the Cochrane Library, and reference lists of manuscripts up to April 2022 using the following terms "computed tomography perfusion," "stroke," "infarct," and "penumbra." Studies were included if they reported perfusion thresholds and undertook co-registration of CTP to reference standards. The quality of studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool and Standards for Reporting of Diagnostic Accuracy (STARD) guidelines. Results: A total of 24 studies were included. A meta-analysis could not be performed due to insufficient data and significant heterogeneity in the study design. When reported, the mean age was 70.2 years (SD+/-3.69), and the median NIHSS on admission was 15 (IQR 13-17). The perfusion parameter identified for the core was relative cerebral blood flow (rCBF), with a median threshold of <30% (IQR 30, 40%). However, later studies reported lower thresholds in the early time window with rapid reperfusion (median 25%, IQR 20, 30%). A total of 15 studies defined a single threshold for all brain regions irrespective of collaterals and the gray and white matter. Conclusion: A single threshold and parameter may not always accurately differentiate penumbra from core and oligemia. Further refinement of parameters is needed in the current era of reperfusion therapy. [ABSTRACT FROM AUTHOR]

Purpose: Previous work suggests that Dihydroorotate dehydrogenase (DHODH) inhibition via teriflunomide (TERI) may provide protection in multiple disease models. To date, little is known about the effect of TERI on the heart. This study was performed to assess the potential effects of TERI on cardiac ischemia reperfusion injury. Methods: Male and female rat hearts were subjected to global ischemia (25 min) and reperfusion (120 min) on a Langendorff apparatus. Hearts were given either DMSO (VEH) or teriflunomide (TERI) for 5 min prior to induction of ischemia and during the reperfusion period. Left ventricular pressure, ECG, coronary flow, and infarct size were determined using established methods. Mitochondrial respiration was assessed via respirometry. Results: Perfusion of hearts with TERI led to no acute effects in any values measured across 500 pM–50 nM doses. However, following ischemia–reperfusion injury, we found that 50 nM TERI-treated hearts had an increase in myocardial infarction (p < 0.001). In 50 nM TERI-treated hearts, we also observed a marked increase in the severity of contracture (p < 0.001) at an earlier time-point (p = 0.004), as well as reductions in coronary flow (p = 0.037), left ventricular pressure development (p = 0.025), and the rate-pressure product (p = 0.008). No differences in mitochondrial respiration were observed with 50 nM TERI treatment (p = 0.24–0.87). Conclusion: This study suggests that treatment with TERI leads to more negative outcomes following cardiac ischemia reperfusion, and administration of TERI to at-risk populations should receive special considerations. [ABSTRACT FROM AUTHOR]

Background: Capsular warning syndrome (CWS) is a rare clinical syndrome characterised by recurrent and transient episodes of focal neurological deficits with high risk of infarction. The exact physiological mechanism of CWS remains unclear but is most commonly believed to be a result of haemodynamic insufficiency in diseased, small penetrating vessels. There are no defined treatment guidelines or established effective therapy. Case presentation: We describe the case of a 65-year-old man who presented to the emergency department with recurrent episodes of dysarthria coupled with right facial droop and right-sided weakness. Symptoms recurred a total of ten times within a span of 3 h. He had new onset atrial fibrillation. An initial cerebral angiogram showed mild intracranial atherosclerotic disease with no proximal large vessel occlusion or acute infarct. Magnetic resonance imaging 1 h later demonstrated an infarct in the left corona radiata. Conclusions: This case illustrates an uncommon etiology of CWS. We will also discuss the lack of consensus in treatment options for CWS to mitigate a complete stroke. [ABSTRACT FROM AUTHOR]

Objectives: Cerebellar infarction is an ischemic or hemorrhagic type episode involving the three main cerebellar arteries. An infarction in each of these arteries causes different but common symptoms, requiring a particularly important contribution of physiotherapy to its treatment. This overview aimed to investigate the effectiveness of physiotherapy programs on the symptoms of patients with cerebellar infarction. Methods: A literature search was performed using eight databases and the keywords, including physiotherapy, physical therapy, rehabilitation, therapeutic exercise, exercise, cerebellar infarct, cerebellar infarction, and cerebellar blockage. The selection process of the final studies was carried out after setting inclusion and exclusion criteria and separately by two reviewers. Results: Out of 1477 initial records, six studies met the inclusion criteria for this overview. Interventions focused on a balance training program and walking training, as opposed to a treadmill training program, seem to improve symptoms in these patients. Also, task-oriented approach was a promising method of rehabilitation. Discussion: Physiotherapy has a beneficial effect on the symptoms of patients with cerebellar infarction and should be considered for the overall recovery of the patient. However, future research is needed due to the small number of studies and to find therapeutically proven forms of intervention. [ABSTRACT FROM AUTHOR]

Purpose: The effect of pretreatment infarct location on clinical outcome after successful mechanical thrombectomy is not understood. Our aim was to evaluate the association between computed tomography perfusion (CTP)-based ischemic core location and clinical outcome following excellent reperfusion in late time windows. Methods: We retrospectively reviewed patients who underwent thrombectomy for acute anterior circulation large vessel occlusion in late time windows from October 2019 to June 2021 and enrolled 65 patients with visible ischemic core on admission CTP who had received excellent reperfusion (modified thrombolysis in cerebral infarction grade 2c/3). Poor outcome was defined as a modified Rankin scale score of 3–6 at 90 days. The ischemic core infarct territories were classified into the cortical and subcortical areas. Multivariate logistic regression and receiver operating characteristic (ROC) curve analyses were used in this study. Results: Of the 65 patients analyzed, 38 (58.5%) had a poor outcome. Multivariable logistic analysis showed that the subcortical infarcts (OR 11.75; 95% CI 1.79–77.32; P = 0.010) and their volume (OR 1.17; 95% CI 1.04–1.32; P = 0.011) were independently associated with poor outcome. The ROC curve indicated the capacity of the subcortical infarct involvement (areas under the curve (AUC) = 0.65; 95% CI, 0.53–0.77, P < 0.001) and subcortical infarct volume (AUC = 0.72; 95% CI, 0.60–0.83, P < 0.001) in predicting poor outcome accurately. Conclusion: Subcortical infarcts and their volume on admission CTP are associated with poor outcome after excellent reperfusion in late time windows, rather than cortical infarcts. [ABSTRACT FROM AUTHOR]

Pituitary adenomas are rare in children, and often present with symptoms of headache, nausea or emesis, visual disturbance, or hormonal hypersecretion. With large tumors, mass effect from the lesion can lead to severe endocrinopathy and compression of intracranial neurovascular structures. In this case report, we describe an unusual presentation of an ischemic stroke in the territory of the right middle cerebral artery resulting from a prolactin-secreting macroadenoma. The patient's primary symptoms were headache, left facial droop, and left hemibody weakness. She was successfully managed with cabergoline, a dopamine agonist, with a reduction in the size of the tumor and normalization of serum prolactin levels. She remained clinically stable throughout her hospitalization, and was safely discharged without surgical intervention. In her recent 2-year follow-up, her tumor and prolactin levels were stable and she had dramatic improvements in her left-sided muscle strength.

Abstract Background Volumetric accuracy of using computed tomography perfusion (CTP) to estimate the post-treatment infarct in stroke patients with successful recanalization after mechanical thrombectomy (MT) has been studied a lot, however the spatial accuracy and its influence factors has not been fully investigated. Methods This retrospective study reviewed the data from consecutive anterior large vessel occlusion (LVO) patients who had baseline CTP, successful recanalization after MT, and post-treatment diffusion-weighed imaging (DWI). Ischemic core on baseline CTP was estimated using relative cerebral blood flood (CBF) of

Abstract Background This study examined neuropathological findings of patients who died following hospitalization in an intensive care unit with SARS-CoV-2. Methods Data originate from 20 decedents who underwent brain autopsy followed by ex-vivo imaging and dissection. Systematic neuropathologic examinations were performed to assess histopathologic changes including cerebrovascular disease and tissue injury, neurodegenerative diseases, and inflammatory response. Cerebrospinal fluid (CSF) and fixed tissues were evaluated for the presence of viral RNA and protein. Results The mean age-at-death was 66.2 years (range: 26–97 years) and 14 were male. The patient’s medical history included cardiovascular risk factors or diseases (n = 11, 55%) and dementia (n = 5, 25%). Brain examination revealed a range of acute and chronic pathologies. Acute vascular pathologic changes were common in 16 (80%) subjects and included infarctions (n = 11, 55%) followed by acute hypoxic/ischemic injury (n = 9, 45%) and hemorrhages (n = 7, 35%). These acute pathologic changes were identified in both younger and older groups and those with and without vascular risk factors or diseases. Moderate-to-severe microglial activation were noted in 16 (80%) brains, while moderate-to-severe T lymphocyte accumulation was present in 5 (25%) brains. Encephalitis-like changes included lymphocytic cuffing (n = 6, 30%) and neuronophagia or microglial nodule (most prominent in the brainstem, n = 6, 30%) were also observed. A single brain showed vasculitis-like changes and one other exhibited foci of necrosis with ball-ring hemorrhages reminiscent of acute hemorrhagic leukoencephalopathy changes. Chronic pathologies were identified in only older decedents: 7 brains exhibited neurodegenerative diseases and 8 brains showed vascular disease pathologies. CSF and brain samples did not show evidence of viral RNA or protein. Conclusions Acute tissue injuries and microglial activation were the most common abnormalities in COVID-19 brains. Focal evidence of encephalitis-like changes was noted despite the lack of detectable virus. The majority of older subjects showed age-related brain pathologies even in the absence of known neurologic disease. Findings of this study suggest that acute brain injury superimposed on common pre-existing brain disease may put older subjects at higher risk of post-COVID neurologic sequelae.

Background. It is known that adaptation to chronic continuous hypoxia leads to a pronounced cardioprotective effect. The efficiency of acute adaptation to hypoxia is reduced in metabolic syndrome. However, the effectiveness of the myocardial infarct size-limiting effect of chronic continuous hypoxia in metabolic syndrome remains an understudied fact. The aim. To study the effectiveness of the development of the myocardial infarct size-limiting effect of chronic continuous hypoxia in rats with metabolic syndrome. Materials and methods. The study was carried out on 43 Wistar rats. Adaptation of animals to chronic hypoxia was performed during 21 days in a hypoxic chamber (12 % O2, 0.3 % CO2). Metabolic syndrome was modeled by keeping rats on a high-carbohydrate and high-fat diet (proteins 16 %, fats 21 %, carbohydrates 46 % (including fructose 17 %), cholesterol 0.125 %, cholic acid 0.5 %) for 12 weeks with replacement of drinking water with 20% fructose solution. Coronary occlusion-reperfusion was performed in vivo. The effect of chronic hypoxia and metabolic syndrome on myocardial infarct size was assessed. Results. It was found that myocardial infarct size in rats after chronic continuous hypoxia was 38 % less than in animals of the control group. In rats which were kept on a high-carbohydrate and high-fat diet we observed the obesity, decreased glucose tolerance, increased serum triglycerides level, and hypertension. Adaptation to chronic continuous hypoxia in animals on a high-carbohydrate and high-fat diet improved carbohydrate metabolism, but did not affect the severity of other metabolic disorders. At the same time, the myocardial infarct size-limiting effect of chronic hypoxia was not observed in rats with metabolic syndrome. Conclusion. Metabolic syndrome eliminated myocardial infarct size-limiting effect of chronic continuous hypoxia.

Aim:Cerebral small vessel disease (CSVD) is a representative cause of stroke, cognitive impairment, and age-related disability, and it is shown to be associated with some traditional atherosclerotic risk factors. This study investigated relationship between the presence and severity of intracranial arterial calcification (ICAS) and the findings of CSVD.Methods:Three hundred eighty-nine patients over the age of 40 who underwent non-enhanced cranial computed tomography (CT) and magnetic resonance imaging between January 01 and December 31, 2018, were included in the retrospective study. ICAS was scored on CT. CSVD findings, enlarged perivascular spaces (BGPVS, CSPVS), white matter hyperintensities [white matter hyperintensity was scored at periventricular (PVWMHI), white matter hyperintensity was scored at subcortical (SCWMHI)], cortical atrophy [global atrophy (GA) score, and medial temporal atrophy (MTA), Koedam score] were scored in MR images. The presence of acute, chronic, and lacunar infarcts was recorded. After controlling for age and gender, the correlation between ICAS and CSVD markers was examined.Results:A positive correlation was found between ICAS score and BGPVS (r: 0.463 p

Background and purposeComputed tomography perfusion (CTP) has successfully extended the time window for reperfusion therapies in ischemic stroke. However, the published perfusion parameters and thresholds vary between studies. Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses of Diagnostic Test Accuracy Studies (PRISMA-DTA) guidelines, we conducted a systematic review to investigate the accuracy of parameters and thresholds for identifying core and penumbra in adult stroke patients.MethodsWe searched Medline, Embase, the Cochrane Library, and reference lists of manuscripts up to April 2022 using the following terms “computed tomography perfusion,” “stroke,” “infarct,” and “penumbra.” Studies were included if they reported perfusion thresholds and undertook co-registration of CTP to reference standards. The quality of studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool and Standards for Reporting of Diagnostic Accuracy (STARD) guidelines.ResultsA total of 24 studies were included. A meta-analysis could not be performed due to insufficient data and significant heterogeneity in the study design. When reported, the mean age was 70.2 years (SD+/−3.69), and the median NIHSS on admission was 15 (IQR 13–17). The perfusion parameter identified for the core was relative cerebral blood flow (rCBF), with a median threshold of

IntroductionNeurocognitive symptoms and dysfunction of various severities have become increasingly recognized as potential consequences of SARS-CoV-2 infection. Although there are numerous observational and subjective survey-reporting studies of neurological symptoms, by contrast, those studies describing imaging abnormalities are fewer in number.MethodsThis study conducted a metanalysis of 32 studies to determine the incidence of the common neurological abnormalities using magnetic resonance imaging (MRI) in patients with COVID-19.ResultsWe also present the common clinical findings associated with MRI abnormalities. We report the incidence of any MRI abnormality to be 55% in COVID-19 patients with perfusion abnormalities (53%) and SWI abnormalities (44%) being the most commonly reported injuries. Cognitive impairment, ICU admission and/or mechanical ventilation status, older age, and hospitalization or longer length of hospital stay were the most common clinical findings associated with brain injury in COVID-19 patients.DiscussionOverall, the presentation of brain injury in this study was diverse with no substantial pattern of injury emerging, yet most injuries appear to be of vascular origin. Moreover, analysis of the association between MRI abnormalities and clinical findings suggests that there are likely many mechanisms, both direct and indirect, by which brain injury occurs in COVID-19 patients.

Background: Endometrial carcinosarcomas are rare and carry a very poor prognosis. They usually present with extensive lymphatic spread. An acute presentation of a stroke may reveal the underlying diagnosis. Case presentation: A woman in her 50s with no reported medical history presented to the emergency department as a code stroke. She was found during the evening by her sister leaving the bathroom disheveled. At that time, she was found to be mute, not following commands, with left gaze deviation and right hemiparesis. Computed tomography (CT) imaging showed an acute infarct in the left middle cerebral artery M2 branch or frontoparietal territory consistent with acute stroke. Upon further review, the sister states that she has had significant vaginal bleeding and never had menopause. On admission, she had significant anemia. CT of the abdomen and pelvis showed a large right adnexal mass, endometrial thickening, diffuse lymphadenopathy, omental nodularity, and a pulmonary nodule concerning for gynecologic malignancy with metastasis. Surgical pathology showed high grade endometrial carcinosarcoma. She was outside of the tPA window, and neurology determined her not to be a candidate for thrombectomy. She was managed medically with antiplatelet agents, high dose atorvastatin, and blood transfusions. Conclusions: Endometrial carcinosarcoma can present with severe anemia and irregular menstrual bleeding. In patients without routine gynecologic care, endometrial carcinosarcoma can go unnoticed and only be identified after workup for another condition such as acute stroke. Endometrial biopsy for diagnosis may be challenging in a patient with severe anemia. Alternatively, transvaginal ultrasonography with Doppler study and magnetic resonance imaging may be used to support the diagnosis. Furthermore, endometrial carcinosarcoma can complicate ischemic stroke management as it can present with bleeding and make it difficult to use anticoagulating agents. [ABSTRACT FROM AUTHOR]