John and Lindsay are proud to announce the fourth edition of the Cortical Ribbon. We are crossing borders, blowing minds, and as always, squeezing a corny joke or two in when we can (our editorial staff suffers from a touch of the Witzelsucht). This week’s edition includes some hot off the press trial data and fascinating space medicine pearls.
Study Snippet – Wake up to a New DAWN.
Care to see some cold hard evidence in support of the 11 overnight stroke consults? Ever wonder why we are called for patient who was dizzy, weak, confused, numb, or silent sometime in the last 24 hours?
The number needed to treat in the DAWN trial, which included patients presenting within 24 hours of stroke symptom onset with ICA or proximal MCA occlusions and a tissue perfusion mismatch. Functional independence was achieved in 49% of patients in the thrombectomy group as compared to 13% in the control group. The data seems to fade away around 30mL core infarct size just so you know.
Case of the Week: Sarcoid Strikes Again
Wait… Is it actually sarcoid this time?
A middle aged male with no past medical history presents as a transfer from an outside hospital for a headache. On arrival to the US he started noticing intermittent non-bloody diarrhea, which he attributed to the change in food scene. Over the last three months he began to notice dyspnea on exertion, which was unusual for him as he had always been in good shape. He presented to an outside hospital when his headache of a few days became unbearable. Without spoiling the diagnosis, here is the some interesting findings on his MRI/MRV on arrival:
Findings showed occlusion of the anterior superior sagittal sinus with extensive vasogenic edema within the anterior bifrontal lobes. In addition we see contrast enhancement in a lobar, patchy distribution near the region of the likely venous outflow occlusion. At this point in time, differential was most suggestive of sarcoidosis versus lymphoma. Given his diarrhea, there was concern for an ulcerative colitis picture leading to a hypercoagulable state, but colonoscopy done as an inpatient was negative. CXR was obtained even prior to this scan given his dyspnea on exertion, which revealed large mediastinal lymphadenopathy, confirmed on chest CT. He underwent a transbronchial biopsy which revealed the classic non-caseating granulomas seen in sarcoidosis. He was treated with a three day course of IV steroids and discharged on a slow PO steroid taper. He will follow up with us in clinic to continue his clinical management.
There are a few interesting take away points from this case. This patient presented with diarrhea but had a negative colonoscopy. Primary involvement of sarcoidosis in the GI tract is quite rare and this patient’s colonoscopy biopsies were negative. Interestingly, celiac disease has been associated with sarcoidosis, although this patient tested negative. It is unclear if the diarrhea was a red-herring or if it will further pan out as an associated process. Secondly, sarcoidosis places patients at a higher risk for venous thromboembolism, although cerebral venous sinus thrombosis in this setting is rarely reported.
The Price is Rite Review
Visual Impairment and Intracranial Pressure Syndrome
This one is for all of the child astronauts turned adult neurologists. One particular downside to long-term spaceflight is the development of visual problems via optic disc edema. The disorder, named Visual Impairment and Intracranial Pressure Syndrome, does not have a defined mechanism, however elevated ICP is thought to be the culprit. How unfortunate would it be for NASA to send 30 astronauts to Mars with an unknown proportion arriving on the red planet with visual deficits? In an aim to better understand this phenomenon a group of radiologists compared MRI scans of astronauts before and after short term (control) vs long-term (exposure) spaceflights. They found long term spaceflight was associated with an upward shift of the brain and narrowing of the central sulcus and rotation of the cerebral aqueduct (video demonstrations here). On another note, the somatosensory cortex also grows while you are in space. Nothing like swimming through space for six months straight to demonstrate brain plasticity!
This is your Brain on Poetry – Weekly Neurology Haikus
Big brow and nipple discharge
Might be a tumor