Acute disseminated encephalomyelitis (ADEM) is an uncommon diagnosis in adults. It is known to be due to an abnormal immune response to a systemic infection rather than direct viral invasion to the central nervous system. There have been few reports of ADEM diagnosed in the setting of COVID-19 systemic infection. However, we report a case of Coxsackie induced ADEM that remitted but got exacerbated by COVID-19 infection. The patient contracted the COVID-19 infection shortly after being discharged to a rehabilitation facility. Direct COVID-19 neuroinvasion was ruled out via CSF PCR testing for the virus. The patient responded well to pulse steroid therapy and plasmapheresis in both occasions. We hypothesize that COVID-19 infection can flareup a recently remitted ADEM via altering the immune responses. It is known now that COVID-19 infection can produce cytokine storming. Cytokine pathway activation is known to be involved in the pathology of ADEM. Caution regarding discharging immune suppressed patient to the inpatient rehabilitation facility should be made in the era of COVID-19 pandemic.

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BACKGROUND AND IMPORTANCE: Intraparenchymal hemorrhage (IPH) is a debilitating and highly morbid type of stroke with limited effective treatment modalities. Minimally invasive evacuation with tissue plasminogen activator (rt-PA) has demonstrated promise for mortality/functional improvements with adequate clot volume reduction. In this study, we report 2 cases of continuous rt-PA infusion using a closed circuit, dual lumen catheter, and irrigation system (IRRAflow) for IPH treatment. CLINICAL PRESENTATION: A 55-year-old man was admitted for acute onset left hemiparesis; he was found to have right basal ganglia IPH. He was treated with continuous rt-PA irrigation using the IRRAflow device, at a rate of 30 mL/h for 119 hours, with a total volume reduction of 87.8 mL and post-treatment volume of 1.2 mL. At 3-month follow-up, he exhibited a modified Rankin score of 4 and improved hemiparesis. A 39-year-old woman was admitted for acute onset left facial droop, left hemianopsia, and left hemiparesis; she was diagnosed with a right basal ganglia IPH. She was treated with drainage and continuous rt-PA irrigation at 30 mL/h for 24 hours, with a total hematoma volume reduction of 41 mL and with a final post-treatment volume of 9.1 mL. At 3-month followup, she exhibited a modified Rankin score of 3 with some improvement in left hemiparesis. CONCLUSION: Continuous rt-PA infusion using a minimally invasive catheter with saline irrigation was feasible and resulted in successful volume reduction in 2 patients with IPH. This technique is similar to the Minimally Invasive Surgery Plus rt-PA for Intracerebral Hemorrhage Evacuation (MISTIE) approach but offers the potential advantages of less breaks in the sterile circuit, continuous intracranial pressure monitoring, and may provide more efficient clot lysis compared with intermittent bolusing.

Pearls cLongitudinally extensive transverse myelitis (TM) or TM with inconclusive CSF findings should raise concern for prion disease (also known as Creutzfeldt-Jacob disease [CJD]) especially in the setting of associated cognitive impairment. c CJD associated with focal findings should raise suspicion for spinal cord involvement and warrants spinal imaging. c Spinal cord involvement in CJD could suggest more rapid disease progression, although further investigations are warranted. Oy-sters cThe MRI findings in the brain typically associated with CJD may not appear until later in disease progression. c Evaluation of a patient presenting with subacute to acute myelopathy should include CSF testing for prion disease when there is associated rapid decline in mental status.A 57-year-old man with a history of monoclonal B-cell lymphocytosis was admitted because of 2 months of progressive clumsiness, gait instability, and bowel/bladder incontinence. There was no family history of dementia or similar symptoms. Neurologic examination showed poor attention, tangential thinking, dysarthria, right leg weakness, right arm ataxia, tremors, and an upgoing right toe. There was no sensory level and jaw jerk was not tested. In addition to cerebral injury, these symptoms, together with incontinence, were clinically more suggestive of a primary myelopathy. However, uncertainty about spinal vs cortical pathology remained and thus MRI spine and brain were obtained. MRI spine ( figure, A and B) demonstrated a longitudinally extensive transverse myelitic (LETM) lesion in the cervicothoracic (C6-T1) region while MRI brain was unremarkable. CSF analysis demonstrated the following: glucose 93 mg/dL, protein 55 mg/dL, white blood cells <3, and red blood cells <3. Cytology showed no abnormal cells to suggest CNS lymphomatous involvement. Previous evaluation for monoclonal B-cell lymphocytosis revealed a kappa light chain restricted CD20+ population comprising 12% of the patient's lymphocytes. This was monitored biannually without treatment and was noted to have improved on its own by the time of hospital presentation. Further workup for LETM, including aquaporin-4 antibody, immunoglobulin G index, oligoclonal band index, antinuclear antibody, extractable nuclear antigen antibodies, vitamin B 12 , copper, vitamin E, autoimmune, and paraneoplastic antibody testing, were all unrevealing. Infectious evaluation was negative in the CSF (including HIV, herpes simplex virus 1, herpes simplex virus 2, cytomegalovirus, and varicella-zoster virus) and serum (including Lyme antibodies, human T-cell lymphotropic virus, fungal serologies, hepatitis, and syphilis). CT chest was negative for evidence of sarcoidosis.

Background Hyperbaric oxygen therapy (HBOT) for the treatment of acute stroke has been under the radar for a long time. Previous studies have not been able to prove efficacy. Several factors might have contributed to such inconsistent results. The timing of delivering the hyperbaric oxygen in relation to the stage of stroke evolution may be an important factor. This was not taken into account in the previous studies as there was no feasible and standardized method to assess the penumbra in the acute phase. Now with the perfusion scan appearing as a key player in the acute stroke management, precise stroke patient selection for hyperbaric oxygen therapy deserves a second chance similar to mechanical thrombectomy. Case presentation A 62-year-old female patient who presented with acute large vessel stroke was not eligible for chemical or mechanical thrombectomy. There was a large penumbra on imaging. She got treated with several sessions of hyperbaric oxygen over a 2-week period immediately after stroke. The patient showed significant improvement on the follow-up perfusion imaging as well as some clinical improvement. The more impressive radiological improvement was probably due to the presence of relatively large core infarction at baseline affecting functional brain areas. The patient continued to improve clinically on her 6-month follow up visit. Conclusion Our case demonstrates immediate stroke-related penumbra improvement associated with HBOT. Based on that, we anticipate a potential role for HBOT in acute stroke management considering precise patient selection. Future randomized controlled trials are needed and should take that in consideration.

Background: Respiratory centers are known to be present in the central medulla oblongata and pons. There are multiple complex respiratory networks involving these centers. The midbrain periaqueductal grey is believed to act as a regulator of the respiratory function. The effect of brain-stem strokes on respiration remains understudied. There is a lack of clear understanding of the anatomical influence of such strokes on respiration. We attempted to identify brain-stem locations with the highest liability for respiratory failure in case of stroke. Methods: We included all ischemic and hemorrhagic brain-stem strokes from our stroke-registry between 2016 and 2018 then performed univariate/multivariate regression-analyses on variables that might predict respiratory failure and the need for intubation. The brain stem was divided into nine locations (right lateral, central, left lateral in each of the midbrain, pons, and medulla oblongata). Results: Out of 128 brain-stem strokes of different sizes and etiologies, central midbrain strokes were the only significant and independent affected location associated with respiratory failure and endotracheal intubation (coefficient= 0.1256, 95%-CI= 0.0175, 0.2338, p= 0.023). R-squared was equal to 15% when only central midbrain strokes stayed in the model. Conclusions: While one might assume that central medullary and pontine strokes have the most impact on respiration; our results show that central midbrain is the most impactful, accounting for about 15% of respiratory instability associated with brain-stem strokes. This can be explained by the adaptive nature of respiratory circuits within the medulla and pons. Central periaqueductal grey within the midbrain controls the rate and depth of respiration and might not have the same flexibility present elsewhere.