Context: Trigeminal neuralgia is typically associated with structural lesions that affect the brainstem, pre-ganglionic roots, gasserian ganglion and the trigeminal nerve. The association of trigeminal neuralgia with infarction of the dorsolateral medulla is rare, being more associated with pontine lesions, in the context of brainstem infarction. Methods: Report the case of a 55-year-old male patient, who presented with a left dorsolateral bulbar infarction, and developed a ipsilateral trigeminal neuralgia afterwards. Case report: A 55-year-old man attended to the emergency room referring sudden incoordination of the left limbs, associated with numbness of the contralateral limbs. The neurological examination showed nystagmus, numbness of the left face, ataxia of the left limbs and numbness of the right limbs. The Magnetic Resonance of the Brain revealed an area of recent infarction in the left posterolateral aspect of the medulla. He underwent thrombolysis, evolving with complete resolution of symptoms. In the week after the initial event, he returned to the outpatient clinic, reporting paroxysms of excruciating pain in the upper lip, nose and left zygomatic region, being diagnosed with neuralgia of the maxillary segment of the trigeminal nerve, improving with introduction of Gabapentin. Conclusion: Although most cases of trigeminal neuralgia are determined by vascular compression of the trigeminal nerve root entry zone, other causes must be considered. The association of this condition with dorsolateral medulla infarction is rare, with only 4 cases reported in the last 10 years.

Context: Vogt-Koyanagi-Harada disease is an inflammatory disorder, which presents with intraocular, auditory and central nervous system involvement. It has two distinct courses: acute onset and chronic recurrence, whose differential diagnoses are, respectively, diseases of the optic neuromyelitis spectrum, and chronic meningitis. The diagnostic criteria developed by the international disease committee in 2001 classify patients into: probable disease (ocular findings only), incomplete (ocular plus cutaneous system or neurological manifestations) and complete (when the three forms occur together). Methods: Report the case of a patient seen at the emergency room of Santa Casa de São Paulo, diagnosed with Vogt-Koyanagi-Harada disease. Case report: 43-year-old woman, reporting occipital headache, with irradiation to the retro-orbital region, progressed to sudden bilateral amaurosis, in addition to conjunctival hyperemia. Neurological physical examination presented bilateral visual acuity (Snellen)> 20/200, poorly delimited optical discs. Uveitis and scleritis were also found. Brain and orbit MRI showed: bilateral retinal detachment, with small subretinal collections; regular thickening and impregnation of the choroid; tenuous episcleral impregnation; alteration of the sign of the inner ears, more evident in the cochleae; tenuous linear leptomeningeal impregnation at the level of the cerebellobulbar cistern. Liquor: 21 cells (99% lymphocytes), 31 proteins and 47 glucose, negative culture for bacteria. We proceeded to infusion 1000mg of methylprednisolone for 3 days, with daily use, subsequently, of prednisone 60mg, with significant improvement of the condition. Conclusions: It is a rare disease, but it must be recognized by every neurologist, since it is treatable and can leave serious visual sequelae.

Background: The Three Territory Sign (TTS) is a radiologic marker of ischemic stroke associated with malignant neoplastic diseases (Trousseau Syndrome) and corresponds to a rare stroke etiology. Case Report: Female, 62-year-old patient, with comorbidities of smoking, hypertension and diabetes, presented with a sudden faciobrachial-predominant left hemiparesis settled in the day before the admission. Diagnosed with a metastatic rectal adenocarcinoma seven months before, she underwent a rectosigmoidectomy three months ago and developed deep vein thrombosis, starting anticoagulant therapy with rivaroxaban 20mg daily. A Magnetic Resonance Imaging (MRI) revealed several lesions with restricted diffusion in multiple vascular territories, bilaterally, corresponding to ischemic stroke. Etiologic investigation did not detect signs of cardioembolism, nor significant vessel stenosis or unstable atherosclerotic plaques. In admission, she had a D-dimer level of 11,43μg (0- 0,5μg/mL). Conclusion: The evidence of TTS is about six times more frequent in stroke related to malignancies compared to cardioembolic etiology. The D-dimer is a marker of malignancies in cryptogenic stroke, elevated in 75% of cases. The most common associated neoplasms are pulmonary (40%) and gastrointestinal (33,3%). In the MRI, the lesions can be isolated or gathered, generally small and peripheral. There is no evidence regarding the ideal preventive therapy. It is necessary to reinforce the importance of investigating malignancies in patients presenting with cryptogenic stroke and TTS, a syndrome that is still poorly recognized.

Background: Intravenous thrombolysis is the standard medical treatment for acute ischemic stroke (AIS) within 4.5 hours of symptom onset, and symptomatic hemorrhagic transformation (sHT) is the most feared complication of this treatment. Objective: To describe the prevalence, risk factors, treatment and outcome of sHT. Design and setting: This is a retrospective cross-sectional study in a quaternary care hospital in Sao Paulo, Brazil. Methods: We reviewed 90 records of patients with AIS submitted to thrombolysis from March 2018 to February 2020. Evaluation of brain imaging after thrombolysis and the treatment initiated after detection of hemorrhage were made. Results: The overall prevalence of HT was 18.9% (n = 17, mean age 69.4±14.6 years, 58.8% males) and 8.9% (n = 8) of sHT. The most prevalent comorbidities were renal impairment (82%), hypertension (76.4%), diabetes mellitus (35.2%), atrial fibrillation (35.2%) and smoking (35.2%). The median baseline NIHSS score was 17. The most prevalent radiological classification of post-thrombolysis HT was class 2 (41.1%) from the Heidelberg Bleeding Classification. Cryoprecipitate and tranexamic acid were administered in 11.8% (n = 2). The mortality rate for HT was 35.3% (n = 6). Antiplatelet or anticoagulant therapy was initiated after a mean of 24.6 days from HT diagnosis and there was no stroke recurrence at 90 days. Conclusion: We showed a prevalence of sHT and related risk factors aligned with other studies, but with high mortality rates, despite being a stroke service. The late initiation of antiplatelets or anticoagulants did not lead to stroke recurrence at 90 days.

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