Stroke Notes 665 1 Both authors contributed equally to this work. Discussion The ATH connects the temporal lobe to the prefrontal cortex and is known as a component of Papez’s circuit [3]. Papez’s circuit includes the mamillothalamic tract, which connects the thalamus to the mamillary body, and is thought to be involved in emotion and memory. Damage in the ATH is associated with memory and motor performance deficits: mamillothalamic tract damage is re- lated to long- and short-term memory deficits [4]; the ATH is the primary region involved in amnesic symptoms in alcoholic Kor- sakoff’s syndrome [5]. In addition, perseverative behavior [6] or dystonic hand tremors [7] were observed after ATH infarctions. Hence, in the present case, the improvement in emotion and memory after an ATH infarction was a paradoxical outcome. We found severe atrophy of the temporal lobe including the hippocampus and amygdala in the early stages of dementia. In contrast, the frontal cortex function may have been preserved be- cause the frontal lobe atrophy was not severe. Therefore, we spec- ulate that the temporal lobe degeneration might have disturbed the frontal cortical function and the ATH infarction may have reduced this disturbance, thus normalizing the frontal cortical function rather than causing an impairment. Indeed, the ATH is a recognized therapeutic target in epilepsy treatments [8]. The case presented here suggests that the ATH is a critical in- termediary point between the temporal and frontal lobes. Thus, the ATH might be an effective target for the treatment of emo- tional and memory disturbances in dementia that involves severe temporal lobe pathology. References 1 Ballard C, Howard R: Neuroleptic drugs in dementia: benefits and harm. Nat Rev Neurosci 2006; 7: 492–500. 2 Reisberg B, Borenstein J, Salob SP, Ferris SH, Franssen E, Georgotas A: Behavioral symptoms in Alzheimer’s disease: phenomenology and treatment. J Clin Psychiatry 1987;48(suppl):9–15. 3 Aggleton JP, Brown MW: Interleaving brain systems for episodic and recognition memory. Trends Cogn Sci 2006; 10: 455–463. 4 Van der Werf YD, Scheltens P, Lindeboom J, Witter MP, Uylings HB, Jolles J: Deficits of memory, executive functioning and attention fol- lowing infarction in the thalamus; a study of 22 cases with localised lesions. Neuropsychologia 2003; 41: 1330–1344. 5 Harding A, Halliday G, Caine D, Kril J: Degeneration of anterior tha- lamic nuclei differentiates alcoholics with amnesia. Brain 2000; 123: 141–154. 6 Ghika-Schmid F, Bogousslavsky J: The acute behavioral syndrome of anterior thalamic infarction: a prospective study of 12 cases. Ann Neu- rol 2000; 48: 220–227. 7 Cho C, Samkoff LM: A lesion of the anterior thalamus producing dys- tonic tremor of the hand. Arch Neurol 2000; 57: 1353–1355. 8 Kerrigan JF, Litt B, Fisher RS, Cranstoun S, French JA, Blum DE, Dich- ter M, Shetter A, Baltuch G, Jaggi J, Krone S, Brodie M, Rise M, Graves N: Electrical stimulation of the anterior nucleus of the thalamus for the treatment of intractable epilepsy. Epilepsia 2004; 45: 346–354. Katsumasa Muneoka, MD, PhD Hirasawa Kinen Hospital 3-20-1 Kitano Tokorozawa, Saitama 359-1152 (Japan) Tel. +81 4 2947 2466, Fax +81 4 2947 2482 E-Mail kmuneoka@med.showa-u.ac.jp Introduction Evaluating the indication of i.v. thrombolysis in acute stroke patients requires a careful work-up within a short time frame. Ruling out cerebral hemorrhage by CT is of highest priority. How- ever, there may be more pitfalls in emergency stroke cases, which is illustrated in a patient who presented with acute neurological symptoms and back pain. Case Description A 62-year-old retired chemical laboratory worker was referred to the emergency room with numbness and weakness of his right arm and leg with suspected acute stroke. He was seen by a neu- rologist 1 h and 45 min after symptom onset. Sudden-onset hemi- paresis had started immediately after he had used the bathroom, together with severe pain between his shoulder blades radiating to the right arm. On neurological examination the patient was alert and fully orientated, there was no aphasia or apraxia. He showed equivocal right facial weakness (facial asymmetry) and a right MRC grade 3–4 flaccid hemiparesis with a plantar extensor response and hypesthesia on the right side of the body. Reflexes were +++/+++ and symmetrical, the NIHSS score on admission was counted as 6 points. An ECG and routine blood tests were within normal limits. The blood pressure was 137/97 mm Hg. I.v. thrombolysis was considered, but due to the initial pain syndrome there was a sus- picion of an aortic and carotid artery dissection (and subsequent middle cerebral artery infarction). A cranial CT was negative for signs of hemorrhage or ischemic infarction, or arterial dissec- tion. A CT scan of the aorta showed no arterial dissection. Sub- sequently, his wife arrived and reported that the facial asymme- try (mimicking right facial weakness) had been present before. A further neurological examination revealed a Brown-Séquard syndrome with reduction of pain and temperature sensation on the left below C4 level in addition to the hemiparesis and hypes- thesia of the right arm and leg. The thoracic CT scan was re- viewed and the suspicion of focal hemorrhage was confirmed by MRI (fig. 1, 2) demonstrating a cervical epidural hematoma caus- ing compression of the cord affecting the nerve roots at levels C4 to C7 on the right. The patient underwent emergency right hemi- laminectomy at levels C5 and C6. He subsequently recovered without sequelae. Discussion Spontaneous spinal epidural hematoma (SSEH) is rare, but particularly since the availability of i.v. thrombolysis physicians Cerebrovasc Dis 2008;26:665–666 DOI: 10.1159/000172974 Intravenous Thrombolysis Cancelled in Acute Right Hemiparesis Marcus D’Souza a, 1 , Achim Gass a, b, 1 , Philippe Lyrer a , Hans-Werner Ott b , Thomas Baumann a Departments of a Neurology and b Neuroradiology, University Hospital of Basel, Basel, Switzerland