Basilar artery occlusion in migraine-like headache: a possible triggering effect of sumatriptan.

Headache is a common symptom at the onset of acute ischemic cerebrovascular disease. Simultaneous development of migraine-like headache and stroke in the same patient makes it difficult to differentiate between migraine-induced stroke and migraine-like headache attributed to ischemic stroke. We report a case of a 34-year-old woman with no previous migraine history who presented with migraine-like headache, thought to be a first attack of migraine, and who developed brainstem infarction shortly after triptan administration. Magnetic resonance imaging revealed an acute pontine infarction, and CT angiography revealed occlusion of the basilar artery. A detailed etiological evaluation revealed no risk factor for ischemic stroke. We believe that the migraine-like headache was the first symptom of cerebral ischemia and that sumatriptan accelerated the development of the infarction. This case report emphasizes the importance of accurate diagnosis of migraine before using triptans. Secondary causes of migraine-like headache should be excluded, especially in patients with migraine-like headache for the first time.

Cerebrovascular events after bevacizumab treatment: an early and severe complication.

BACKGROUND: The indications for bevacizumab (a vascular endothelial growth factor inhibitor) have been expanded recently. Despite concerns for cerebrovascular events from bevacizumab treatment, detailed clinical and radiologic information are lacking. METHODS: Using the Mayo Clinic Rochester database (January 2006-September 2010), we identified bevacizumab-treated patients who developed intracerebral hemorrhage, ischemic stroke or transient ischemic attack within 3 weeks of bevacizumab treatment. Functional recovery was assessed using the modified Rankin scale 3 months following the onset of cerebrovascular events. RESULTS: Ten consecutive patients (median age 58 years, range 37-86) were included in this study. These patients received bevacizumab for a median duration of 3 months (range 2-4 months) for cancer treatment, and developed cerebrovascular events that comprised intratumoral hemorrhage (n = 7), cerebral watershed infarction (n = 1), transient ischemic attack (n = 1), and left vertebral artery occlusion (n = 1). Seven patients had chronic hypertension which was adequately controlled with a single anti-hypertensive agent. Significant increase in blood pressure was observed in nine patients during their acute presentation as compared with their baseline outpatient readings. Six patients died within 3 months of these cerebrovascular events, and the remaining four patients had modest functional recovery. CONCLUSIONS: Cerebrovascular events are early and serious complications that should be considered in bevacizumab-treated patients who present with an acute neurologic deterioration.

Differential Interstrain Susceptibility to Vertebrobasilar Dolichoectasia in a Mouse Model.

BACKGROUND AND PURPOSE: Vetebrobasilar dolichoectasia is characterized by arterial elongation, dilation, and tortuosity and leads to high risks of ischemic stroke. Our aim was to investigate the differential susceptibility to elastase-induced vertebrobasilar dolichoectasia induction in 2 different mouse strains. MATERIALS AND METHODS: Elastase (25 mU) was injected into the cisterna magna in C57BL/6J (n = 36) and 129/SvEv (SV129) (n = 36) mice. Control animals were injected with heat-inactivated elastase (n = 12 for each strain). At 3, 7, 14, and 28 days after elastase injection, MICROFIL polymer perfusion was performed. The arterial tortuosity index and the percentage increase in diameter were calculated for the basilar artery. Arterial samples were processed for conventional histologic examination, immunostaining, and matrix metalloproteinase expression. A ≥50% increase in diameter and a tortuosity index of ≥10 for the basilar artery were used to indicate success in achieving vertebrobasilar dolichoectasia. RESULTS: Successful vertebrobasilar dolichoectasia induction was noted in 67% (18 of 27) of the C57BL/6J strain versus 0% (0 of 19) of the SV129 strain (P < .001). Vertebrobasilar dolichoectasia was not observed in sham-operated controls. Both the tortuosity index and diameter increase for the basilar artery were greater in the C57BL/6J strain compared with the SV129 strain (56.3% ± 16.4% versus 21.1% ± 21.6% for diameter, P < .001; 17.4 ± 7.6 versus 10.4 ± 3.8 for tortuosity index, P < .001). Expression of pro-matrix metalloproteinase-2 and pro- and active matrix metalloproteinase-9 was increased in elastase-injected C57BL/6J animals compared with elastase-injected SV129 animals (P = .029, 0.029, and 0.029, respectively). Inflammation scores were significantly higher in C57BL/6J animals versus SV129 animals (P < .001). C57BL/6J subjects demonstrated arterial wall dilation and elongation characterized by internal elastic lamina disruption, muscular layer discontinuity, inflammatory cell infiltration, and high matrix metalloproteinase expression in the media. CONCLUSIONS: C57BL/6J mice demonstrated greater susceptibility to vertebrobasilar dolichoectasia induction than SV129 mice.

Concomitant aneurysm detection in an intracranial dolichoectasia mouse model using a MicroFil polymer perfusion technique.

OBJECTIVE: To assess the feasibility of using MicroFil polymer perfusion to detect concomitant saccular aneurysms in an intracranial arterial dolichoectasia (IADE) model in mice, and to report detailed histomorphometric features of these aneurysms. MATERIALS AND METHODS: IADE models were created in C57/BL6 mice via microsurgical injection of 25 mU elastase into the cisterna magna. The cerebral vasculature was perfused with MicroFil polymer and harvested at 1, 3, and 7 days, and 2 and 4 weeks (n=8 for each group). IADE was defined by a tortuosity index >10 combined with a 25% increase in diameter of the A1 segment of the anterior cerebral artery (ACA), internal carotid artery (ICA), or basilar artery compared with the baseline of controls, which received heat-inactivated elastase. Saccular aneurysm occurrence rate, location, and morphological parameters were investigated using macroscopic and microscopic analysis. RESULTS: IADE was present in 95% (36/38) of the subjects, with a mortality rate of 5% (2/40). Fifteen concomitant saccular aneurysms were detected in 8 (21%) of the 38 surviving mice, including 6 at the posterior communicating artery, 1 along the ACA, 2 along the anterior communicating artery complex, 3 along the ICA, and 3 along the middle cerebral artery. Rupture was confirmed in two aneurysms. Histological examination indicated that the aneurysms develop via arterial-wall remodelling, which is characterized by internal elastic lamina disruptions and muscular layer discontinuity in the media. CONCLUSIONS: The proportion of subjects developing saccular aneurysms in addition to IADE in our mouse model is similar to the 15% of patients with IADE who have concomitant saccular aneurysms.

[Status of oral contraceptives as a risk factor in cerebrovascular diseases]. / Zum Stellenwert der oralen Kontrazeptiva als Risikofaktor zerebraler Gefässerkrankungen.

A critical review of the relevant literature revealed that the incidence of subarachnoid haemorrhage is increased in women taking oral contraceptives and the mortality rate is higher. The data concerning correlation between the use of oral contraceptives and other cerebrovascular disorders are less conclusive. Taking oral contraceptives seems to result in a higher risk of stroke, but there is no definite correlation to the incidence of strokes with a fatal outcome. However, in the case of the coexistence of more than one risk factor, including cigarette smoking, the risk of cerebrovascular disease is considerably increased for women using oral contraceptives. Age also seems to be a significant factor. Women older than 44 should avoid oral contraceptives in general; women between 35 and 44 should use oral contraceptives only if additional risk factors are absent, i.e. if they are non-smokers. Indeed, in the presence of this or other risk factors younger women should also avoid taking oral contraceptives.

Hemodynamic vertebrobasilar insufficiency as an adverse effect of antihypertensive therapy.

A 63-year-old white male with a 25-year history of hypertension experienced the onset of intermittent diplopia and gait disturbance 24 hours after a change in antihypertensive medication from atenolol 50 mg/d to enalapril 5 mg bid. Three weeks later, the patient was admitted with a worsening of symptoms. Cerebral arteriography revealed significant bilateral vertebral artery stenosis. Symptoms continued to progress in the hospital, and at the time of posterior circulation revascularization the patient had a persistent bilateral internuclear ophthalmoplegia and right ptosis. The need for a neurovascular workup and adjustment of therapy in patients with antihypertensive-associated cerebral ischemia is discussed.

[Neurological manifestations in the vertebro-basilar system suggesting pregnancy toxemia]. / Manifestations neurologiques en territoire vertébro-basilaire révélatrices d'une toxémie gravidique.

Early CT scan showed a large hypodensity throughout midbrain. Brainstem auditory evoked potential showed initially an abolition of III and V pikes suggesting brainstem injury. Two days later neurologic examination and brain stem auditory evoked potential returned to normal. CT scan performed three weeks after the onset was normal. These finding suggest a vasospasm; in this case betasympathomimetic agents given two weeks before the onset of toxemia for preterm labor could lead to the vasospasm.

Transient global amnesia after cerebral angiography with iohexol.

We describe a patient without a previous history of migraine or epilepsy and with no known vascular risk factors, who suffered subarachnoid haemorrhage. During vertebral angiography using nonionic contrast medium (iohexol), spasm of the basilar artery was seen. The patient suffered transient global amnesia. Angiography 3 months later with the same contrast medium was normal and produced no further deficit. This case lends support to the supposed ischaemic aetiology of transient global amnesia; in patients without other evidence of cerebrovascular disease, arterial spasm may be responsible.

'Ecstasy'-induced subarachnoid haemorrhage: an under-reported neurological complication?

In the face of escalating recreational use of 'Ecstasy' (3,4-methylenedioxymethamphetamine, MDMA), physicians need to be aware of its possible adverse effects. We report two young patients who suffered subarachnoid haemorrhage following ingestion of 'Ecstasy' tablets. Angiographic studies demonstrated features consistent with vasculitis in both cases. Recognition of this association is important and highlights the significance of eliciting a careful drug history, particularly in cases of 'angiogram negative' subarachnoid haemorrhage.