A novel approach to diagnose reversible cerebral vasoconstriction syndrome: a case series.

BACKGROUND: Reversible cerebral vasoconstriction syndrome (RCVS) is classically diagnosed based on the presence of severe thunderclap headache, focal neurologic symptoms, and the radiographic findings of reversible diffuse segmental cerebral vasoconstriction. We present a diagnostic test that may assist in the clinical diagnosis and facilitate treatment. METHODS: From October 1, 2010, to August 1, 2013, we identified consecutive patients who presented with a presumptive diagnosis of RCVS and underwent cerebral diagnostic angiography with intra-arterial (IA) vasodilator therapy. Medical records including clinical presentation, radiographic, and angiographic images were all reviewed. RESULTS: We identified a total of 7 patients (4 females; age range, 22-56; mean, 45 years) who met our inclusion criteria. Four patients received a combination of milrinone and nicardipine infusion either in the internal carotid arteries or in the left vertebral artery; the remaining patients received IA therapy solely with either nicardipine or milrinone. Five patients had a positive angiographic response, defined as significant improvement or resolution of the blood vessels irregularities. All 5 patients had a definite discharge diagnosis of RCVS. The remaining 2 patients had a negative angiographic response and based on their clinical and radiographic course had a final diagnosis of intracranial atherosclerotic disease. CONCLUSIONS: Our small case series suggest that IA administration of vasodilators is safe and may aid in distinguishing vasodilator responsive syndromes such as RCVS from other causes. Further study is required with long-term clinical outcome to determine the utility of this diagnostic test.

Intra-Arterial Eptifibatide in the Management of Thromboembolism during Endovascular Treatment of Intracranial Aneurysms: Case Series and a Review of the Literature.

OBJECTIVES: Thromboembolic complications are well recognized during the endovascular management of intracranial aneurysms. In this study, we present a case series of 40 patients with intraprocedural thrombotic complications who were treated with intra-arterial eptifibatide (IAE), and a review of the literature. METHODS: Twenty-five patients with ruptured intracranial aneurysms (RIA), 10 with unruptured intracranial aneurysms (UIA) and 5 with aneurysmal subarachnoid hemorrhage-induced vasospasm (VSP) received IAE for intraprocedural thrombi during endovascular treatment. Rates of recanalization, strokes, and hemorrhagic complications were assessed. RESULTS: Recanalization was achieved in 96% (24/25) of the RIA patients [72% (18/25) complete; 24% (6/25) partial], in 100% (10/10) of the UIA patients [90% (9/10) complete; 10% (1/10) partial], and in 100% (5/5) of the VSP patients [80% (4/5) complete; 20% (1/5) partial]. Strokes following intraprocedural thrombosis were coil-related (20%, 5/25) or stent-related (12%, 3/25) in RIA patients, stent-related (10%, 1/10) in UIA patients, and heparin-induced thrombocytopenia type II-related (60%, 3/5) or vasospasm-related (20%, 1/5) in VSP patients. There were no intracerebral hemorrhagic complications in UIA. Intracerebral hemorrhage was observed in 20% of the RIA patients (5/25), all of whom had received intra-arterial thrombolytics and/or high-dose heparin infusion in addition to IAE; in 12%, this was external ventricular drain-related (3/25), 4% had parenchymal hematoma type 1 (1/25), and 4% parenchymal hematoma type 2 (1/25). One of the 5 VSP patients, who had received argatroban in addition to IAE, had parenchymal hematoma type 1. No clinically significant systemic hemorrhage was observed in this study. CONCLUSION: Treatment of thromboembolic complications with IAE during endovascular management of aneurysms was effective in achieving recanalization and overall well tolerated in this series.

Reversible cerebral vasoconstriction syndrome in a patient taking citalopram and Hydroxycut: a case report.

INTRODUCTION: Reversible cerebral vasoconstriction syndrome presents with thunderclap headaches accompanied by mild neurologic deficits and is characterized by multifocal narrowing of the cerebral arteries that resolves over days to weeks. This syndrome may be idiopathic or occur in special contexts, most often involving adrenergic or serotonergic overactivity. To the best of our knowledge, reversible cerebral vasoconstriction syndrome has not previously been reported in association with Hydroxycut use in the literature. CASE PRESENTATION: We report the case of a 65-year-old Caucasian woman on longstanding citalopram who developed reversible cerebral vasoconstriction syndrome two weeks after beginning to take the weight-loss supplement Hydroxycut. CONCLUSION: There are sparse data about the safety of herbal supplements such as Hydroxycut, even though the Food and Drug Administration has banned some herbal ingredients, such as ephedra, that were in this preparation in the past. This case highlights the importance of considering herbal supplements and potential drug interactions in the genesis of otherwise unexplained reversible cerebral vasoconstriction syndrome.

Infectious burden and risk of stroke: the northern Manhattan study.

OBJECTIVE: To determine the association between a composite measure of serological test results for common infections (Chlamydia pneumoniae, Helicobacter pylori, cytomegalovirus, and herpes simplex virus 1 and 2) and stroke risk in a prospective cohort study. DESIGN: Prospective cohort followed up longitudinally for median 8 years. SETTING: Northern Manhattan Study. Patients Randomly selected stroke-free participants from a multiethnic urban community. Main Outcome Measure Incident stroke and other vascular events. RESULTS: All 5 infectious serological results were available from baseline samples in 1625 participants (mean [SD] age, 68.4 [10.1] years; 64.9% women). Cox proportional hazards models were used to estimate associations of each positive serological test result with stroke. Individual parameter estimates were then combined into a weighted index of infectious burden and used to calculate hazard ratios and confidence intervals for association with risk of stroke and other outcomes, adjusted for risk factors. Each individual infection was positively, though not significantly, associated with stroke risk after adjusting for other risk factors. The infectious burden index was associated with an increased risk of all strokes (adjusted hazard ratio per standard deviation, 1.39; 95% confidence interval, 1.02-1.90) after adjusting for demographics and risk factors. Results were similar after excluding those with coronary disease (adjusted hazard ratio, 1.50; 95% confidence interval, 1.05-2.13) and adjusting for inflammatory biomarkers. CONCLUSIONS: A quantitative weighted index of infectious burden was associated with risk of first stroke in this cohort. Future studies are needed to confirm these findings and to further define optimal measures of infectious burden as a stroke risk factor.

Pin1 colocalization with phosphorylated tau in Alzheimer's disease and other tauopathies.

Pin1, a peptidyl-prolyl isomerase binds to mitotic serine or threonine phosphoproteins. In Alzheimer's disease (AD) evidence points to the reactivation of mitosis in vulnerable neurons. Tangles composed of hyperphosphorylated tau contain phosphorylated Thr231 (pThr231 tau), which occurs to a greater extent in the AD brain than in the normal brain, and Pin1 has been shown to bind pThr231 tau. Here, Pin1 distribution in AD, and its colocalization with pThr231 tau in AD, FTDP-17 (P301L), Pick's disease (PiD), and PSP was investigated using TG-3, a monoclonal antibody to conformationally altered pThr231 tau. The Pin1 antibody A-20 detected granular Pin1 staining in AD brains, but not in normal brains. A-20 immunoreactive granules colocalized with TG-3-stained granules but not with TG-3-stained pretangles, tangles, or Pick bodies in AD, PiD, and FTDP-17 (P301L). Pin1 granules were sparse in PSP, and rarely did A-20 colocalize with TG-3. The appearance of Pin1 granules in the early stages of AD, PiD, and FTDP-17 (P301L) implicates Pin1 in their pathogenesis but not in PSP.