Cerebellar mutism syndrome of non-tumour surgical aetiology-a case report and literature review.

Cerebellar mutism syndrome (CMS) is a well-known complication of posterior fossa (PF) tumour surgery. CMS has previously been reported in cases of non-tumour surgical aetiology in a limited number of publications. We report a case of a 10-year-old girl who suffered a cerebellar haemorrhage and subsequent CMS following surgical treatment of a ruptured arteriovenous malformation (AVM) in the cerebellar vermis. The AVM was removed acutely through a transvermian access, and hydrocephalus was treated with temporary external drainage. In the postoperative period, she suffered diffuse vasospasms of the anterior cerebral circulation and had a permanent shunt placed for hydrocephalus. Her mutism resolved after 45 days but severe ataxia persisted. To our knowledge, this is the first reported case of CMS related to a vermian haemorrhagic stroke with postoperative diffuse vasospasms. Based on this case, we present a literature review on CMS of non-tumour surgical origin in children.

Safety and functional outcome analysis of ventriculoperitoneal shunt placement for hydrocephalus within the critical phase of possible delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage.

Shunt-dependent hydrocephalus (HC) is a common sequela following aneurysmal subarachnoid hemorrhage (aSAH). However, there is still poor evidence regarding the optimal timing of ventriculoperitoneal shunt (VPS) placement, particularly in the context of early aSAH-associated complications such as delayed cerebral ischemia (DCI). The purpose of this study was to compare the impact of early (< 21 days after aSAH) versus late (≥ 21 days after aSAH) VPS placement on the functional clinical outcome. We retrospectively analyzed data from 82 patients with VPS placement after aSAH enrolled in our institutional database between 2011 and 2021. We compared two groups, early VPS placement (< 21 days after aSAH) versus late VPS placement (≥ 21 days after aSAH) in terms of demographics, SAH grading, radiological parameters, externalized cerebrospinal fluid diversions, DCI, VPS variables, and functional outcome. We identified 53 patients with early and 29 patients with late VPS implantation. Baseline variables, such as the modified Rankin Scale (mRS), the World Federation of Neurological Surgeons Scale, the Glasgow Coma Scale, and Fisher grade were not significantly different between the groups. Postoperatively, the mRS (p = 0.0037), the Glasgow Outcome Scale (p = 0.0037), and the extended Glasgow Outcome Scale (p = 0.0032) showed significantly better functional results in patients with early cerebrospinal fluid diversion. The rate of DCI did not differ significantly between the groups (p = 0.53). There was no difference in the rate of VPS placement associated complications (p = 0.44) or overall mortality (p = 0.39). Early shunt implantation, within 21 days after aSAH and therefore during the timeframe of possible DCI, might not be harmful in patients developing HC after aSAH.

Non-steroidal anti-inflammatory drugs in the pathophysiology of vasospasms and delayed cerebral ischemia following subarachnoid hemorrhage: a critical review.

Aneurysmal subarachnoid hemorrhage (aSAH) is a life-threatening condition associated with the development of early brain injury (EBI) and delayed cerebral ischemia (DCI). Pharmacological treatment of vasospasm following aSAH currently mainly comprises nimodipine administration. In the past few years, many drugs that can potentially benefit cases of subarachnoid hemorrhage have become available. The objective of this review is to critically assess the effects of non-steroidal anti-inflammatory drugs (NSAIDs) following aSAH. A systematic literature review was conducted following PRISMA guidelines. The search was aimed at studies addressing aSAH and NSAIDs during the 2010 to 2019 period, and it yielded 13 articles. Following the application of search criteria, they were divided into two groups, one containing 6 clinical articles and the other containing 7 experimental articles on animal models of aSAH. Inflammatory cerebral changes after aneurysm rupture contribute to the development of EBI, DCI and cerebral vasospasm. It appears that NSAIDs (especially coxibs) are even more effective in reducing vasospasm than nimodipine. Other beneficial effects of NSAIDs include reduction in mortality, improved functional outcome and increased hypoaggregability. However, despite these positive effects, there is only one randomized, double-blind, placebo-controlled trial showing a tendency towards a better outcome with lower incidence of vasospasm or mortality in patients following aSAH.

Angioplasty with the scepter C dual lumen balloon catheter and postprocedural result evaluation in patients with subarachnoid hemorrhage related vasospasms.

BACKGROUND: Delayed cerebral ischemia is one of the leading causes of death and disability in patients with subarachnoid hemorrhage (SAH). Transluminal balloon angioplasty (TBA) is a therapeutic option for vasospasms affecting proximal intracranial arteries. METHODS: Aim of this study was to report our experience using the Scepter C balloon catheter in the treatment of cerebral vasospasms due to SAH and evaluate the postprocedural result with the iFlow tool. We reviewed cases of patients treated at our hospital from 2014 to 2018. Patients were screened with transcranial doppler sonography (TCD) and multimodal computed tomography. In case of significant vasospasms, patients were transferred to the angiography suite and treated. We used the iFlow tool to quantify and evaluate the angiographic results by measuring and comparing peak density values on angiograms before and after the mechanical dilation. RESULTS: The use of the Scepter C balloon catheter was feasible in all cases. Vasospasms of the anterior cerebral artery were treated in ten cases. We didn't observe complications or vasospasm recurrences of the treated arteries. The temporal difference between distal vessels and the proximal reference vessel was significantly reduced from a mean of 53%, prior to dilatation, to 26% after the treatment. The difference between pre-dilatation and post-dilatation values was statistically significant for the anterior circulation at the proximal as well as at the distal vessels. CONCLUSIONS: We successfully treated endovascularly patients suffering from cerebral vasospasms refractory to medical treatment using the Scepter C balloon catheter. We didn't observe any complications. The therapeutic effect could be easily and reliably assessed with the iFlow tool.

Cerebral Infarction in Young Marijuana Smokers - Case Reports.

INTRODUCTION: Causality of marijuana abuse with development of ischemic stroke has been indicated by numerous case reports and epidemiological studies. As a possible pathophysiological mechanism, the most common consideration is cardiac embolization during paroxysmal atrial fibrillation, systemic hypotension or multifocal intracerebral vasoconstriction. CASE REPORTS: We present three case reports of marijuana consumers who were admitted to our comprehensive stroke center due to ischemic stroke within 18-month period of our investigation. In one case, the cause of stroke was not related to the use of marijuana, it was a manifestation of antiphospholipid syndrome. In two cases the association with the abuse of this drug is probable but not certain. In both these cases, an isolated occlusion in vertebrobasilar arterial system was detected, without finding of a cerebral vessels stenosis. Although we did not register the atrial fibrillation, we consider cardiac embolization as probable etiological mechanism of stroke in both cases. In one case, paradoxical embolization due to the persistent foramen ovale represents another potential etiological mechanism. CONCLUSIONS: Cannabinoid use may cause ischemic stroke, especially in the younger age category. Therefore, in these patients we recommend focusing on the history of cannabinoid abuse and carry out toxicological urine tests.

Ondansetron-induced pseudoallergy with non-ischemic myocardial injury: A rare case report of Kounis syndrome.

Ondansetron is an FDA-approved selective serotonin 5-HT3 receptor commonly indicated as an anti-emetic agent for nausea and vomiting. It is rare to observe fatal reactions from ondansetron despite having no allergies or previous exposure. We report a case of anaphylactoid reaction with spontaneous coronary vasospasms in response to intravenous ondansetron.

How to differentiate intracranial atherosclerotic disease or vasospasms after mechanical thrombectomy. Be patient or vasodilator is the secret?

Here we describe a successful mechanical thrombectomy (MT) for acute large vessel occlusion in stroke treatment with one passage (thrombolysis in cerebral infarction, TICI 3). Immediately after the withdrawing of the stent retriever, a narrowing of the middle cerebral artery was diagnosed. The rate of vasospasms during this procedure can be as higher as 41% (range from 6-41%). Here we describe our protocol when a narrowing of the artery is visualized after a stent retriever is withdrawn. A patient presented in our emergency room with National Institute of Health Stroke Scale (NIHSS) of 21, Alberta Stroke Program Early CT Score (ASPECTS) 8, computed tomography angiography revealed occlusion of the M1 segment and MT was indicated. One passage TICI Ⅲ was achieved. After that, the image showed a narrowing of the artery. We present one case of a spasm after stent retriever technique for MT, we injected vasodilator and the artery became normal in a few minutes differentiating between atheromatous stenosis and vasospasm. We present a technical note that can help to make the differentiation of vasospasm or atheromatous disease after MT with the stent retriever technique.

Bibliometric Analysis of the Top 100 Most Cited Articles on Cerebral Vasospasm.

OBJECTIVE: Bibliometric analysis reflects the scientific recognition and influential performance of a published article within its field. Our aim is to identify and analyze the top 100 most-cited articles on cerebral vasospasm. METHODS: A title-specific search was carried out using the Scopus database. The top 100 cited articles including the keywords "Cerebral Vasospasm" AND "Vasospasm" were retrieved and stratified in a descending order: title, authors, institution, publishing journal, country of origin, year of publication, and topic of each article were studied. RESULTS: The top 100 articles have an accumulative citation count of 20,972, with 209 average citations per article. Publication dates ranged from 1968 to 2012, with the most productive years between 1998 and 2005. Clinical studies are the most frequent category, followed by pathophysiology. The list includes 7 clinical trials, which received accumulative citations of 1525. The top cited article had received 2109 citations, with 52.7 citations per year. The top 100 articles were published across 14 countries, with most originating from the United States. The lead research institution was the University of Alberta. The most used journal was Journal of Neurosurgery. CONCLUSIONS: Bibliometric analysis has garnered major interest in recent years. It shows the publication trends, knowledge evolution, and evidence-based practice throughout the years. The collection of highly cited articles may assist physicians in gaining a better understanding of the nature of cerebral vasospasm and optimize their clinical practice.

Clarithromycin-induced Coronary Vasospasms Caused Acute Coronary Syndrome in a 19-year-old Male Patient.

A 19-year-old-man was admitted to our hospital with intermittent chest pain. The day before admission, he had been diagnosed with enteritis and prescribed clarithromycin. He had experienced severe chest pain three times after taking clarithromycin; thus, acute coronary syndrome (ACS) was suspected. Emergent coronary angiography showed normal coronary arteries; however, the result of a subsequent acetylcholine provocation test was positive. We diagnosed him to have ACS caused by coronary vasospasms and suspected clarithromycin-induced Kounis syndrome. Although more common in older patients, Kounis syndrome must be suspected and a thorough medication history should be taken whenever a patient complains of chest pain.

Diverse phenotypic expression associated with the same genetic variant in female heterozygote patients of Anderson-Fabry disease: a case series.

BACKGROUND: Anderson-Fabry disease (AFD) is an X-linked lysosomal storage disorder resulting from a mutation of alpha-galactosidase A gene (GLA), causing deficiency in alpha-galactosidase activity. The enzyme deficit can lead to storage of globotriaosylceramide in various organs including heart. Studies suggest that vasospastic angina (VSA) is associated with AFD. CASE SUMMARY: This clinical case series aimed to present two female patients with AFD, including progressive cardiac involvement: a 50-year-old woman (patient number 1) and a 39-year-old woman (patient number 2) who are siblings with a male AFD patient harbouring p. Arg342Glu missense variant in alpha-galactosidase A gene (GLA), who suffered VSA and subsequent ventricular fibrillation. Enzymatic tests and genetic analysis confirmed AFD in both female patients and histological tests revealed globotriaosylceramide deposits in their hearts. In patient number 1, a 12-lead electrocardiography and transthoracic echocardiography revealed cardiac hypertrophy. Coronary angiography revealed no organic coronary artery stenosis and vasospasms was induced by spasm provocation test. In patient number 2, no signs of cardiac hypertrophy were found, and coronary arteries had no organic stenosis with negative spasm provocation test. Both patients received enalapril therapy and enzyme replacement therapy (ERT). DISCUSSION: Different phenotype of AFD was occurred even with the same genetic variant in female heterozygote patients. The duration of exposing accumulation of Gb3 might affect cardiac hypertrophy and vasospasms. Coronary angiography with acetylcholine provocation test should be considered in female AFD patient, especially in case with cardiac hypertrophy.

Significant reduction of vascular reactivity with dantrolene and nimodipine in diabetic rats: a potential approach to cerebral vasospasm management in diabetes.

BACKGROUND: Diabetics have a higher risk of developing cerebral vasospasms (CVSPs) than non-diabetics. Current therapies are ineffective in reducing CVSPs, but a a combination of dantrolene and nimodipine may be a viable treatment. Considering the potentially harmful secondary effects of dantrolene, however, we evaluated the efficacy of 10 µM dantrolene compared to 50 µM dantrolene alone or in combination with 50 nM nimodipine. METHODS: Dose-response curves for the phenylephrine (PHE)-induced contraction and acetylcholine (ACh)-induced relaxation were performed on aortic rings from diabetic and non-diabetic rats, before and after a 30-min incubation period with dantrolene (50 µM and 10 µM), alone or in combination with 50 nM nimodipine. RESULTS: Whereas 50 µM dantrolene reduced PHE-induced contraction by 47% in diabetic rats and 29% in controls, 10 µM dantrolene failed to reduce this parameter in either group. Furthermore, 50 µM dantrolene reduced PHE-induced contraction by about 80% in both diabetic and controls when combined with nimodipine (N = 9, P < 0.05). The combination of 10 µM dantrolene and 50 nM nimodipine, however, was ineffective. Only 50 µM dantrolene improved endothelial dysfunction. CONCLUSIONS: Improved endothelial-dependent relaxation and reduced vascular contractility with dantrolene are dose dependent. Thus, although dantrolene appears to be a promising alternative for the treatment of CVSPs when added to conventional therapies, careful titration should be performed to achieve a significant reduction in vascular hyperreactivity. Moreover, if our findings with rats are applicable to humans, the combined use of dantrolene and nimodipine at optimal doses may reduce CVSPs, especially in the diabetic population.

Isoproterenol Causing Coronary Vasospasm and ST Elevations During Tilt Table Testing.

Syncope is a sudden but reversible brief loss of consciousness secondary to an acute reduction of cerebral perfusion. Reflex syncope denotes neurologically mediated syncope, which includes vasovagal, carotid sinus syndrome, and other situational syncope. The most frequent form of syncope is vasovagal, which is triggered by emotional stress or prolonged standing, and may be diagnosed with the tilt table test. A thorough investigation of syncope is necessary as serious cardiovascular disorders may also be a cause. A tilt table test is a widely used tool utilized by clinicians to diagnose vasovagal syncope and is sometimes augmented with isoproterenol, a ß-sympathomimetic that acts on the heart. This report seeks to explain a case of a 48-year-old previously healthy woman who experienced inferior wall ST elevations during tilt table test supplemented with isoproterenol. There is reason to believe that the results of this patient's tilt table test were due to vasovagal syncope in conjunction with right coronary artery vasospasm.

Risk factors and short-term outcome in patients with angiographically negative subarachnoid hemorrhage.

OBJECTIVES: The objective of this study was to identify prognostic factors for clinical outcome in patients with non-traumatic, angiographically negative subarachnoid hemorrhage. Furthermore, the aim was to investigate if patients on anticoagulant therapy may have a more unfavorable outcome than patients not receiving anticoagulant therapy. MATERIALS AND METHODS: This study contains a retrospective analysis of 95 patients with non-traumatic, non-aneurysmal subarachnoid hemorrhage who were admitted to our institution in the period 2000-2011. The patients were classified according to risk factors, clinical presentation at admission, anticoagulant therapy at the time of hemorrhage and complications. The outcome was assessed with modified Rankin Score at discharge. RESULTS: Patients who were exposed to risk factors combined with a higher WFNS score at admission had an unfavorable outcome according to the modified Rankin Score at discharge. Unfavorable outcome was evaluated in relation to sex, anticoagulant therapy, hypertension, smoking and alcohol abuse. A strong correlation with anticoagulant therapy, smoking and alcohol abuse was found. None of the patients who developed vasospasms in this study were receiving anticoagulant therapy. CONCLUSION: There is a correlation between antithrombotic state at admission and unfavorable outcome for patients with non-traumatic, non-aneurysmal subarachnoid hemorrhage. The results from this study indicate that patients on anticoagulant therapy have a higher risk of developing complications after non-aneurysmal angiographically negative subarachnoid hemorrhage compared to patients who were not receiving anticoagulant therapy.

Endothelin-1 and endothelin-2 initiate and maintain contractile responses by different mechanisms in rat mesenteric and cerebral arteries.

BACKGROUND AND PURPOSE: Endothelin (ET)-1 and ET-2 cause potent long-lasting vasoconstrictions by tight binding to smooth muscle ETA receptors. We tested the hypotheses that different mechanisms mediate initiation and maintenance of arterial contractile responses to ET-1 and ET-2 and that this differs among vascular beds. EXPERIMENTAL APPROACH: Segments of rat mesenteric resistance artery (MRA) and basilar artery (BA) were studied in wire myographs with and without functional antagonists. KEY RESULTS: Sensitivity and maximum of MRA contractile responses to ET-1 were not, or only moderately, reduced by stimulation of soluble GC, AC or K(+) -channels and by an inhibitor of receptor-operated ion channels. However, each of these reduced maintenance of ET-1 effects and relaxed ET-1-induced contractions in MRA. A calcium channel antagonist did not alter sensitivity, maximum and maintenance of ET-1 effects, but relaxed ET-1-induced contractions in MRA. A PLC inhibitor prevented contractile responses to ET-1 and ET-2 in MRA and BA, and relaxed ET-1- and ET-2-induced responses in MRA and ET-1 effects in BA. A Rho-kinase inhibitor did not modify sensitivity, maximum and maintenance of responses to both peptides in both arteries but relaxed ET-2, but not ET-1, effects in MRA and ET-1 effects in BA. CONCLUSIONS AND IMPLICATIONS: PLC played a key role in arterial contractile responses to ETs, but ET-1 and ET-2 initiated and maintained vasoconstriction through different mechanisms, and these differed between MRA and BA. Selective functional antagonism may be considered for agonist- and vascular bed selective pharmacotherapy of ET-related diseases.