Acute necrotizing eosinophilic myocarditis possibly triggered by an antimigraine drug as an uncommon cause of acute heart failure: a case report.

BACKGROUND: Epigastric or chest pain with an abnormal electrocardiogram (ECG) in a young, otherwise healthy patient should trigger an investigation to rule out myocarditis. The myocarditis covers a wide spectrum of severity. The search for the aetiologic factor could be definitive for the success of therapy. CASE SUMMARY: A previously healthy 29-year-old woman presented to the Emergency Room with epigastric pain, eosinophilia, and an abnormal ECG. A thorough evaluation including cardiac magnetic resonance and endomyocardial biopsy was undertaken. A diagnosis of acute necrotizing eosinophilic myocarditis was made. DISCUSSION: The case is particularly unique for its suspected predisposing trigger: an antimigraine drug. A possible systemic hypersensitivity reaction, reflected by the occurrence of concomitant severe serum eosinophilia, acute myocarditis, and central nervous system vasculitis, was successfully treated with steroids, further supporting the diagnosis.

Posterior cerebral artery infarction from middle cerebral artery infarction.

BACKGROUND: While it is known that posterior cerebral artery (PCA) infarction may simulate middle cerebral artery (MCA) infarction, the frequency and localization of this occurrence are unknown. OBJECTIVE: To determine the frequency of PCA infarction mimicking MCA infarction and the territory of the PCA most commonly involved in this simulation. DESIGN: We studied 202 patients with isolated infarction in the PCA admitted to our stroke center to determine the frequency of PCA infarction simulating MCA infarction, the involved PCA territory, and the patterns of clinical presentation. RESULTS: We found 36 patients (17.8%) with PCA ischemic stroke who had clinical features suggesting MCA stroke. The PCA territory most commonly involved was the superficial PCA territory (66.7%), followed by the proximal PCA territory (16.7%) and both the proximal and the superficial PCA territories (16.7%). The principal stroke mechanism was cardioembolic (54.1%) in the superficial PCA territory, lacunar (46.2%) in the proximal PCA territory, and undetermined (40.2%) in both the proximal and the superficial territories. Among the 36 patients, the most common clinical associations were aphasia (13 patients), visuospatial neglect (13 patients), and severe hemiparesis (7 patients). CONCLUSIONS: Posterior cerebral artery infarction simulating MCA infarction is more common than previously thought. Early recognition of the different stroke subtypes in these 2 arteries may allow specific management.

Effect of discontinuing aspirin therapy on the risk of brain ischemic stroke.

BACKGROUND: Aspirin, or acetylsalicylic acid, is widely used to prevent ischemic vascular disease. Clinical and experimental data suggest that a rebound effect occurs 4 or fewer weeks after interruption of aspirin therapy. OBJECTIVE: To study the discontinuation of aspirin therapy as a risk factor for ischemic stroke (IS). DESIGN: Case-control study. SETTING: Stroke unit. PARTICIPANTS: Three hundred nine patients with IS or transient ischemic attack undergoing long-term aspirin treatment before their index event and 309 age-, sex-, and antiplatelet therapy-matched controls who had not had an IS in the previous 6 months. METHODS: We compared the frequency of aspirin therapy discontinuation during the 4 weeks before an ischemic cerebral event in patients and the 4 weeks before interview in controls. RESULTS: The 2 groups had a similar frequency of risk factors, except for coronary heart disease, which was more frequent in patients (36% vs 18%; P < .001). Aspirin use had been discontinued in 13 patients and 4 controls. Aspirin interruption yielded an odds ratio for IS/transient ischemic attack of 3.4 (95% confidence interval, 1.08-10.63; P < .005) after adjustment in a multivariable model. CONCLUSIONS: These results highlight the importance of aspirin therapy compliance and give an estimate of the risk associated with the discontinuation of aspirin therapy in patients at risk for IS, particularly those with coronary heart disease.

Selecting patients for early stroke treatment with penumbra images.

Review of results of experimental and clinical studies indicates that the area of physiologically impaired, but potentially salvageable, tissue surrounding the central core of focal cerebral ischemia that develops shortly after onset of vessel occlusion is complex and dynamic with severity and duration thresholds for hypoxic stress and injury that are specific to tissue site, cell type, molecular pathway or gene expression investigated, and efficiency of collateral or residual flow and reperfusion. Identification of this ischemic penumbra in the acute stroke clinical setting is an important goal for stroke researchers and clinicians. Recent advances in neuroimaging allowed a better understanding of this physiopathological process. However, there is not a perfect penumbra imaging technique and each one has its own advantages and disadvantages. Numerous thrombolytic and potentially neuroprotective agents have been studied in stroke patients, with little success, as the only approved therapy is thrombolysis with recombinant tissue plasminogen activator within 3 h of stroke onset in highly selected patients (<10% of all acute stroke patients in some specialized centers). One major obstacle in the development of effective therapies for ischemic stroke has been the lack of versatile imaging techniques. The development of penumbra concept and its detection through modern cerebral image techniques can extend the patients' selection for thrombolysis. A number of multicenter clinical trials are now under way to test these models and confirm the utility of penumbra imaging for treatment decisions. Present knowledge about visualization of the salvageable penumbra suggests a promising future in which penumbra imaging studies are performed routinely in the acute stroke setting and the data provided by these studies assist in individualizing therapeutic decisions and identifying effective therapies that can be delivered at late time points. So, the main target of management is 'penumbra', or salvageable tissue, which is primarily dependent upon the expediency of the whole process, better expressed by the phrase 'Penumbra (and not Time) is Brain'.