Hemiplegic migraine episode triggered by regadenoson.

SPECT and PET myocardial perfusion imaging (MPI) are widely used to evaluate patients for coronary artery disease. Regadenoson (a selective A2A adenosine receptor agonist) is a commonly used vasodilator agent for stress MPI because of its safety profile and ease of use. Common adverse reactions such as headache, shortness of breath, flushing, and chest and abdominal discomfort are typically mild and can be effectively reversed using methylxanthines such as aminophylline and caffeine. Neurological adverse reactions such as seizure and stroke have rarely been reported with the use of regadenoson. The hemodynamic changes associated with regadenoson administration, such as an exaggerated hypotensive or hypertensive response, may be the cause for the reported cerebrovascular accidents. Activation of central nervous system A2A adenosine receptors is thought to be responsible for seizure episodes in patients with or without known histories of seizure. A2A adenosine receptors activation is also believed to play a role in headaches and migraine. This patient reported who has a history of hemiplegic migraine developed left side weakness and headache following the administration of regadenoson during a PET MPI study. Imaging work-up to rule out cerebrovascular accident was normal. After 1 hour from the onset of his symptoms, his weakness and headache significantly improved with complete resolution within 24 hours. We concluded that regadenoson triggered a hemiplegic migraine episode in this patient, which has not been previously reported in the literature. It may be prudent to avoid regadenoson and adenosine use in patients with a history of hemiplegic migraine.

Acute mental change and hemiplegia after autologous fat injection.

Autologous fat injection is a common procedure used for skin augmentation. It is known to be safe and simple, but severe complications have been reported at times. The authors observed a patient with acute large cerebral infarction including the territories of the anterior and middle cerebral arteries and optic nerve infarction developing after autologous fat transplantation. A 32-year-old woman was referred to the emergency room of our hospital due to sudden stupor. Thirty minutes earlier, she was undergoing cosmetic autologous fat injection into the glabella area by a plastic surgeon at a private clinic. The cause was confirmed to be anterior and middle cerebral arteries infarction on brain imaging studies. When a patient presents abrupt mental change, hemiplegia, ocular pain, or blindness after autologous fat particle injection, physicians must consider cerebral infarction and combined retinal artery occlusion.

The muscle findings in a pediatric patient with live attenuated oral polio vaccine-related flaccid monoplegia.

A pediatric patient, who was given live-attenuated oral polio vaccine twice without distinct gait disturbance during infancy, begun to present limp at 3 years. His gait disturbance became remarkable with aging. At 7 years, he was unable to dorsiflex the left ankle, and presented flaccid monoplegia of the left lower extremity, and the left Achilles tendon reflex was diminished. Magnetic resonance imaging revealed multiple crack-lines in the left anterior tibial muscle, but was unable to detect any distinct lesion at responsible level of L4, L5 and S1 anterior horn cells' degeneration. Electromyography showed continuous fibrillation potentials, but muscle biopsy presented nearly normal in this muscle. The serum levels of polio antibody type 1 and type 2 titers were elevated 64× respectively, while the type 3 antibody titer was not elevated 4×. This patient was diagnosed as live attenuated oral polio vaccine-related flaccid monoplegia, with mild clinical course.

Monoplegia after combined spinal epidural anesthesia.

Serious neurological complications after neuraxial block, including permanent neurological injury, are rare in contemporary anesthetic practice. We report a case of a 36 year old female undergoing a venous stripping operation under combined spinal epidural anesthesia (CSE). The CSE procedure was completed after a second attempt at the L4-L5 level and the surgery was completed uneventfully. After full recovery of motor block in the recovery room, the patient was discharged to the surgical ward. Epidural patient controlled analgesia with levobupivacine 0.125% and fentanyl 2 µg/ml was initiated. 10 hours after surgery, right lower limb sensory loss and monoplegia occurred. The epidural catheter was removed and normal MRI findings were noted. After one month of physical therapy treatment and two months follow up the patient was able to walk with the aid of a walking stick. We discuss factors that might have contributed to radiculopathy and neurotoxicity as a cause of neurologic deficit.

Contrast-induced monoplegia following coronary angioplasty with iopromide.

Seizures, alterations in mental and cerebral functions, and ophthalmoplegia are known side effects of contrast agents. Here we report a case of self-limiting monoplegia in a patient after the administration of intracoronary iopromide after coronary angiography which emphasises that, although benign, contrast-induced monoplegia is a neurological disease which requires careful evaluation and accurate management.

Hemiplejia y afasia transitorias no tromboembólicas: ¿neurotoxicidad por contraste angiográfico? / A case of temporary nonthrombotic hemiplegia and aphasia due to neurotoxicity from angiographic contrast material?

Se presenta el caso de una mujer de 75 años, que desarrolló hemiplejia, afasia y disminución del nivel de conciencia, súbitamente, 3h después de una embolización de aneurisma cerebral. La embolización transcurrió sin complicaciones, con control angiográfico final normal. La tomografía computarizada (TC) craneal postembolización mostró hiperdensidad cortical y de los surcos de la convexidad; hallazgos que desaparecieron en una nueva TC realizada 4h después. Una arteriografía cerebral 24h postembolización presentaba retraso del parenquimograma hemisférico izquierdo respecto del derecho, sin oclusiones vasculares. El déficit neurológico persistió 72h, y se resolvió después, tan súbitamente como se instauró, espontánea y completamente. Éste es uno de los pocos casos descritos de déficit neurológico transitorio en relación con la administración de contraste iodado, fuera de la circulación posterior (ceguera cortical). Cuando se producen síntomas neurológicos tras un tratamiento endovascular cerebral, es fundamental distinguir este excepcional cuadro, probablemente tóxico, de las posibles complicaciones isquémicas del procedimiento (AU)

We present the case of a 75-year-old woman who suddenly developed hemiplegia, aphasia, and reduced consciousness three hours after embolization of a cerebral aneurysm. No complications occurred during embolization and the findings at end-procedure angiography were normal. Cranial computed tomography (CT) after embolization showed hyperdensity of the cortex and sulci of the convexity; another CT examination performed four hours later showed these findings had disappeared. Cerebral arteriography 24h after embolization showed delayed blood flow to the parenchyma of the left hemisphere compared to the right but no vascular occlusion. The neurological deficit lasted 72h and resolved spontaneously and completely as suddenly as it developed. This is one of the few cases of temporary neurological deficit related to iodinated contrast administration to be reported outside the posterior circulation (cortical blindness). When neurological symptoms occur after endovascular procedures in the brain, it is fundamental to distinguish this rare clinical syndrome of probable toxic origin from possible ischemic complications of the procedure (AU)

[A case of temporary nonthrombotic hemiplegia and aphasia due to neurotoxicity from angiographic contrast material?]. / Hemiplejia y afasia transitorias no tromboembólicas: ¿neurotoxicidad por contraste angiográfico?

We present the case of a 75-year-old woman who suddenly developed hemiplegia, aphasia, and reduced consciousness three hours after embolization of a cerebral aneurysm. No complications occurred during embolization and the findings at end-procedure angiography were normal. Cranial computed tomography (CT) after embolization showed hyperdensity of the cortex and sulci of the convexity; another CT examination performed four hours later showed these findings had disappeared. Cerebral arteriography 24h after embolization showed delayed blood flow to the parenchyma of the left hemisphere compared to the right but no vascular occlusion. The neurological deficit lasted 72 h and resolved spontaneously and completely as suddenly as it developed. This is one of the few cases of temporary neurological deficit related to iodinated contrast administration to be reported outside the posterior circulation (cortical blindness). When neurological symptoms occur after endovascular procedures in the brain, it is fundamental to distinguish this rare clinical syndrome of probable toxic origin from possible ischemic complications of the procedure.

Apnoeic spells following general anaesthesia in a patient with familial hemiplegic migraine.

Hemiplegic migraine is an unusual variant of migraine, characterised by a temporary hemiparesis or hemiplegia associated with headache. We report a patient with hemiplegic migraine who developed atypical migraine with apnoeic spells, aphasia and hemiparesis following general anaesthesia. We review the clinical features of hemiplegic migraine and the considerations for its anaesthetic management.

Immune reconstitution inflammatory syndrome associated with PML in AIDS: a treatable disorder.

An HIV-1-infected patient with progressive multifocal leukoencephalopathy presented clinical deterioration and contrast-enhancing lesions on brain nuclear MR after the initiation of highly active antiretroviral therapy (HAART). Brain biopsy identified an inflammatory reaction compatible with immune reconstitution inflammatory syndrome. Treatment with corticosteroids and transient suppression of HAART led to marked neurologic improvement.

Etomidate speech and memory test (eSAM): a new drug and improved intracarotid procedure.

BACKGROUND: The intracarotid amobarbital procedure (IAP) is an important part of comprehensive investigation of patients who are candidates for surgical treatment of epilepsy. Owing to repeated and lengthy shortages of amobarbital, causing delays in elective surgery, attempts have been made to find a suitable alternative anesthetic. The authors report their experience using etomidate, a widely used agent for the induction of anesthesia. METHODS: Sixteen consecutive patients requiring IAP to evaluate memory or to lateralize speech underwent the procedure using etomidate. Prior to the procedure a catheter was placed in the internal carotid artery and an angiogram was performed. EEG was recorded and read online by an electroencephalographer. An anesthetist injected the drug, administered by bolus followed by an infusion, which was maintained until each speech measure had been sampled and new memory items had been introduced. The infusion was then stopped and testing continued as in a standard IAP. RESULTS: In all cases (30 hemispheres) contralateral hemiplegia followed injection. EEG slow waves were observed in every injected hemisphere, with some contralateral slowing anteriorly in 18. Global aphasia with preserved attention and cooperation followed dominant-hemisphere injections. These phenomena remained during infusion, and upon its termination returned gradually to baseline over a period of about 4 minutes. CONCLUSIONS: Etomidate is a viable alternative to amobarbital, and its administration by bolus followed by infusion offers an improvement over the traditional intracarotid amobarbital procedure. Cognitive tests can be performed during an assured hemianesthesia of the injected hemisphere.

Effect of tumor necrosis factor antagonism on allergen-mediated asthmatic airway inflammation.

OBJECTIVE: To assess whether tumor necrosis factor (TNF) antagonism can attenuate eosinophilic airway inflammation in patients with mild-to-moderate allergic asthma. DESIGN: Randomized, double-blind, placebo-controlled trial. SETTING: National Institutes of Health (NIH) Clinical Center. PATIENTS: Twenty-six patients with mild-to-moderate allergic asthma, receiving only inhaled beta-2-agonists, who demonstrated both an early and late phase response to inhalational allergen challenge. INTERVENTION: Injection of a soluble TNF receptor (TNFR:Fc, etanercept, Enbrel) or placebo, 25mg subcutaneously, twice weekly for 2 weeks, followed by a bronchoscopic segmental allergen challenge. MEASUREMENTS: The primary outcome measure was whether TNFR:Fc can access the lung and inhibit TNF bioactivity. Secondary outcome measures included pulmonary eosinophilia, Th2-type cytokines, and airway hyperresponsiveness. RESULTS: Anti-TNF therapy was associated with transient hemiplegia in one patient, which resulted in suspension of the study. Data from the 21 participants who completed the study were analyzed. Following treatment, patients receiving anti-TNF therapy had significantly increased TNFR2 levels in epithelial lining fluid (ELF) (P<0.001), consistent with delivery of TNFR:Fc to the lung. TNF antagonism did not attenuate pulmonary eosinophilia and was associated with an increase in ELF IL-4 levels (P=0.033) at 24h following segmental allergen challenge. TNF antagonism was not associated with a change in airway hyperresponsiveness to methacholine. CONCLUSIONS: TNF antagonism may not be effective for preventing allergen-mediated eosinophilic airway inflammation in mild-to-moderate asthmatics. Transient hemiplegia, which may mimic an evolving stroke, may be a potential toxicity of anti-TNF therapy.