Does eicosapentaenoic acid (EPA) inhibit cerebral vasospasm in patients after aneurysmal subarachnoid hemorrhage?

BACKGROUND: Cerebral vasospasm following subarachnoid hemorrhage (SAH) is a significant cause of morbidity and mortality and recent studies indicate that Rho-kinase plays an important role in the occurrence of such cerebral vasospasm. Eicosapentaenoic acid (EPA), an n-3 polyunsaturated fatty acid, inhibits sphingosylphosphorylcholine (SPC)-induced Rho-kinase activation in vitro, so this study examined whether EPA prevented cerebral vasospasm occurrence after SAH in patients. METHODS: The trial population was 101 patients with SAH subjected to craniotomy and clip application. EPA was orally administered at a daily dose of 1800 mg EPA from day 4 to day 14 to 73 patients; the other 28 constituted the control group, receiving no EPA. RESULTS: EPA significantly curtailed both the occurrence of symptomatic vasospasm (14% EPA group, 36% control, P = 0.019) and of cerebral infarction because of cerebral vasospasm (4% EPA group, 29% control, P = 0.001). Moreover, the percentage of patients with a clinically good outcome was significantly higher in the EPA group (85%, P = 0.022) than in control (64%); there were no deaths in the EPA group but three (11%) in control (P = 0.020). CONCLUSION: These findings suggest EPA inhibits symptomatic cerebral vasospasm and cerebral infarction after SAH and also improves clinical prognosis.

Autoimmune hemolytic anemia as a first manifestation of primary effusion lymphoma.

A 55-year-old man developing transfusion-dependant anemia was diagnosed with autoimmune hemolytic anemia (AIHA). Although he received prednisolone (PSL) (daily 60 mg), his hemoglobin level continued to decrease. After 3 weeks of treatment, he presented with a distension of the abdomen. Cytological examination of ascitic fluid revealed large, immunoblastic lymphocytes with plasmacytoid features and abundant IgM chains on the cellular surface; this was diagnosed as primary effusion lymphoma (PEL). Administration of CHOP (cyclophosphamide, Adriamycin, vincristine, and PSL) chemotherapy elicited regression of ascites as well as recovery of hemoglobin level. We hypothesize that PEL cells generated antibodies against red blood cells, resulting in AIHA resistance to PSL.

Usefulness of hemodynamic evaluation in patients with major cerebral arterial occlusive disease before cardiac surgery.

Patients with ischemic heart disease are often complicated with cerebrovascular disease. The purpose of this study is to examine the usefulness of Xe-CT CBF study in patients with cerebral arterial occlusive disease before cardiac surgery with cardiopulmonary bypass. This study was carried out in 11 patients suffered from ischemic heart disease with cerebrovascular diseases. They had severe stenoses or occlusions of cerebral arteries. Cerebral hemodynamics was measured by Xe-CT. There were no ischemic complications in the brain or heart during the study. Hemispheric CBF in the occlusive side is lower than that in the non-occlusive side. Cerebral ischemic events occurred in one patient after the cardiac surgery. Xe-CT CBF study can be performed safely in patients with ischemic heart disease. The patients with low CBF and low cerebrovascular reserve, had a greater risk of cerebral complication after cardiac surgery with cardiopulmonary bypass.

The value of acetazolamide challenge test in the evaluation of acute stroke.

The acetazolamide (ACZ) challenge test provides a useful information about compromised hemodynamic state in chronic stroke. However, there is no consensus whether this test is of any value in the evaluation of acute ischemic stroke. The purpose of this study is to examine the value of ACZ challenge test in the management of acute ischemic stroke. Study 1: Nineteen patients with acute embolic stroke were subjected to the Xe CT with and without ACZ (17 mg/kg, i.v.) within 6 hours from the onset. The cases included 12 middle cerebral artery (MCA) occlusions and 7 internal carotid artery (ICA) occlusions. The baseline cerebral blood flow (CBF) values and cerebrovascular reserve (CVR) (% increase in CBF after ACZ) were analyzed in 53 affected regions of interest (ROI). The study indicated that the CBF threshold of subsequent permanent infarction was 15 ml/100 g/min and the ROI with negative CVR had a higher incidence of hemorrhagic infarction. Study 2: Xe-CT with and without ACZ was performed in 32 patients with acute occlusion of the main trunks of cerebral arteries within 6 hours after the onset. Occluded arteries were MCA in 20 patients, ICA in 7, both ICA and MCA in 4 and anterior cerebral artery (ACA) in one. The abnormal hemispheric CBF (< 20 ml/100 g/min) and CVR (< 10%) were correlated with the Glasgow outcome scales of the patients. The predictability of Good Recovery, Moderately Disabled, Severely Disabled, Vegetative Survival and Dead were 80%, 50%, 50%, 100% and 100% by CBF criteria, and 80%, 60%, 80%, 100% and 100% by CVR criteria, respectively. There was no significant increase in the predictability of final outcome of the patients by adding the CVR information of the acute stage. The ACZ challenge test has a potential value in the prediction of hemorrhagic transformation of the ischemic regions. It does not increase the predictability of the long-term outcome. We do not recommend performing ACZ challenge test on routine basis in the evaluation of acute ischemic stroke.