Percutaneous Coronary Intervention With Dual Antiplatelet Therapy in a Patient With Chronic Subdural Hematoma: Novel Approach.

Subdural hematoma is a type of brain bleed characterized by the accumulation of blood beneath the dura matter. It usually occurs as a sequela of a traumatic event or following the use of antiplatelets and/or anticoagulants. The clinical presentation may include symptoms like headache, confusion, ataxia, and hemiparesis. However, it may even be asymptomatic, especially in the elderly population. The presence of subdural hematoma is a relative contraindication to antiplatelet therapy because of the associated risk of worsening bleeding. Hence, acute coronary syndrome or conditions requiring antiplatelet therapy presents a management dilemma when they coexist with subdural hematoma. This paper reports a case of successful use of dual antiplatelets post percutaneous coronary intervention in a patient with spontaneous chronic subdural hematoma. Our patient had a history of coronary artery disease six months prior to stent placement and was on dual antiplatelet therapy. He developed a headache some months later and his neurologist, on evaluating him, made a diagnosis of subdural hematoma, evident on magnetic resonance imaging of the brain. His antiplatelet therapy was discontinued, and he subsequently had a bilateral middle meningeal artery embolization. Following the procedure, a left heart catheterization was done with appropriate interventions for acute coronary syndrome diagnosed at the time of presentation. He was later discharged on dual antiplatelet therapy, followed up on outpatient at scheduled intervals, and was found stable. This case report suggests that individuals with chronic subdural hematoma who may require antiplatelet therapy can still go on to receive the medication after undergoing a bilateral middle meningeal artery embolization. More observational studies are needed to make this the standard of care.

Use of Arterial Spin-Labeling in Patients with Aneurysmal Sub-arachnoid hemorrhage.

Delayed cerebral ischemia (DCI) due to cerebral vasospasm following aneurysmal subarachnoid hemorrhage (aSAH) has long been recognized as a major source of morbidity and mortality. Early detection of cerebral vasospasm and identification of patients who are likely to become symptomatic is crucial to guide aggressive medical and/or endovascular interventions. Magnetic resonance imaging using arterial spin-label (ASL) is a noninvasive mean for assessing cerebral blood flow and is based on direct magnetic labeling of arterial blood water protons. The diagnostic role of ASL in acute ischemic stroke, epilepsy, and neurodegenerative disorders has been explained in multiple studies but its ability to predict vasospasm in aSAH has not been published before. The purpose of this study is to highlight the diagnostic implications of different perfusion patterns of ASL in patients with aSAH which can be utilized to prevent DCI in such patients when other commonly used modalities are not available, contraindicated, or fail to detect vasospasm.

Cross-circulation thrombectomy with use of a stent retriever: A case report.

Introduction The efficacy of the endovascular treatment of acute ischemic stroke has been substantiated by several recent randomized clinical trials. While intra-arterial therapy has significantly evolved in recent years, anatomic cerebrovascular variants and disease burden can present challenges to timely recanalization. We present the first reported case of anterior-to-posterior mechanical clot retrieval with use of a stent retriever. Case description A 53-year-old man presented with basilar artery thrombosis. Endovascular mechanical clot retrieval was performed. The typical, antegrade, access to the basilar artery thrombus was precluded by the findings of a hypoplastic left vertebral artery and an occluded proximal right vertebral artery. Given a number of factors including the patient's worsening symptoms and the high morbidity and mortality associated with basilar stroke, cross-circulation-anterior-to-posterior-intra-arterial therapy was performed. Thrombectomy of the basilar thrombus was achieved via the right internal carotid artery and right posterior communicating artery. Conclusion To our knowledge, we report the first case of cross-circulation, anterior-to-posterior thrombectomy, with the use of a stent-retriever device. Cross-circulation stroke treatment may be beneficial in cases of proximal vessel occlusion or anatomical constraints. Larger studies will need to evaluate the safety and efficacy of these approaches.

Seizure Prophylaxis in the Immediate Post-Hemorrhagic Period in Patients with Aneurysmal Subarachnoid Hemorrhage.

INTRODUCTION: Seizures are a well-known complication of aneurysmal subarachnoid hemorrhage (aSAH) and occur most commonly in the immediate posthemorrhagic period. Most commonly used antiepileptic drugs (AEDs) for seizure prophylaxis in aSAH include phenytoin and levetiracetam. There is no reliable data available on the safety and efficacy of restricting AED prophylaxis only till the aneurysm is secured. METHODS: We retrospectively chart reviewed patients admitted to our neurosciences intensive care unit (NICU) with aSAH during the past two years. Seizure incidence was studied in patients treated with phenytoin versus levetiracetam and in patients treated for 3-7 days vs. those where AED was discontinued immediately after aneurysm was secured. RESULTS: In 28 patients, AED prophylaxis was discontinued immediately after the aneurysm was secured, and in 21 patients, it was continued for 3-7 days. Of the 28 patients who received AED prophylaxis for less than or equal to two days, phenytoin was used in 20 patients and levetiracetam was used in eight patients. In patients receiving AED prophylaxis for 3-7 days, phenytoin was used in eight cases and levetiracetam was used in 13 cases. None of these patients had seizures reported during hospitalization or at three-month follow-up. CONCLUSION: Stopping the AED prophylaxis immediately after aneurysm coiling is not associated with increased risk of seizures. Seizures at presentation in patients with aSAH are not associated with development of epilepsy at three months. Both phenytoin and levetiracetam are well tolerated in patients with aSAH when limited to the immediate posthemorrhagic period.

Acute visual loss in a patient with spinal cord injury.

INTRODUCTION: Patients with spinal cord injury (SCI), especially those with injury at and above T6, are prone to transient episodes of hypertension induced by noxious triggers below the level of SCI, known as autonomic dysreflexia (AD). An uncommonly reported presentation of AD is posterior reversible encephalopathy syndrome (PRES). CASE PRESENTATION: A 50-year-old male with the history of paraplegia from SCI presented with sepsis secondary to baclofen pump and urinary tract infections. On hospital day 4, he developed acute bilateral vision loss. The next morning he had a generalized-tonic-clonic seizure followed by cardiac arrest, with return of spontaneous circulation following resuscitation. Magnetic resonance imaging brain demonstrated multifocal areas of hyperintensity on T2 fluid-attenuated inversion recovery sequence, most pronounced in the occipital lobes. Systolic blood pressures (SBP) were under 180 mmHg throughout hospital stay but above his baseline (SBP 90 mmHg). PRES was diagnosed on the basis of clinical and radiologic evidence. With strict blood pressure (BP) control, there was resolution of visual abnormalities, headaches, encephalopathy, and seizures. DISCUSSION: Although PRES has been most commonly described in malignant hypertension, it can be seen in patients with normotension or moderate hypertension who have low baseline BPs, such as patients with SCI. These patients are prone to AD due to imbalanced sympathetic outflow to vasculature below the level of injury caused by noxious stimulus. This results in massive regional vasoconstriction leading to an uncontrolled rise in BP above baseline. This episode of PRES could have been prevented by identifying patient's risk, recognizing early signs and potential triggers of AD, and implementing aggressive treatment of the underlying noxious stimuli.