Safety and feasibility of intra-arterial nicardipine for the treatment of subarachnoid hemorrhage-associated vasospasm: initial clinical experience with high-dose infusions.

BACKGROUND AND PURPOSE: Delayed cerebral ischemia from vasospasm is a major complication after aneurysmal subarachnoid hemorrhage (SAH), but complications and/or low efficacy are associated with current therapy. We report our initial experience with intra-arterial use of a calcium channel blocker, nicardipine. MATERIALS AND METHODS: A retrospective review of a consecutive series of patients with clinical and angiographic vasospasm treated with intra-arterial nicardipine was performed. Standard criteria for definition of significant, intractable vasospasm after aneurysmal SAH were used. After catheter angiographic confirmation of vasospasm, arteries showing severe narrowing were targeted for superselective catheterization. Nicardipine was infused at a high dose rate (0.415-0.81 mg/min). Contrast injections were performed at 2-5-mg intervals to assess effective response (a 60% increase in arterial diameter of the most severely decreased in caliber vessel compared with the very first angiographic run). RESULTS: Eleven consecutive patients underwent a total of 20 procedures; most had SAH with high Hunt and Hess grades (III or IV). All had depressed level of consciousness; others had paresis (7/20, 35%), aphasia (1/20, 5%), and facial nerve palsy (1/20, 5%). Between 10 and 40 mg of nicardipine was used. A 60% increase in diameter of the main affected artery compared with the initial diameter measured in the initial angiographic run was achieved in all procedures. Clinical improvement (resolved focal symptoms or increased Glasgow Coma Score) occurred in 10 of 11 patients (91%). One patient died from complications of the initial hemorrhage. No complications occurred after 16 of 20 procedures (80%); minor complications without sequelae occurred after the remaining procedures. Follow-up of at least 2 months in 10 survivors revealed minor or no deficits in most patients with a Glasgow Outcome Score of 1 or 2 in 9 of 10 patients (90%). CONCLUSION: In this small series, high-dose intra-arterial nicardipine infusion to treat SAH-associated vasospasm seems to be safe and effective.

Hydatid disease of the interventricular septum causing pericardial effusion.

Echinococcal infestation of the heart is uncommon. We report a case of a 35-year-old man with an hydatid cyst located in distal interventricular septum. Clinical presentation was chest pain and urticaria. Diagnosis was made by echocardiography and magnetic resonance imaging. Surgical resection was performed; the cyst was punctured and its content was drained, hypertonic glucose solution was instilled for sterilization, and it was removed. The patient did well and remains asymptomatic. Diagnosis and ultimate surgical treatment of this disease prevented potentially lethal complications such as cyst rupture with embolic phenomena and anaphylactic shock.

Anomalous coronary artery origin associated with bicuspid aortic valve in a patient with rheumatic mitral stenosis: a case report.

A rare case of an anomalous left coronary artery arising from the right sinus of Valsalva associated with bicuspid aortic valve is presented. This case is unique because these congenital anomalies were associated with rheumatic mitral stenosis. This anomalous coronary origin was found at catheterization before balloon mitral valvuloplasty. The clinical significance of this finding is discussed.

Spinal gout: a great mimicker. A case report and literature review.

Spinal gout is not as rare as was previously thought and mimics heterogeneous spinal conditions such as rheumatoid, septic, seronegative arthropathies and primary or secondary neoplasms. Imaging findings are nonspecific and usually manifest late. In clinical settings, suspicious for spinal gout, needle biopsy may help for further characterization. A 57-year-old man with no significant past medical history presented in the emergency department with severe non radiating low back pain of one week duration. His laboratory tests were significant for uric acid of 642 µmol/L, erythrocyte sedimentation rate 93 mm/hour, and C-reactive protein 8.3 mg/dl. The lumbar spine MRI showed nonspecific acute inflammatory extensive lumbar facet arthropathy and soft tissue enhancement. The radiological and clinical information was insufficient to differentiate among septic arthritis, rheumatoid arthritis, seronegative arthropathy or gout. A lumbar facet fluoroscopy-fluoroscopic CT-guided needle biopsy was performed. The biopsy demonstrated negative birefringent crystals consistent with gout. Although the spinal gout is not rare, few case reports describe the role of needle biopsy and mimics. We present a comparative review of limited reports addressing the role of needle biopsy in mimics of spinal gout.

Progressive AVM Thrombosis after Onyx Embolization with Angiographic Cure.

Intracranial arteriovenous malformations (AVMs) have a cumulative risk of hemorrhage and refractory seizures. Pre-surgical Onyx embolization of cerebral AVMs improves clinical outcome. A 45-year-old man with a history of seizures was diagnosed with a Spetzler-Martin grade 4 AVM in the right occipital lobe. As per initial assessment, three to four sessions were required for adequate devascularization of the AVM before offering either surgery or gamma knife treatment. We achieved 10% and 70% devascularization in the first and second stage Onyx18 embolization respectively. Subsequent bilateral internal carotid, external carotid, vertebral and right posterior cerebral artery superselective angiography performed six weeks after the second stage of embolization demonstrated unexpected complete angiographic cure of the AVM.