Lessons Learned from a Fulminant Case of Reversible Cerebral Vasoconstriction Syndrome: Past Medical History Misleads the Diagnosis and Intra-Arterial Milrinone Offers Diagnostic Utility / 신경중재치료의학

A 34-year-old post-partum female having dermatomyositis developed headache and became comatose after a seizure episode. Magnetic resonance imaging of brain showed a massive left ganglio-capsular bleed for which decompressive surgery was done. Computed tomographic angiography showed multiple foci of narrowing and irregularities in distal cerebral vessels. In view of dermatomyositis, the diagnosis of vasculitis was considered and pulse therapy of intravenous methylprednisolone was started. The patient, however, showed no improvement and developed new brain infarcts. She was subsequently taken up for a diagnostic cerebral angiography which showed multifocal severe narrowing in bilateral major cerebral arteries. These angiographic abnormalities showed excellent reversibility to intra-arterial milrinone and hence, reversible cerebral vasoconstriction syndrome (RCVS) was diagnosed. Normal angiographic findings in the first week do not rule out the disease and a repeat angiography should be considered if the clinical suspicion of the RCVS is high. Intra-arterial milrinone has a high diagnostic utility.

Tenecteplase versus alteplase (TENVALT): A study comparing two thrombolytic agents in acute ischemic stroke

@#Background & Objective: The Indian data comparing the efficacy and safety outcomes of tenecteplase and alteplase in acute ischemic stroke is scarce. We aimed to compare the outcomes of two agents in an Indian population. Methods: TENVALT study was a single centre, retrospective study. Patients aged 18 years or older with acute ischemic stroke were included in this study if they presented within 3 hours of symptom onset and had a deficit with National Institute of Health Stroke Scale (NIHSS) score > 4, had a modified Rankin score (mRS) of 2 or less before the stroke onset and had no evidence of hemorrhage on non-contrast computed tomography of brain. A good functional recovery (mRS score of 0-2) at the end of three months was defined as the primary efficacy outcome. The development of symptomatic intracerebral hemorrhage was considered as the primary safety outcome. Results: A total of 120 patients (alteplase, n=65; tenecteplase, n=55) underwent stroke thrombolysis during this study. The mean age of the presentation in tenecteplase group was 66.6 years and in alteplase group was 62.5 years. Most of the study subjects were males in both the groups (tenecteplase, 78.2%; alteplase, 61.5%). Hypertension was the most common comorbidity in both the groups (tenecteplase, 67.3%; alteplase, 76.9%). Median mRS score at 3 months of follow up was 2 in tenecteplase and 1 in alteplase group; however, the difference between the total number of patients having good functional recovery (mRS 0-2) in the two groups was not statistically significant (tenecteplase 74.5 vs alteplase 87.7%, P=0.09). The total number of patients who had symptomatic intracranial hemorrhage was comparable between the two groups (tenecteplase, 5.5%; alteplase, 6.2%). Conclusion: Tenecteplase appears to be an efficacious alternative to alteplase for stroke thrombolysis and may be better suited to developing countries considering its low cost and ease of administration.

A Case of Wegener's Granulomatosis Presenting with Unilateral Facial Nerve Palsy.

Wegener's granulomatosis or granulomatosis with polyangiitis is a necrotizing vasculitis affecting both arterioles and venules. The disease is characterized by the classical triad involving acute inflammation of the upper and lower respiratory tracts with renal involvement. However, the disease pathology can affect any organ system. This case presents Wegener's granulomatosis presenting with facial nerve palsy as the first manifestation of the disease, which is rarely reported in medical literature.