ABSTRACT
BACKGROUND Cerebral amyloid angiopathy (CAA) is an increasingly recognized cause of lobar intracerebral hemorrhage (ICH) and cognitive impairment in the aging population. Magnetic resonance imaging (MRI) of cerebral microbleeds is the most reliable option for clinical diagnosis of suspected CAA. The pathophysiology of microbleeds and ICH in CAA is not well understood, but it is thought to be the result of vessel weakening and rupture secondary to amyloid deposition. Little evidence has been established pertaining to the time course of recurrent CAA-related microbleeds or larger hemorrhages. Although several risk factors have been associated with an increased risk of ICH in CAA, there are no current treatment guidelines for recurrent hemorrhaging in CAA. CASE REPORT We present a rare case of rapidly sequential and fatal lobar hemorrhaging in the setting of suspected CAA, diagnosed by numerous microbleeds on MRI, compounded by the use of subcutaneous heparin in a 63-year-old female patient. CONCLUSIONS This case broadens our understanding of a rarely identified progression of CAA and illustrates the need for further investigation of the use of subcutaneous heparin in the setting of probable CAA.
Subject(s)
Cerebral Amyloid Angiopathy/complications , Cerebral Hemorrhage/etiology , Brain/diagnostic imaging , Cerebral Amyloid Angiopathy/diagnosis , Cerebral Hemorrhage/diagnosis , Diagnosis, Differential , Fatal Outcome , Female , Humans , Magnetic Resonance Imaging , Middle Aged , Tomography, X-Ray ComputedABSTRACT
PURPOSE: Bleeding is the major side effect of thrombolysis with alteplase (tissue plasminogen activator, t-PA) used for the treatment of acute ischemic stroke. Life-threatening intracranial, retroperitoneal, gastrointestinal, respiratory, and genitourinary bleeding can occur with the use of t-PA. Vitreo-retinal bleeding in the context of acute ischemic stroke treatment has not been reported in the literature before and therefore is not posed as a potential risk during decision making. Here we describe the first reported case of vitreo-retinal hemorrhage due to alteplase administration in a patient with acute ischemic stroke. SUMMARY: An 84-year-old white male presented to the emergency room with complaints of right arm and leg weakness. The onset of symptoms was approximately 30 min prior to presentation to the emergency room. After ruling out contraindications including the presence of hemorrhage on head CT scan, patient was administered alteplase within 2 hours of symptom onset. Four hours after the administration of alteplase, the patient developed right-sided vision changes. A repeat CT scan demonstrated a newly developed right intraocular hemorrhage. Throughout the hospital course, patient's neurological status improved, but he continued to have right-sided visual loss. CONCLUSION: Clinicians should be aware of the potential for ocular hemorrhage especially in high-risk patients. The likelihood of a subsequent vision-loss needs to be therefore discussed with the patient and family in such situations.
ABSTRACT
BACKGROUND: West Nile Virus (WNV) is a flavivirus WNV that has spread westwards across North America in recent years. It can cause a febrile illness and infection of the central nervous system, which is associated with poor outcome. METHODS: We retrospectively studied the clinical and neuroradiologic features of 39 consecutive patients admitted during summer of 2002 that had IgM in the cerebrospinal fluid positive for WNV. RESULTS: Fever, headache and altered mentation were predominant clinical features. Clinically significant involvement of lower motor neurons was seen in few cases. Magnetic resonance imaging (MRI) of the brain did not show changes attributable to meningitis or encephalitis except for one case of subcortical signal abnormalities. Unfavorable prognostic factors are old age, decreased level of alertness and elevated serum creatinine. CONCLUSIONS: Encephalopathic presentations, with or without additional neurological focality, dominated this series. Fever and meningitic signs are often absent. Involvement of lower motor neurons was uncommon. Given the paucity of positive findings, the value of MRI to support the diagnosis of WNV-meningoencephalitis is limited.
