Karanbir Singh

Posterior reversible encephalopathy syndrome secondary to blood transfusion

The appearance of posterior reversible encephalopathy syndrome (PRES) after blood transfusion is rare and has only been reported in three patients to our knowledge. We report a fourth patient with PRES secondary to blood transfusion. A 36-year-old woman with a history of menorrhagia presented to the emergency department with severe fatigue. She had a hemoglobin of 1.7 g/dl and received four units of red blood cells over 15 hours. On day 6 post-transfusion she returned with confusion, headache and a generalized tonic-clonic seizure. The MRI of her brain was consistent with PRES. The following day her confusion worsened, repeat MRI of the brain showed new T2-weighted lesions. Over next 10 days her mental status gradually improved close to her baseline. A repeat MRI of the brain showed resolution of the T2-weighted lesions. The clinical presentation, radiological findings and disease progression in our patient was consistent with PRES. Other than the blood transfusions, there were no apparent risk factors for PRES. The prior three patients with post-transfusion PRES have been reported in middle-aged women with uterine fibroids. It is suspected that these patients have a subacute to chronic anemic state due to ongoing menorrhagia. It is interesting to note that no cases of PRES post-transfusion have been reported in the setting of acute blood loss, such as from trauma. It is postulated that an abrupt increase in hemoglobin causes a rapid rise in blood viscosity and loss of hypoxic vasodilation. Subsequent endothelial damage and brain capillary leakage results in PRES. This constellation of changes may not occur after transfusion in patients with more acute blood loss.

Is acute reperfusion therapy safe in acute ischemic stroke patients who harbor unruptured intracranial aneurysm

Background Intracranial aneurysms are currently considered as contraindication for intravenous thrombolysis in acute ischemic stroke, very likely due to a possible increase in the risk of bleeding from aneurysm rupture; however, there is limited data available on whether intravenous thrombolysis is safe for acute ischemic stroke patients with pre-existing intracranial aneurysms. Aims and/or hypothesis To find out the safety of intravenous thrombolysis in acute ischemic stroke patients who harbor unruptured intracranial aneurysms. Methods We retrospectively reviewed the medical records and cerebrovascular images of all the patients treated with intravenous thrombolysis for acute ischemic stroke in our center from the beginning of 2006 till the end of April 2014. Those with unruptured intracranial aneurysm present on cerebrovascular images prior to acute reperfusion therapy were identified. Post-thrombolysis brain imaging was reviewed to evaluate for any intraparenchymal or subarachnoid hemorrhage related or unrelated to the aneurysm. Results A total of 637 patients received intravenous thrombolysis for acute ischemic stroke in our center during an 8.3-year period. Thirty-three (5.2%) were found to have at least one intracranial aneurysms. Twenty-three (70%) of those received only intravenous thrombolysis, and 10 patients received combination of intravenous and intra-arterial throm-bolysis. The size of the largest aneurysm was 10 mm in maximum diameter (range: 2-10 mm). The mean size of aneurysms was 4.8 mm. No symptomatic intracranial hemorrhage occurred among the 23 patients receiving only intravenous thrombolysis. Out of those who received a combination of intravenous and intra-arterial thrombolysis, one developed symptomatic intracranial hemorrhage in the location of acute infarct, distant to the aneurysm location. Conclusion Our findings suggest that neither intravenous thrombolysis nor combination of intravenous and intra-arterial thrombolysis increases the risk of aneurysmal hemorrhage in acute ischemic stroke patients who harbor unruptured intracranial aneurysms less than 10 mm in diameter. Their listing in exclusion criteria for intravenous throm-bolysis should be reconsidered to assure appropriate use of acute reperfusion therapy in this group of patients.

Safety of intravenous thrombolysis for acute ischemic stroke in patients with preexisting intracranial neoplasms: a case series

Intracranial neoplasms are currently considered a contraindication for intravenous (IV) thrombolysis in acute ischemic stroke (AIS) patients (1,2). Minimal data are available on the safety of IV thrombolysis for AIS in patients with preexisting intracranial neoplasm. We sought to determine the safety of IV recombitant tissue plasminogen activator (rtPA) in such patients through a retrospective hospital-based study. We retrospectively reviewed the medical records of patients who received IV rtPA for AIS from January 2006 to April 2014 at our tertiary academic medical center. All patients were treated based on the standard protocol adopted from the American Heart Association/ American Stroke Association within 4.5 h of AIS onset (2). Patients who received intra-arterial (IA) thrombolysis after IV rtPA were included. A subset of patients with definite intracranial neoplasms from this cohort was identified. Follow-up computed tomography (CT) or magnetic resonance imaging (MRI) within 24 to 36 h of IV rtPA administration and medical records were reviewed to determine the number of patients with symptomatic intracranial hemorrhage (sICH) in this subset. sICH was defined as intracranial hemorrhage (ICH) with an increase in National Institutes of Health Stroke Scale of at least 4 points (3). In addition, hemorrhage within the neoplasm was evaluated. Six hundred thirty-seven patients received full dose IV rtPA for AIS within the study period. Preexisting intracranial neoplasms were found in 13 of the 637 patients reviewed (2%). The demographics of the patients are outlined in Table 1. None of the 13 patients developed sICH or hemorrhage into the tumor after thrombolysis. To the best of our knowledge, our study is the largest on the safety of IV rtPA for AIS in patients with preexisting intracranial neoplasms. This study is also the first report, to our knowledge, of patients with intracranial neoplasm who received IV rtPA followed by IA thrombolysis with mechanical thrombectomy devices. Our study should be interpreted in light of several limitations. It is a single-center study with a low number of cases; in addition, we have no malignant neoplasm in our cohort and no generally valid conclusion can be drawn about the safety of IV thrombolysis in all grades of intracranial neoplasm. Our finding suggests that IV rtPA administration for AIS does not increase the risk of hemorrhage within the neoplasm in patients with preexisting benign intracranial neoplasm. Their listing in exclusion criteria for rtPA should be reconsidered to assure appropriate use of IV rtPA in this group of patients. We hope our study will encourage other centers to look into their data and study this further, so as to determine the actual risk of hemorrhage with rtPA in patients with intracranial neoplasms.