Michael J Wilder

Repetitive use of intra-arterial verapamil in the treatment of reversible cerebral vasoconstriction syndrome

Reversible cerebral vasoconstriction syndrome (RCVS) typically presents with recurrent thunderclap headaches and neurological deficits that are usually self-limiting. The intra-arterial (IA) use of vasodilators for RCVS has been reported for severe cases. Patients with RCVS have the potential for serious and permanent neurological deficits. It is a rare disorder, with a recent surge in the number of reports, and probably continues to be under-diagnosed. We report two patients with RCVS with severe neurological sequelae, treated in a large tertiary hospital. Both patients received high-dose cortico steroids due to the possibility of angiitis of the central nervous system, but they deteriorated neurologically, which suggests that steroids may have a deleterious effect in RCVS. Treatment with IA verapamil resulted in reversal of vasoconstriction, but multiple treatments were necessary. Therefore, IA administration of verapamil is a possible treatment for severe RCVS, but there is only limited sustained improvement in vasodilation that may require repetitive treatments with a currently undetermined optimal treatment interval.

Quality of Life after Intra-arterial Therapy for Acute Ischemic Stroke

Few data exist about health-related quality of life outcomes after intra-arterial therapy (IAT) for acute ischemic stroke (AIS). We assessed stroke-specific quality of life (SS-QOL) in survivors of stroke after IAT. Consecutive patients undergoing IAT for AIS from 2005 to 2010 were retrospectively identified via an institutional database. SS-QOL (using the SS-QOL score) and disability status (modified Rankin Scale [mRS]) were prospectively assessed via mailed questionnaire. We analyzed quality of life (QOL) scores by domain and summary score, with a summary score of 4 or more defined as a good outcome. Analysis of variance (ANOVA) was used to model the effect of final recanalization status, stroke severity, and mRS on total QOL score. ANOVA and Pearson correlations were used to test the association between stroke severity/mRS and QOL/time since stroke, respectively. Of 99 patients with AIS, 61 responded, yielding 11 interim deaths, 7 incomplete surveys, and 43 complete surveys for analysis. Among responding survivors, overall QOL score was 3.9 (standard deviation 0.7); 77% of these reported good QOL. Scores were higher in recanalized patients in 11 of 12 domains but was significant only for mood. Although mRS was associated with stroke severity, QOL was independent of both. Seventy-seven percent of survivors of AIS who received IAT reported good QOL. Furthermore, these data suggest that SS-QOL is an independent outcome from stroke severity and disability status.

Reproducibility of ABC/2 Method to Determine Infarct Volume and Mismatch Percentage with CT Perfusion

Our aim is to implement a simple, rapid, and reliable method using computed tomography perfusion imaging and clinical judgment to target patients for reperfusion therapy in the hyper‐acute stroke setting. We introduce a novel formula (1–infarct volume [CBV]/penumbra volume [MTT] × 100%) to quantify mismatch percentage.

Delayed onset of anterior spinal artery syndrome after repair of aortic coarctation

Study Design. A case report. Objective. We report a case of delayed anterior spinal artery syndrome after repair of aortic coarctation in which the symptoms did not appear until 6 months after surgery. Summary of Background Data. Residual dilatation of the anterior spinal artery after surgery can mimic a dilated intraspinal vein, which could lead to the erroneous diagnosis of spinal arteriovenous malformation as the cause for anterior spinal artery syndrome. Methods. A 40-year-old man with a history of hypertension underwent surgical bypass of the left subclavian artery to descending thoracic aorta to treat coarctation of the thoracic aorta and had an uncomplicated postoperative course. Six months later, he developed numbness and weakness in his hands. Magnetic resonance image showed abnormal signal within the cervicothoracic spinal cord and prominent flow voids within the ventral spinal canal. Spinal digital subtraction angiography revealed slow flow in a dilated intraspinal vessel. Given the history of aortic coarctation repair, the possibility that this represented a residually dilated anterior spinal artery rather than an arteriovenous malformation was considered and confirmed on magnetic resonance imaging. Results. In our patient, institution of an anticoagulation medication regime resulted in rapid improvement of neurological symptoms, underscoring the importance of the awareness of this phenomenon. Conclusion. Delayed anterior spinal artery syndrome after aortic coarctation repair because of anterior spinal artery thrombosis can manifest even 6 months postoperatively. Careful analysis of pre- and postoperative cross-sectional imaging should provide the correct diagnosis. Spinal digital subtraction angiography is probably unnecessary and must be interpreted with caution.