Niranjan Singh

Cannabis-Related Stroke: Case Series and Review of Literature

Marijuana, or cannabis, is one of the most commonly used illicit drugs worldwide. Although there are some case reports of stroke associated with cannabis use, there is no information on a causal role of cannabis in stroke. We identified 14 patients admitted to St Louis University Hospital between January 2004 and July 2007 with ischemic stroke who had documented clear exposure to cannabis during or before symptom onset and a positive urine screen for cannabis. We report this series, along with 3 cases previously reported by our group, for a total of 17 patients (13 men and 4 women), with a mean age of 41 years (range, 15-63 years). Nine patients were under age 45 years, 4 had a history of hypertension, and 10 sustained stroke in the posterior circulation. Headache, dysarthria, and ataxia were the most common presenting symptoms. Five patients had recurrent stroke with reexposure to cannabis. No patient had a prothrombotic state or cardiac source of embolism. Autopsy performed in 2 patients revealed hemorrhagic infarct with no evidence of vasculitis or embolus. The absence of other vascular risk factors in most of our patients, the temporal relation of symptom onset to cannabis exposure, and the recurrence of symptoms in a few patients with reexposure suggest a causal role of cannabis in these cases of ischemic stroke. However, this causal association cannot be definitely ascertained, given the descriptive nature of our series. More research is needed to explore this possible causal association.

Pontine warning syndrome: case series and review of literature.

Crescendo transient ischemic attacks (TIAs) are defined as repeated frequent short-lasting episodes of focal neurologic deficit due to cerebral ischemia. The capsular warning syndrome, a subset of crescendo TIA, consists of repetitive episodes of motor dysfunction due to ischemia in the region of internal capsule. It is not clear that patients with ischemia in the pons can have a similar clinical presentation and course. We report 11 cases presenting with crescendo TIA in the form of pure motor hemiparesis or ataxic hemiparesis that later proved to have a paramedian pontine infarct. The presumed mechanism of these infarcts is penetrating basilar artery branch occlusion at their origin, also called basilar branch disease.

Levetiracetam-induced thrombocytopenia among inpatients: a retrospective study.

Lately, few case reports have brought forth limited cases of levetiracetam (LEV)‐induced thrombocytopenia. To estimate the burden of LEV‐induced thrombocytopenia, we reviewed medical records of 758 patients aged 18 years or older who received LEV during their stay at the University Hospital from June 2005 to December 2008. In patients identified with thrombocytopenia, records were reviewed to establish a cause of thrombocytopenia and possible causal role of LEV. Of 758 patients, 29 patients were identified with thrombocytopenia while on LEV therapy. For 23 patients, an alternative cause for thrombocytopenia was established; 4 patients had preexisting thrombocytopenia without any appreciable change in platelet count after addition of LEV. One patient had limited data for identifying the cause of thrombocytopenia. A single patient had clear temporal co‐relation and association of thrombocytopenia with LEV therapy. LEV‐induced thrombocytopenia is a rare but reversible complication of LEV therapy. The mechanism remains unknown.

Ondansetron and seizures.

Experimental studies suggest that 5‐hydroxytryptamine (5‐HT) receptors play a role in epileptogenesis and seizure propagation. Ondansetron, a 5‐HT3 receptor antagonist, has been reported to have proconvulsant and anticonvulsant effects in animals. We describe three patients who developed seizures after receiving ondansetron. There were two females and one male. Ages ranged from 38–56 years. None had a previous or family history of seizures. Four milligrams (mg) of ondansetron was given intravenously for severe nausea and vomiting in association with migraine, gastritis, and diabetic ketoacidosis. A generalized tonic–clonic seizure occurred in each patient—12, 15, and 22 min after injection. Brain magnetic resonance imaging (MRI) and electroencephalography (EEG) were normal in all patients. Although no antiepileptic drugs were given, none had seizure recurrence subsequently. The temporal relationship between ondansetron administration and seizures, lack of EEG or MRI abnormalities, and absence of seizure recurrence suggest that the seizures were causally related to ondansetron in our patients.

Cortical Neurochemical Profile Depends on the Origin and the Site of the Central Nervous System Injury

Interventions: Not applicable. Main Outcome Measures: Head CT, DRS, and FIM. Results: No statistical differences were found in functional status between the axial and extra-axial groups, except for the FIM follow-up after 1 year, which unexpectedly showed the axial group having greater functional recovery (P1⁄4.046). The combined lesion group showed statistically significant greater negative impact on functional status than the other groups across all three time points. Conclusions: Combined lesions negatively affect functional status more than axial lesions or extra-axial lesions. The effect of combined injuries will increase the awareness of healthcare providers and likely inform the patient care and patient likelihood of recovery. Level of Evidence: Level II

Poster 305 Neural Status of Intact Spinal Cord is a Better Predictor of Surgery Outcome Than Clinical and Imaging Features of Spinal Cord Insult in Cervical Spondylotic Myelopathy: A Case Report

Case/Program Description: A 21-year-old man with no past medical history was admitted for rehabilitation center for C3 AIS A tetraplegia due to a motor vehicle accident with resultant traumatic brain injury and polytrauma 18 months prior. During his hospitalization, he had been on indwelling catheter which was changed monthly. Following a difficult catheter change, he experienced abdominal distention, headache, dizziness and dyspnea. Bladder scan showed 570ml urinary retention. Eventually a new indwelling catheter was replaced successfully after multiple attempts in 10 minutes. Approximately 600ml urine came out. Meanwhile, he continued to have symptoms of headache, dizziness, dyspnea, but was alert and conscious. During the episode, his blood pressure was 50/32 and heart rate was 140s. Setting: Tertiary care hospital. Results: The patient was placed in the supine position. One dose of midodrine 10mg was given and repeated BP was 50/32. Rapid response was initiated. One IV line was obtained and IV fluid bolus started. After these measures, his BP returned to his baseline of 86/52, and his HR was down to 105. The patient was rechecked in two hours, and his vital signs were stable and symptoms resolved. Discussion: Autonomic dysreflexia occurs most often in patients with spinal cord injury with spinal lesions above the T6 spinal cord level. It is characterized by paroxysmal hypertension, sweating, headache and reflex bradycardia. Stimulation from the bladder from high pressures or overdistention is the most common cause of autonomic dysreflexia. However, in this case, bladder distention is adversely associated with hypotention, tachycardia and headache. Mechanism is unknown. Conclusions: This is an unusual case of bladder distension associated with hypotension rather than autonomic dysreflexia in a patient with chronic complete tetraplegia secondary to traumatic spinal cord injury. Physician should aware of atypical presentations of autonomic dysfunction in SCI. Level of Evidence: Level V

Headache Syndromes and Sleep

The enigmatic relationship between headache and sleep has been known for a long period of time. The basis of this relationship has been explored and validated by various studies. This has led to better understanding of the relationship between these two entities. Further, it has implications for diagnosis of headache type and management. We describe the association of various headache syndromes with sleep disorders.