Sharathchandra Bidari

Posterior reversible encephalopathy syndrome (PRES) and CT perfusion changes

Posterior reversible encephalopathy syndrome ( PRES) can present with focal neurologic deficits, mimicking a stroke and can often represent a diagnostic challenge when presenting atypically. A high degree of suspicion is required in the clinical setting in order to yield the diagnosis. Cerebral CT perfusion (CTP) is utilized in many institutions as the first line in acute stroke imaging. CTP has proved to be a very sensitive measure of cerebral blood flow dynamics, most commonly employed to delineate the infarcted tissue from penumbra (at-risk tissue) in ischemic strokes. But abnormal CTP is also seen in stroke mimics such as seizures, hypoglycemia, tumors, migraines and PRES. In this article we describe a case of PRES in an elderly bone marrow transplant recipient who presented with focal neurological deficits concerning for a cerebrovascular accident. CTP played a pivotal role in the diagnosis and initiation of appropriate management. We also briefly discuss the pathophysiology of PRES.

Treatment of stroke related refractory brain edema using mixed vasopressin antagonism: a case report and review of the literature

BackgroundElevated intracranial pressure from cerebral edema is the major cause of early mortality in acute stroke. Current treatment strategies to limit cerebral edema are not particularly effective. Some novel anti-edema measures have shown promising early findings in experimental stroke models. Vasopressin antagonism in stroke is one such target which has shown some encouraging preliminary results. The aim of this report is to highlight the potential use of vasopressin antagonism to limit cerebral edema in patients after acute stroke.Case presentationA 57-year-old Caucasian man with new onset diplopia was diagnosed with vertebral artery aneurysm extending into the basilar circulation. He underwent successful elective vertebral artery angioplasty and coiling of the aneurysm. In the immediate post-operative period there was a decline in his neurological status and brain imaging revealed new midbrain and thalamic hemorrhage with surrounding significant brain edema. Treatment with conventional anti-edema therapy was initiated with no significant clinical response after which conivaptan; a mixed vasopressin antagonist was started. Clinical and radiological evaluation following drug administration showed rapid clinical improvement without identification of significant adverse effects.ConclusionsThe authors have successfully demonstrated the safety and efficacy of using mixed vasopressin antagonist in treatment of stroke related brain edema, thereby showing its promise as an alternative anti-edema agent. Preliminary findings from this study suggest mixed vasopressin antagonism may have significant utility in the management of cerebral edema arising from cerebrovascular accident. Larger prospective studies are warranted to explore the role of conivaptan in the treatment of brain edema and neuroprotection.

Takayasu's arteritis: Is it a reversible disease? Case Report and Literature Review

Background: Takayasus arteritis (TA) is a rare and potentially devastating condition leading to prolonged morbidity and even death. Case Description: We report an 18-year-old female presenting with an acute ischemic stroke treated with intravenous thrombolysis and subsequent endovascular therapy (ET) with excellent results followed by chronic treatment with immunosuppressants after a formal diagnosis of TA. Following immunosupression, improvement was noted in critical stenoses of the extracranial large vessels. Conclusion: These observations underscore the importance of early initiation of therapy to halt or even reverse vascular pathology, though frequent follow up is mandatory as relapse is common. In this article we provide brief review of the current literature on TA related to pathophysiology, criterion for diagnosis, therapy, and follow up.

Trends in the management of atrial fibrillation: A neurologist’s perspective

Cardiac embolism, primarily from atrial fibrillation (AF), is implicated in a quarter of all ischemic strokes. In the setting of AF, contraindications to traditional therapies can create a clinical dilemma when choosing an agent for secondary stroke prophylaxis. Newer horizons in the medical and surgical management of AF have helped us choose from a wide variety of available therapies, the best possible management. In this article, we review the current trends in AF management including newer oral anticoagulants as well as surgical devices from a neurologists view.

Oral verapamil in the prevention of recurrent cerebral ischaemia due to post‐stent vasospasm

Endovascular embolization of basilar tip aneurysms (BTA) is performed to prevent rupture, but little is known regarding post‐procedural vasospasm and its consequences. We relate management of post‐procedural vasospasm found in cardiovascular literature on this rare post‐procedural intracranial complication.