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He A, Dong K, Zhao W, Zhao B, Sun W, Wu X, Lu X, Chen Y, Song H. Recurrent ischemic stroke from reversible extracranial internal carotid artery and middle cerebral artery vasospasm: A case report. Brain Circ 2023; 9:258-261. [PMID: 38284115 PMCID: PMC10821686 DOI: 10.4103/bc.bc_47_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 09/14/2023] [Accepted: 09/18/2023] [Indexed: 01/30/2024] Open
Abstract
Idiopathic internal carotid artery (ICA) vasospasm is a rare cause of ischemic stroke. Its pathophysiology remains unclear and diagnostic and treatment protocols are yet to be defined. A 45-year-old male, presenting with recurrent transient dizziness, blurred vision, and speech disturbances, was diagnosed with recurrent ischemic stroke caused by bilateral ICA and middle cerebral artery (MCA) vasospasm, and the vascular ultrasound and imaging techniques have grabbed the reversible changes in a short time. This case underscores the importance of considering idiopathic ICA vasospasm as a potential cause of recurrent ischemic stroke, even in the absence of common diagnostic markers. The case also indicates the possible, albeit rare, involvement of the MCA in this condition. Therefore, it is crucial to maintain a high index of suspicion for idiopathic ICA vasospasm in similar clinical presentations and to explore more inclusive diagnostic criteria.
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Affiliation(s)
- Aini He
- Department of Neurology, Xuanwu Hospital, Capital Medicine University, Beijing, China
| | - Kai Dong
- Department of Neurology, Xuanwu Hospital, Capital Medicine University, Beijing, China
| | - Wenbo Zhao
- Department of Neurology, Xuanwu Hospital, Capital Medicine University, Beijing, China
| | - Benke Zhao
- Department of Neurology, Xuanwu Hospital, Capital Medicine University, Beijing, China
| | - Wei Sun
- Department of Neurology, Xuanwu Hospital, Capital Medicine University, Beijing, China
| | - Xiao Wu
- Department of Neurology, Xuanwu Hospital, Capital Medicine University, Beijing, China
| | - Xia Lu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medicine University, Beijing, China
| | - Yanfei Chen
- Department of Neurosurgery, Xuanwu Hospital, Capital Medicine University, Beijing, China
| | - Haiqing Song
- Department of Neurology, Xuanwu Hospital, Capital Medicine University, Beijing, China
- Beijing Stroke Quality Control Center, Beijing, China
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Collins L, Lam L, Kleinig O, Proudman W, Zhang R, Bagster M, Kovoor J, Gupta A, Goh R, Bacchi S, Schultz D, Kleinig T. Verapamil in the treatment of reversible cerebral vasoconstriction syndrome: A systematic review. J Clin Neurosci 2023; 113:130-141. [PMID: 37267876 DOI: 10.1016/j.jocn.2023.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 05/19/2023] [Accepted: 05/20/2023] [Indexed: 06/04/2023]
Abstract
INTRODUCTION Extrapolating from efficacy in subarachnoid haemorrhage (SAH), nimodipine has been used as a treatment for reversible cerebral vasoconstriction syndrome (RCVS). However, 4-hourly dosing is a practical limitation and verapamil has been proposed as an alternative. The potential efficacy, adverse effects, preferred dosing and formulation of verapamil for RCVS have not been systematically reviewed previously. METHOD A systematic review was conducted of the databases PubMed, EMBASE, and the Cochrane Library from inception to July 2022 for peer-reviewed articles describing the use of verapamil for RCVS. This systematic review adheres to the PRISMA guidelines and was registered on PROSPERO. RESULTS There were 58 articles included in the review, which included 56 patients with RCVS treated with oral verapamil and 15 patients treated with intra-arterial verapamil. The most common oral verapamil dosing regimen was controlled release 120 mg once daily. There were 54/56 patients described to have improvement in headache following oral verapamil and one patient who died from worsening RCVS. Only 2/56 patients noted possible adverse effects with oral verapamil, with none requiring discontinuation. There was one case of hypotension from combined oral and intra-arterial verapamil. Vascular complications including ischaemic and haemorrhagic stroke were recorded in 33/56 patients. RCVS recurrence was described in 9 patients, with 2 cases upon weaning oral verapamil. CONCLUSIONS While no randomised studies exist to support the use of verapamil in RCVS, observational data support a possible clinical benefit. Verapamil appears well tolerated in this setting and represents a reasonable treatment option. Randomised controlled trials including comparison with nimodipine are warranted.
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Affiliation(s)
- Luke Collins
- Flinders Medical Centre, Bedford Park, SA 5042, Australia.
| | - Lydia Lam
- University of Adelaide, Adelaide, SA 5005, Australia
| | | | | | - Ruyi Zhang
- Flinders Medical Centre, Bedford Park, SA 5042, Australia
| | - Michelle Bagster
- University of Adelaide, Adelaide, SA 5005, Australia; Lyell McEwin Hospital, Elizabeth Vale, SA 5112, Australia
| | - Joshua Kovoor
- University of Adelaide, Adelaide, SA 5005, Australia; Royal Adelaide Hospital, Adelaide, SA 5000, Australia
| | - Aashray Gupta
- University of Adelaide, Adelaide, SA 5005, Australia
| | - Rudy Goh
- Lyell McEwin Hospital, Elizabeth Vale, SA 5112, Australia
| | - Stephen Bacchi
- Flinders Medical Centre, Bedford Park, SA 5042, Australia; University of Adelaide, Adelaide, SA 5005, Australia; Royal Adelaide Hospital, Adelaide, SA 5000, Australia
| | - David Schultz
- Flinders Medical Centre, Bedford Park, SA 5042, Australia
| | - Timothy Kleinig
- University of Adelaide, Adelaide, SA 5005, Australia; Royal Adelaide Hospital, Adelaide, SA 5000, Australia
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Arning C. Ultrasound Criteria for Diagnosing Spontaneous Cervical Artery Dissections. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2023; 44:126-150. [PMID: 36746198 DOI: 10.1055/a-2004-4986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Spontaneous dissection of brain-supplying cervical arteries, which also includes findings after minor injuries, is one of the main causes of ischaemic strokes in young adults. Strokes due to dissection are usually due to arterio-arterial embolism. They are rarely the first symptom of dissection because an intraluminal thrombus must first develop. Therefore, early diagnosis of dissection can contribute to stroke prevention - through immediate therapy with anticoagulants or antiplatelet drugs. This article describes the diagnostic criteria and typical findings of spontaneous dissection, in which no dissecting membrane is to be expected as in aortic dissection. Traumatic dissections following blunt or penetrating injuries also present with different findings. Examiners should be aware of possible differential diagnoses whose ultrasound image may mimic a dissection. A frequently occurring but avoidable cause of misdiagnosis is idiopathic carotidynia. Ultrasound also enables differentiation between dissection and vasculitis or carotid web and detection of normal variants such as fenestration of the vertebral artery. Further possibilities for misdiagnosis may arise in the presence of a variant of the ascending pharyngeal artery or in extracranial vasospasm. The different imaging techniques for the detection of a dissection are complementary, as false-negative findings occur with all techniques; no method serves as the gold standard. In any case, ultrasound can make an important contribution to the detection of a dissection, and it is worth knowing the diagnostic criteria.
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