[Cerebral ischemia as first manifestation of paroxysmal nocturnal hemoglobinuria]

INTRODUCTION

Paroxysmal nocturnal hemoglobinuria (PNH) is an acquired clonal disease characterized by chronic intravascular hemolysis, cytopenia and increased tendency to thrombosis. Arterial thrombosis has been observed in patients with PNH but is uncommon compared with venous thrombosis. Cerebral arterial thrombosis has been anecdotally described as the first clinical manifestation of PNH.

CASE DESCRIPTION

We present the case of a 48-yearold male who was admitted because of high-grade fever and infarction in the left middle cerebral artery territory. Other associated findings were mild anemia (hemoglobin level: 10.1 g/dl), renal ischemia and intra-abdominal venous thrombosis. Recurrent arterial and venous thromboembolic events were observed during his hospital stay. The diagnosis of PNH was confirmed by flow cytometric analysis.

CONCLUSIONS

PNH is a rare cause of cerebral ischemia and it should be considered in stroke patients with abnormal blood findings or marked prothrombotic tendency. We discuss the treatment guidelines and prevention of thrombotic complications.

Does a relationship exist between carotid stenosis and lacunar infarction?

BACKGROUND AND PURPOSE

The presence of carotid stenosis (CS) in a patient with lacunar stroke is usually considered an indication of atherosclerosis and not directly related to the development of this infarction subtype. This study was designed to determine the relationship between CS and lacunar infarction (LI) and to assess the differences between single and multiple LIs.

METHODS

We classified 330 patients with a first-ever cerebral infarction in the carotid territory into LI and non-LI (NLI) groups. In the LI group, patients with a single LI and those with multiple LIs were identified. In this last subgroup, 2 patterns were identified: 1 subtype with lacunar lesions distributed in both cerebral hemispheres, and another with lesions predominantly in 1 hemisphere.

RESULTS

In the LI group, isolated CS was significantly more frequent on the homolateral side than on the contralateral side (odds ratio [OR], 5.5; 95% CI, 1.2 to 23; P=0.03). A significant relationship between the pattern of distribution of the infarctions in only 1 hemisphere and homolateral CS >70% was observed (OR, 4.4; 95% CI, 0.9 to 19; P=0.03). In a multivariate analysis, the following variables were found to predict unilateral multiple LI: left ventricular hypertrophy (OR, 9.1; 95% CI, 2.5 to 33.6) and homolateral CS >75% (OR, 14.4; 95% CI, 2.0 to 99.6).

CONCLUSIONS

The significant incidence of isolated ipsilateral CS in patients with LI located in the carotid territory and the relationship of CS to ipsilateral multiple LI suggest that CS has a very important role in the development of LI.