London, United Kingdom 2013 Poster Session Red Cerebrovasc Dis 2013; 35 (suppl 3)1-854 357 144 Interesting and challenging cases Bilateral cerebral infarcts in a young male cannabis consumer M. Terceño1, Y. Silva2, C. van Eendenburg3, J. Serena4, M. Castellanos5 Josep Trueta University Hospital. Girona. Neurology Service, Girna, SPAIN1, Josep Trueta University Hospital. Girona. Neurology Service, Girona, SPAIN2, Josep Trueta University Hospital. Girona. Neurology Service, Girona, SPAIN3, Josep Trueta University Hospital. Girona. Neurolo-gy Service, Girona, SPAIN4, Josep Trueta University Hospital. Girona. Neurology Service, Girona, SPAIN5 Objective: To study the case of a 37-year-old male consulting for headache and bilateral blindness secondary to bilateral stroke with multiple cerebral artery stenosis and consider differential diagno-sis with entities presenting with headache. Methods: patient with no medical history of migraine and regular cannabis consumer was visited at our centre for headache and progressive decrease in visual acuity. The neurological examination showed mixed aphasia and bilateral visual acuity of 0.1. Cerebral MRI revealed cerebral infarctions in the bilateral MCA and PCA territory, and transcranial Duplex (Duplex-CT) showed multiple ste-nosis of the intracranial arteries. The patient was treated with corticosteroids and nimodipine due to the diagnostic suspicion of cerebral vasculitis. Results: After 3 months, the patient had a neurological improvement. The intracranial flow was nor-mal in the follow-up DCT. A diagnosis of reversible cerebral vasoconstriction syndrome (RCVS) was made. Discussion: RCVS is a little known entity combining several pathologies with the common denom-inator of reversible vasoconstriction of the cerebral arteries. It may be spontaneous or triggered by exogenous factors such as cannabis. The study of the cerebral vasculature by angiography or DCT are the key to the diagnosis. RCVS tends to affect young people and early diagnosis is essential to prevent neurological sequelae secondary to stroke due to vasoconstriction. The differential diagnosis must consider other such as migrainous infarction, cerebral venous thrombosis and isolated central nervous system vasculitis. A detailed history looking for precipitating factors and the demonstration of intracranial stenosis and its resolution in the subsequent 12 weeks are essential elements of a cor-rect diagnosis. Except in cases presenting with stroke, the prognosis is usually good. RCVS is a rare cause of headache whose early identification and monitoring is important to avoid permanent neurological deficit. 145 Interesting and challenging cases Feeling the Pressure! Case Presentation of a Patient with Malignant Cerebellar Infarction D. Ní Chróinín1, A. Abdul Azim2, P. Kelly3, D. Quinn4, C. Donegan5 Department of Care of the Elderly, Beamont Hospital, Dublin, IRELAND1, Department of Care of the Elderly, Beamont Hospital, Dublin, IRELAND2, Department of Care of the Elderly, Beamont Hospital, Dublin, IRELAND3, Department of Care of the Elderly, Beamont Hospital, Dublin, IRE-LAND4, Department of Care of the Elderly, Beamont Hospital, Dublin, IRELAND5 Case: Mr. PF, an independent 80 year-old, presented acutely with ataxia, discoordination (left worse than right) and dysarthria, accompanied by occipital headache and vomiting. Background included hy-pertension, dyslipidaemia, and prior smoking. On arrival to hospital, symptoms were rapidly im-proving (NIHSS 4), and thrombolysis was not pursued. Initial CT brain was normal (Figure 1a). However, 48 hours later, Mr. PF deteriorated, with agitation quickly followed by progressive drows-iness. Urgent CT brain revealed left cerebellar hypodensity, with oedema and 4th ventricular efface-ment (Figure 1b). Neurosurgery were consulted, and Mr. PF underwent emergency external ventric-ular drain insertion. As he was intolerant of subsequent attempts to wean from the ventricular drain, a ventriculoperitoneal shunt was inserted. Mr. PF did well post-operatively, and following rehabilita-tion, successfully returned home. Discussion: European Stroke Organisation and NICE Guidelines suggest considering craniectomy for patients <60 years old with malignant middle cerebral artery infarction. Results of DESTINY-II indicate that patients aged >60 years may benefit similarly.World Stroke Congress 2012 However, data pertaining to malignant (space-occupying) infarcts affecting the posterior circulation have been limited to case series, often retrospective, and a non-randomised German-Austrian trial (GASCIS), limited by pronounced inequalities between treatment groups (medical V surgical).Jauss 1999 The optimal management of malignant cerebellar infarction has thus yet to be established. Conclusion: Life-threatening oedema may develop following cerebellar infarction, but best management in such cases is unclear. Although the evidence base is limited, older patients may benefit from neurosurgi-cal intervention. While suboccipital craniectomy is an option, less invasive decompressive interven-tions such as shunt insertion may be an effective alternative, as for Mr. PF. Further randomised con-trolled trials are needed.
Karger_ESC London_2013
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