22. European Stroke Conference 148 Interesting and challenging cases Intravenous thrombolisys for ischemic stroke in a patient with severe multiple sclerosis: diag-nostic, therapeutic and prognostic concerns. G. Gialdini1, A. Chiti2, N. Giannini3, E. Terni4, G. Orlandi5, U. Bonuccelli6 Neurological Clinic, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, ITALY1, Neurological Clinic, Department of Clinical and Experimental Medicine, Universi-ty of Pisa, Pisa, ITALY2, Neurological Clinic, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, ITALY3, Neurological Clinic, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, ITALY4, Neurological Clinic, Department of Clinical and Ex-perimental Medicine, University of Pisa, Pisa, ITALY5, Neurological Clinic, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, ITALY6 Background: as for the majority of autoimmune diseases, patients with multiple sclerosis (MS) are at higher risk of stroke in comparison with healthy population. In patients with MS presenting at the Emergency Department with an acute neurological deficit, the selection for thrombolysis may be challenging considering differential diagnosis (stroke vs MS relapse), hemorrhagic hazard (because of concomitant demyelinated plaques) and previous disability, raising concerns about benefit/risk ra-tio. Methods and Results: a 61 years old male presented with acute onset of left facio-brachial weak-ness and severe dysarthria (NIHSS:15). The diagnosis of secondary progressive MS with residual paraplegia (EDSS: 7) had been posed 20 years before; at presentation, specific treatment included azathioprine and beta-interferon. Of note, patient had been regularly working at University as a Pro-fessor, being able to drive a car with modified commands. Urgent CT scan showed diffuse hypon-density of the white matter, probably related to MS. In the suspect of acute ischemic stroke, intrave-nous thrombolysis was performed about one hour after symptoms’ onset with early improvement of neurological deficit (NIHSS 11; in particular, dysartria became very mild). MRI was performed after 24 hours and showed a right rolandic infarct with a mild hemorrhagic transformation. Extensive diagnostic work-up found no specific risk factor and stroke was classified as cryptogenetic. Patient was discharged with antitrombotic therapy (ASA 100 mg/die) and was able to carry on with his pre-stroke life. Discussion: When diagnosis of hyperacute ischemic stroke is posed (basing on clinical and, if the case, MRI data), previous diagnosis of MS, even when associated with severe disability, should not prevent from thrombolysis. In fact, it appears a safe and efficacious symptoms-tailored therapy able to limit additional disability, preserving patient’s quality of life. 360 © 2013 S. Karger AG, Basel Scientific Programme 149 Interesting and challenging cases Dural arteriovenous fistula and fluctuating neurologic symptoms J.H. Park1, S.W. Han2, J.S. Baik3, J.Y. Kim4, J.H. Park5, J.H. Lee6 Department of Neurology, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, SOUTH KOREA1, Department of Neurology, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, SOUTH KOREA2, Department of Neurology, Sanggye Paik Hospital, Inje Uni-versity College of Medicine, Seoul, SOUTH KOREA3, Department of Neurology, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, SOUTH KOREA4, Department of Neurology, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, SOUTH KOREA5, Department of Neurology, National Health Insurance Corporation Ilsan Hospital, Goyang, SOUTH KOREA6 Background Dural arteriovenous fistula (DAVF) is an infrequent variety of cerebrovascular disease and accounts for 10 to 15% of all brain arteriovenous malformation. While the cause of a DAVF is not always clear, there is a similar consensus on the common predisposing factor : cerebral venous thrombosis (CVT). Methods We report a patient of DAVF secondary to bilateral sigmoid sinus thrombosis who had fluctuating neurologic symptoms. Case A 69-year-old woman with a history of hypertension admitted to hospital due to a transient left hemiparesis and dysarthria 1 day ago. On neurologic examination, she had mild dysarthria, left cen-tral type facial palsy and hemiparesis, and papilledema on both eye. Brain MRI showed multifocal high signal intensity lesions in left occipital and bilateral frontal cortex. T2-weighted MRI showed multifocal dilated cerebellar and meningeal veins. She sequentially had confusional mentality and a conventional cerebral angiography confirmed a thrombosis of the bilateral sigmoid sinus and DAVF at bilateral occipital area causing retrograde flow within superior sagittal sinus and bilateral cortical veins (Borden type 2). She had no history of coagulopathy or other systemic disease. She was treat-ed with anticoagulation for the venous thrombosis and her headache was marked improved. Howev-er, she experienced the fluctuation of neurologic symptoms (confusion, memory impairment, postur-al tremor and gait disturbance). Conclusion There are two possible mechanisms to contribute for fluctuating neurologic symptoms in this pa-tient. First, regardless of the initial anticoagulation therapy, insufficient venous recanalization might not solve venous hypertension. Second, fluctuating neurologic symptoms also might be the result of the retrograde venous reflux. These two mechanisms should not be seen as being in competition but rather they seem to be same pathomechanisms; Venous hypertension.
Karger_ESC London_2013
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