A 39-year-old woman taking a monoamine oxidase inhibitor presented with a 1-week history of severe non-thunderclap headache and visual field deficits. Brain CT showed infarcts in both parietal lobes, with narrowing of intracranial vessels on CT angiogram (figure 1), suggesting either vasculitis or reversible cerebral vasoconstriction syndrome (RCVS). Despite treatment with both methylprednisolone and nimodipine, she experienced progressive aphasia and right leg weakness. She underwent an urgent cerebral angiogram (figure 2), during which intra-arterial milrinone reversed both the vasoconstriction and its symptoms, thereby confirming RCVS. Intra-arterial milrinone may be useful to differentiate vasculitis from RCVS1 and may serve as a treatment for RCVS, but requires prospective evaluation.
Substantial narrowing of vessels in the anterior circulation bilaterally (A) and the basilar artery (C). Bilateral medial parietal and left lateral parietal infarcts on noncontrast CT (B) and DWI (D).
Left internal carotid artery angiogram before (A) and after (B) intra-arterial milrinone injection. Left vertebral artery angiogram before (C) and after (D) intra-arterial milrinone.
Acknowledgments
Acknowledgment: The authors acknowledge coauthor Dr. Cheemun Lum, who died prior to publication of this article.
Footnotes
Author contributions: Michelle Laneuville: clinical care of patient, drafting and revising the manuscript. Joy Ding: clinical care of patient, drafting and revising the manuscript. Michel Shamy: clinical care of patient, drafting and revising the manuscript. Cheemun Lum: imaging acquisition and revising the manuscript. Dar Dowlatshahi: case concept and revising the manuscript.
Study funding: No targeted funding reported.
Disclosure: The authors report no disclosures relevant to the manuscript. Go to Neurology.org for full disclosures.
- © 2017 American Academy of Neurology
References
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