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September 05, 2017; 89 (10) NeuroImages

Intra-arterial milrinone may differentiate fulminant RCVS from vasculitis

Michelle Laneuville, Joy Ding, Michel Shamy, Cheemun Lum and Dar Dowlatshahi
First published September 4, 2017, DOI: https://doi.org/10.1212/WNL.0000000000004337
Michelle Laneuville
From The Ottawa Hospital, Canada.
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Joy Ding
From The Ottawa Hospital, Canada.
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Michel Shamy
From The Ottawa Hospital, Canada.
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Cheemun Lum
From The Ottawa Hospital, Canada.
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Dar Dowlatshahi
From The Ottawa Hospital, Canada.
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Intra-arterial milrinone may differentiate fulminant RCVS from vasculitis
Michelle Laneuville, Joy Ding, Michel Shamy, Cheemun Lum, Dar Dowlatshahi
Neurology Sep 2017, 89 (10) 1093-1094; DOI: 10.1212/WNL.0000000000004337

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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.

Figure 1
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Figure 1 CT angiogram, brain CT, and diffusion-weighted imaging (DWI) on MRI consistent with both reversible cerebral vasoconstriction syndrome and vasculitis

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).

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Figure 2 Conventional cerebral angiogram demonstrates reversal after milrinone

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

  1. 1.↵
    1. Singhal AB,
    2. Topcuoglu MA
    . Glucocorticoid-associated worsening in reversible cerebral vasoconstriction syndrome. Neurology 2017;88:228–236.
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