Idiopathic Intracranial Hypertension Related to Chronic Use of Mesalamine: A Case Report and Literature Review

Idiopathic intracranial hypertension (IIH) is commonly seen related to iatrogenic causes such as excess retinol, tetracyclines, and amiodarone. We report a case of IIH likely related to mesalamine use. A 63-year-old woman presented with transient episodes of diplopia and headaches. She was diagnosed with irritable bowel syndrome and started on mesalamine 8 months prior. Her neurologic examination was significant for papilledema and bilateral partial abducens nerve palsies. Her opening pressure was 27 cm H2O. Discontinuation of mesalamine in conjunction with acetazolamide correlated with improvement of her papilledema and diplopia. At 6-month follow-up, she still remained asymptomatic. IIH is likely a rare side effect of mesalamine use likely related to 5-aminosalycilate use. This class of medication typically causes headache so this is likely a more complex version. The mechanism of how this occurs is largely unknown. Patients presenting with new onset headache or diplopia acutely or chronically on mesalamine should have ophthalmologic evaluation urgently to evaluate for IIH

Is there a role for B cells in chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids? A case report

Background Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is a recently defined inflammatory disorder of the central nervous system, prominently involving the brainstem. This condition is diagnosed based on clinical presentation, imaging findings and robust response to steroids, along with histopathology. Case presentation Here, we describe a case of a 47‐year‐old woman who presented with gait ataxia, bilateral leg weakness and urinary retention. Initial imaging studies were unremarkable, but on follow up she was found to have multiple enhancing lesions in the left cerebellar peduncle associated with a clinical relapse. Several weeks later, and after being treated with ocrelizumab, a B‐cell targeted therapy, she developed new neurological symptoms and was found to have new lesions on brain imaging. She was diagnosed with probable CLIPPERS. She was started on azathioprine and remained asymptomatic with normal brain imaging for several months. Conclusions Despite adequate depletion of circulating B cells, the patient continued to have relapses associated with CLIPPERS. This supports the notion that targeted peripheral B‐cell therapy does not stop the progression of CLIPPERS

Ischemic Stroke Secondary to Left Ventricular Noncompaction

Left ventricular noncompaction (LVNC) is a rare cause of cardiomyopathy that can lead to systemic embolism and ischemic stroke. LVNC results from the arrest of ventricular myocardium compaction during embryogenesis. Multiple other cardiac complications coexist with this cardiomyopathy, and one of the potential consequences is cardioembolic events causing ischemic stroke. This condition can be underdiagnosed or misdiagnosed as hypertrophic or dilated cardiomyopathy. We report a patient who presented with recurrent embolic ischemic stroke secondary to LVNC that was overlooked on initial transthoracic echocardiographic studies. After an unremarkable laboratory workup, transesophageal echocardiogram (TEE) revealed noncompaction of the myocardium within the apex of the left ventricle, confirmed by cardiac magnetic resonance imaging (MRI). The patient was anticoagulated with warfarin and discharged to a rehabilitation facility. Increased understanding and awareness of the diagnosis, clinical manifestations, and management of LVNC are advised, particularly in patients with recurrent embolic stroke of undetermined source. Screening of all first-degree relatives with this familial condition is recommended as well, as appropriate treatment can prevent cardiac complications and sudden death

Intracranial hemorrhage in the setting of posterior reversible encephalopathy syndrome: two case reports and a review.

Posterior reversible encephalopathy syndrome (PRES) is clinically characterized by seizures, changes in vision, altered mental status, and headache, with associated radiologic changes on brain imaging. Intraparenchymal hemorrhage is a rare complication of PRES and an atypical initial presentation of this condition. In this report, we discuss two patients who presented with multifocal cerebral hemorrhages that were later attributed to PRES. We further expand on the pathophysiology, management, and prognosis on patients with hemorrhagic PRES. Increased awareness of this complication of PRES is important in guiding prognostication and treatment

Risk factors for coronary artery disease and acute coronary syndrome in patients ≤40 years old.

OBJECTIVE: In this study, we assessed the risk factor profile in premature coronary artery disease (CAD) and acute coronary syndrome for adults ≤40 years old. METHODS: A retrospective chart analysis of 397 patients ≤40 years old admitted from 2005 to 2014 for chest pain and who underwent coronary arteriography. RESULTS: Of 397 patients that had undergone coronary arteriography, 54% had CAD while 46% had normal coronary arteries. When compared with patients with normal coronary arteries, patients with CAD were more likely to smoke tobacco, have dyslipidemia, be diabetic, have BMI \u3e30 kg/m(2), have a family history of premature CAD and be male in gender. CONCLUSION: Healthcare intervention in the general population through screening, counseling and education regarding the risk factors is warranted to reduce premature CAD

Morbidity and Mortality of Congestive Heart Failure in Trauma Patients.

BACKGROUND: Cardiovascular morbidity and mortality in heart failure (HF) patients comprise a major health and economic burden, especially when readmission rate and length of stay (LOS) are considered. With increasing average life expectancy, HF prevalence continues to rise. Diseases such as diabetes mellitus, hypertension and ischemic heart disease continue to be the leading causes of HF. Current data suggest that HF is the most common cause for hospital admission in patients older than 65 years. OBJECTIVE: In this study, we sought out to compare the 30-day readmission rate in trauma patients who have a preexisting history of HF to those who do not have a history of HF. Additionally, we emphasized the effect of different cardiac variables in the HF group such as the pathophysiology of HF (HF with preserved ejection fraction [HFpEF] versus HF with reduced ejection fraction [HFrEF]) and the etiology of HFrEF (ischemic versus nonischemic). METHODS: A retrospective chart analysis of 8,137 patients who were admitted to our hospital between 2005 and 2013 secondary to trauma with an Injury Severity Score RESULTS: Of 8,137 trauma patients, 334 had preexisting HF, of which 169 had HFpEF while 165 had HFrEF). Of the 165 HFrEF cases, 121 were ischemic in etiology versus 44 nonischemic. Of 334 HF patients, 81 patients (24%) were readmitted within 30 days versus 1,068 (14%) of the non-HF patients (95% CI: 1.52-2.25, relative risk: 1.85, P \u3c 0.0001). Of the 81 readmitted HF patients, 64 had HFpEF while 35 had HFrEF. There was no statistical significance observed in any of the endpoints in the HFpEF versus HFrEF groups. Mortality, 30-day readmission and LOS were all significantly higher in the ischemic versus nonischemic HFrEF group. CONCLUSIONS: In our trauma population, HF patients had a significantly higher 30-day readmission rate when compared to non-HF patients. The pathophysiology of HF (HFpEF versus HFrEF) did not seem to play a role. However, after subgroup analysis of the HFrEF group based on etiology, all endpoints including mortality, readmission and LOS were significantly higher in the ischemic HFrEF subgroup rendering this entity higher importance when treating trauma patients with preexisting HF

The Effect of Regional Anesthetic Sphenopalatine Ganglion Block on Self-Reported Pain in Patients With Status Migrainosus.

BACKGROUND: Status migrainosus (SM) is defined as a debilitating migraine attack lasting more than 72 hours in patients previously known to suffer from migraine headache. Typically, these attacks fail to respond to over the counter and abortive medications. The sphenopalatine ganglion (SPG) plays a critical role in propagating both pain and the autonomic symptoms commonly associated with migraines. SPG block via transnasal lidocaine is moderately effective in reducing migraine symptoms, but this approach is often poorly tolerated and the results are inconsistent. We proposed that an SPG block using a suprazygomatic injection approach would be a safe and effective option to abort or alleviate pain and autonomic symptoms of SM. METHODS: Through a retrospective records review, we identified patients with a well-established diagnosis of migraine, based on the International Headache Society criteria. Patients selected for study inclusion were diagnosed with SM, had failed to respond to 2 or more abortive medications, and had received a suprazygomatic SPG block. Patients had also been asked to rate their pain on a 1-10 Likert scale, both before and 30 minutes after the injection. RESULTS: Eighty-eight consecutive patients (20 men and 68 women) received a total of 252 suprazygomatic SPG block procedures in the outpatient headache clinic after traditional medications failed to abort their SM. At 30 minutes following the injections, there was a 67.2% (±26.6%) reduction in pain severity with a median reduction of 5 points (IQR= -6 to -3) on the Likert scale (ranging from 1 to 10). Overall, patients experienced a statistically significant reduction in pain severity (P \u3c .0001). CONCLUSION: The SPG is known to play an integral role in the pathophysiology of facial pain and the trigeminal autonomic cephalalgias, although its exact role in the generation and maintenance of migraine headache remains unclear. Regional anesthetic suprazygomatic SPG block is potentially effective for immediate relief of SM. We believe the procedure is simple to perform and has minimal risk