Unexpected Haemorrhage Location after Intravenous Thrombolysis for Left Middle Cerebral Artery Infarction

Emergency intravenous thrombolytic therapy saves stroke patients. However, unexpected circumstances still occur. Here we report two patients who received intravenous thrombolytic therapy for acute ischaemic infarction and suffered brainstem haemorrhage within 3 hours of thrombolysis. Both patients had left middle cerebral artery ischaemic infarction but not basilar artery infarction. The haemorrhages were concurrent with extremely high blood pressure. Extremely high blood pressure during thrombolysis not only increases possibility of haemorrhagic transformation of ischaemic infarction but also chance of intraparenchymal haemorrhage. (Hong Kong j.emerg.med. 2014;21:112-115)

Enoxaparin-induced alopecia in patients with cerebral venous thrombosis

OBJECTIVE

To report three cases of alopecia induced by the anticoagulant enoxaparin in cerebral venous thrombosis (CVT) patients.

CASE SUMMARY

Three female patients were treated initially with direct intrasinus urokinase, and then followed by low-molecular-weight heparin (LMWH) enoxaparin at 1 mg/kg given subcutaneously twice daily for 3 weeks. It was switched to oral anticoagulant warfarin at 5 mg daily for another 6 months. Nearly 3 weeks after the initiation of anticoagulation, all of the three patients complained of excessive hair loss with large areas of patchy, non-scarring alopecia. Hair growth returned to normal within 1 month after the completion of enoxaparin.

DISCUSSION

Unfractionated heparin remains the first-line treatment of CVT because of its efficacy, safety and feasibility. Alopecia has been reported as a side effect of LMWHs dalteparin and tinzaparin. The pattern of hair loss, telogen effluvium, involves the induction of the hair follicle into a resting phase without apparent pathologic implication. In addition, this article also reviewed other medications taken by the patients that are possibly associated with hair loss.

CONCLUSION

From the review of literature, there is no report of alopecia caused by urokinase. Using the Naranjo ADR Probability Scale, a score of 6 suggests that enoxaparin was the probable cause of alopecia in our three patients. This report introduces evidence of alopecia as a probable side effect of enoxaparin, but stresses the efficacy and safety of LMWH. As this is not a life-threatening disorder, we hope to increase the awareness of pharmacists and clinicians to this relatively rare but important side effect.

Effectiveness of low-dose ASA in prevention of secondary ischemic stroke, the ASA Study Group in Taiwan

This randomized double-blind controlled study was carried out to investigate the effect of 100 mg acetylsalicylic acid (ASA) per day on the secondary prevention of ischemic stroke. Patients who suffered a first ischemic stroke from 13 participating hospitals were enrolled. They were independent or only partially dependent in activities of daily living and all had received brain CT for diagnosis. Eligible patients were randomly allocated to the 100 mg ASA or the nicametate citrate (a vasodilator) groups, and trial medications were started within three to six weeks after the onset of stroke. The primary end point was cerebral reinfarction, and intracranial hemorrhage was classified as an adverse event. Four hundred and sixty-six patients participated in this study; and 222 cases (136 males and 86 females) were allocated to the ASA group while 244 cases (150 males and 94 females) were assigned to the nicametate group. No significant difference in baseline characteristics between the two groups was observed. Cerebral reinfarction developed 6.3% (14/222) in the ASA group and 11.9% (29/244) in the nicametate group. According to the Cox's proportional hazards model, the estimated risk ratio (ASA group vs. nicametate group) was 0.538, with a 95% confidence interval of 0.284-1.019. The result was of borderline statistical significance. The risk for cerebral reinfarction was reduced by almost 50% among those who took 100 mg ASA versus those who took nicametate.

Watershed infarction of spinal cord after the embolization of bronchial artery: a case report

A case of watershed infarction in the spinal cord is reported. The patient underwent bronchial artery embolization for control of massive hemoptysis. The bronchial arteriogram was carefully examined and focused on blood supply to the spinal cord prior to embolization. Acute paraparesis followed the embolization procedure even though there was no visible spinal supply on the arteriogram. Magnetic resonance imaging showed a hyperintensity lesion over the watershed region which is located at the central portion of the upper thoracic cord. This case is reported to emphasize the significant role which angiographically invisible small vessels can play in the blood supply to the spinal cord. The vascular system of the spinal cord and the prevention of spinal cord ischemia secondary to embolization are further discussed here.

Melkersson-Rosenthal syndrome: a case report

The Melkersson-Rosenthal syndrome (MRS) is a rare disease which includes a triad of orofacial swelling, recurrent facial nerve paralysis and plicated tongue. MRS can still be diagnosed when any two of the conditions are present. Because of its rarity, it is usually ignored and misdiagnosed. Herein, a diabetic female patient with this syndrome, previously diagnosed as Bell's palsy, is described. This case report is presented to encourage awareness of this entity among medical practitioners. In addition, the MRS literature is reviewed with respect to incidence, etiology, clinical features, pathology, differential diagnosis and treatment.

Meralgia paresthetica: the diagnostic value of somatosensory evoked potentials

Somatosensory evoked potentials elicited by stimulation of the lateral femoral cutaneous nerve were investigated in 20 able-bodied persons and 22 patients diagnosed clinically to have meralgia paresthetica. There was no statistically significant difference between the right and left sides for P0 and N1 latencies in able-bodies subjects. For all patients, abnormalities were found on the side clinically affected. The mean values were 38.11 msec for P0 and 47.49msec for N1 on the affected side and 32.62msec and 41.44msec on the unaffected side (p less than .01). The mean latency differences between the two sides P0 and N1 were 5.49msec and 6.05msec, respectively (p less than .01). Hence, this technique proved to be a useful objective diagnostic aid in meralgia paresthetica.

Transient global amnesia associated with a right sphenoid ridge meningioma: a case report

Transient global amnesia is a self-limited disorder and is regarded as a benign syndrome of vascular etiology. We described a 65-year-old woman who experienced a single episode of transient global amnesia and subsequently developed a right hemispheric syndrome and permanent loss of recent memory. Neuroradiologic investigations and surgical operations revealed a right sphenoid ridge meningioma. Although the syndrome is most often benign, the possibility of mass lesion should be carefully assessed.