A 60-year-old woman on venlafaxine presented with headache and left-sided weakness 1 month after undergoing right common carotid artery stenting. Catheter-based angiogram identified new irregularities of the right anterior cerebral and right middle cerebral artery (figure, A–C). Investigations for vasculitis, including CSF studies, were unremarkable. The vessel irregularities and symptoms improved after administration of intra-arterial verapamil (figure, D–F). Unilateral reversible cerebral vasoconstriction syndrome has previously been described after carotid endarterectomy. The mechanism is unclear; however, it may be due to disturbance of cerebral autoregulation.1,2 Concomitant use of a serotonin and norepinephrine reuptake inhibitor may have been a predisposing factor.
OBJECTIVE: We present the case of a pseudo-hyperdense MCA sign in HSV encephalitis to raise awareness of this potentially confusing diagnosis. Non-dominant hemispheric strokes can present with confusion and encephalopathy with a hyperdense sign that can lead to mistriaging if the associated edema is not appreciated.
In patients with severe aortic valve stenosis at intermediate surgical risk, transcatheter aortic valve replacement (TAVR) with a self-expanding supra-annular valve was noninferior to surgery for all-cause mortality or disabling stroke at 2 years. Comparisons of longer-term clinical and hemodynamic outcomes in these patients are limited.To report prespecified secondary 5-year outcomes from the Symptomatic Aortic Stenosis in Intermediate Risk Subjects Who Need Aortic Valve Replacement (SURTAVI) randomized clinical trial.SURTAVI is a prospective randomized, unblinded clinical trial. Randomization was stratified by investigational site and need for revascularization determined by the local heart teams. Patients with severe aortic valve stenosis deemed to be at intermediate risk of 30-day surgical mortality were enrolled at 87 centers from June 19, 2012, to June 30, 2016, in Europe and North America. Analysis took place between August and October 2021.Patients were randomized to TAVR with a self-expanding, supra-annular transcatheter or a surgical bioprosthesis.The prespecified secondary end points of death or disabling stroke and other adverse events and hemodynamic findings at 5 years. An independent clinical event committee adjudicated all serious adverse events and an independent echocardiographic core laboratory evaluated all echocardiograms at 5 years.A total of 1660 individuals underwent an attempted TAVR (n = 864) or surgical (n = 796) procedure. The mean (SD) age was 79.8 (6.2) years, 724 (43.6%) were female, and the mean (SD) Society of Thoracic Surgery Predicted Risk of Mortality score was 4.5% (1.6%). At 5 years, the rates of death or disabling stroke were similar (TAVR, 31.3% vs surgery, 30.8%; hazard ratio, 1.02 [95% CI, 0.85-1.22]; P = .85). Transprosthetic gradients remained lower (mean [SD], 8.6 [5.5] mm Hg vs 11.2 [6.0] mm Hg; P < .001) and aortic valve areas were higher (mean [SD], 2.2 [0.7] cm2 vs 1.8 [0.6] cm2; P < .001) with TAVR vs surgery. More patients had moderate/severe paravalvular leak with TAVR than surgery (11 [3.0%] vs 2 [0.7%]; risk difference, 2.37% [95% CI, 0.17%- 4.85%]; P = .05). New pacemaker implantation rates were higher for TAVR than surgery at 5 years (289 [39.1%] vs 94 [15.1%]; hazard ratio, 3.30 [95% CI, 2.61-4.17]; log-rank P < .001), as were valve reintervention rates (27 [3.5%] vs 11 [1.9%]; hazard ratio, 2.21 [95% CI, 1.10-4.45]; log-rank P = .02), although between 2 and 5 years only 6 patients who underwent TAVR and 7 who underwent surgery required a reintervention.Among intermediate-risk patients with symptomatic severe aortic stenosis, major clinical outcomes at 5 years were similar for TAVR and surgery. TAVR was associated with superior hemodynamic valve performance but also with more paravalvular leak and valve reinterventions.
A 30-year-old woman, previously well, presented to an outside hospital after being found lying on her bedroom floor, with a history of confusion, headache, deja vu and fever. She had been discharged the day before having had normal investigations for headache, including a CT and MR scans, both read as normal. Laboratory studies showed a urinary tract infection with leucocytosis, but she was afebrile. She was discharged home with medications to treat her urinary tract infection and headache.
During a second presentation to the outside hospital, her cerebrospinal fluid (CSF) showed a pleocytosis and she was started on acyclovir, empirically to treat viral encephalitis. EEG showed right-sided sharp waves. Her neurological condition further deteriorated and she was intubated for airway protection and transferred to the Presbyterian Hospital. On examination, she was …
