Diffuse Fluid-Attenuated Inversion Recovery Hyperintensity in Subarachnoid Space Following Cerebral Angiography and Intravenous Thrombolysis

Ramin Zand, Shailesh Male, John K. Lynch

Research output: Contribution to journalArticlepeer-review

Abstract

Objective Transient cortical blindness (TCB) is a relatively rare but well-recognized complication following cardiovascular and cerebral angiography. Methods A 68-year-old male developed TCB following cerebral angiography along with punctate diffusion lesion evident on emergent magnetic resonance imaging (MRI). The patient received intravenous tissue plasminogen activator (IV-tPA) for suspected stroke. Results Follow-up MRI revealed diffuse hyperintensities in subarachnoid space in fluid-attenuated inversion recovery (FLAIR) sequence mostly in bilateral occipital lobes. Conclusion The finding on the FLAIR as described in this case is an indication of diffuse disruption of the blood-brain barrier perhaps secondary to cerebral angiography, high blood pressure, and IV-tPA. To the best of our knowledge, this is the first reported case of TCB with diffuse postcontrast FLAIR changes.

Original languageEnglish (US)
Pages (from-to)e1-e3
JournalJournal of Stroke and Cerebrovascular Diseases
Volume24
Issue number12
DOIs
StatePublished - Dec 1 2015

Bibliographical note

Funding Information:
A 68-year-old, left-handed, Caucasian male presented to our emergency department with chief complaint of confusion for 6 hours. His past medical history was significant for high blood pressure, hyperlipidemia, and psoriasis. At home, he was on scheduled hydralazine, losartan, simvastatin, as well as cortisone injection every 3 months. His last cortisone injection was almost 3 months before his presentation. He admits that he occasionally uses marijuana and he had used marijuana on the night before his presentation. His initial exam was significant for blood pressure of 220/120 and mild to moderate confusion in the absence of other neurological deficits. He had an urgent magnetic resonance imaging and magnetic resonance angiogram of the head and neck, which was only significant for a 50% midbasilar stenosis. The patient was admitted to the medical intensive care unit with the initial diagnosis of hypertensive encephalopathy. His symptoms resolved by the next day. On the second day of hospitalization the “code stroke” was called while the patient was undergoing a cerebral angiogram for better evaluation of basilar stenosis. The National Institutes of Health (NIH) stroke team immediately evaluated the patient. The NIH Stroke Scale score was calculated as 5 for confusion and disorientation in addition to significant bilateral visual blurriness. An urgent MRI with and without contrast was performed, which revealed a punctate foci of diffusion restriction in the right occipital lobe with a corresponding signal drop on apparent diffusion coefficient sequence ( ). The patient received intravenous tissue plasminogen activator (IV-tPA) for suspected acute stroke. Shortly after tPA administration, the patient became completely blind. The repeat MRI done immediately after IV-tPA revealed no new diffusion lesion; however, it was significant for diffuse hyperintensities in subarachnoid space in the fluid-attenuated inversion recovery sequence ( ). The patient's visual disturbance and confusion gradually improved within 3 days. His visual and neurological examination was back to the baseline in his hospital discharge follow-up visit after a week. This case was part of the NIH Stroke Natural History database. This registry has been approved by the NIH Institutional Review Board. We also obtained the patient's written consent for the purpose of this report. Fig 1 Fig 2

Publisher Copyright:
© 2015 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Keywords

  • Cortical
  • angiography
  • blindness
  • magnetic resonance imaging

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