Other Features

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Fever, hypertension, circulating immune

Eosinophilia, fever, rhematoid factor

Drug-induced cryoglobulins, circulating immune complexes cANCA-positive; upper and lower respiratory tract involvement

Granulomas in skin, muscle, liver, nodes

High ESR, jaw claudication, scalp tender

High CSF protein, no systemic symptoms

Systemic symptoms, hypertension

Strokes and meningoencephalitis with focal brain stem lesions

Vertigo, tinnitus, decreased hearing, cornea opacification

Characteristic sheathing of retinal arteries and veins and vitreous hemorrhages

High CSF protein

Skin, GI, and brain infarcts

Antiphospholipid antibodies common cANCA, Classic antineutrophil cytoplasmic antibody; CSF, cerebrospinal fluid; ESR, erythrocyte sedimentation rate; f/m, female-to-male; GI, gastrointestinal.

DRUG-RELATED VASCULOPATHIES

Illicit drug use and abuse has unfortunately become an important cause of stroke, especially in young individuals. This topic is discussed in Chapt"39 . XabJ.e,45z4, outlines the common drugs implicated and some features of the strokes that they cause.

MIGRAINE-RELATED STROKE

Stroke is a rare but potentially devastating complication of migraine. y , y y '57] Infarction is thought to be due to prolonged intense vasospasm associated with migraines. Intense vasospasm can impede flow, promoting thrombosis. Platelets are activated during migraine and the vasoconstrictive process itself may stimulate the endothelium to release factors that promote thrombosis. Severe vasoconstriction and thrombi have been demonstrated in patients with migraine who have PCA

and basilar artery territory infarcts. y , y

To complicate matters, atherosclerotic lesions in the coronary arteries of humans--and in the extracranial and retinal arteries of experimental animals--seem to predispose them to superimposed vasoconstriction. Thus, vasoconstriction can complicate atherostenosis. TCD shows promise of identifying vasoconstriction by showing high velocities that change with time and with various pharmacological treatments.

Hemorrhage can occasionally complicate a severe migraine attack. Intense vasoconstriction leads to ischemia of a local brain region, accompanied by edema and ischemia of the small vessels perfused by the constricted artery. Then, when vasoconstriction abates, blood flow to the region is augmented, and the reperfusion can cause hemorrhage from the damaged arteries and arterioles. y The mechanism is the same as that found in hemorrhage after carotid endarterectomy and in reperfusion after brain embolization.

TABLE 45-4 -- DRUG ABUSE AND STROKES

Drug

Route

Ischemia

Hemorrhage

Other Features

Heroin

IV

Strokes--brain and spinal cord

No

Increased gamma globulins

Amphetamines

Oral, IV

No ischemic strokes

SAH, ICH; aneurysms and AVMs rare

Hypertension

Cocaine HCI

Nasal, IV

Ischemic strokes

SAH and ICH; aneurysms and AVMs common

Hypertension

Crack cocaine

Nasal, IV

Ischemic strokes very common

SAH and ICH; aneurysms and AVMs common

Hypertension

Mashed pills

IV

Ischemic strokes

No

Tale particles in eyes and lungs

SAH, Subarachnoid hemorrhage; ICH, intracerebral hemorrhage; AVM, arteriovenous malformation.

Prophylactic agents (most often calcium channel blockers, cyproheptadine, or methysergide) should be maintained as well as agents that modify platelet function and coagulation. Aspirin may be prescribed, but warfarin can be used in patients with prior infarcts.

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