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Selective thrombolysis performed through meningo-ophthalmic artery in central retinal artery occlusion
Journal of Clinical Neuroscience 19 (2012) 462–464
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Case Reports
Selective thrombolysis performed through meningo-ophthalmic artery in central retinal artery occlusion José E. Cohen a,b,⇑, Samuel Moscovici a, Michael Halpert c, Eyal Itshayek a a
Department of Neurosurgery, Hadassah-Hebrew University Medical Center, P.O.Box 12000, Jerusalem 91120, Israel Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel c Department of Ophthalmology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel b
a r t i c l e
i n f o
Article history: Received 23 June 2011 Accepted 29 June 2011
Keywords: Amaurosis Central retinal artery occlusion Ophthalmic artery Stroke Thrombolysis
a b s t r a c t The poor natural history of central retinal artery occlusion (CRAO) is usually not modified with conventional, conservative management techniques. Guidelines for selective intraarterial ophthalmic thrombolysis are still lacking. While many centers continue to perform this procedure with promising results, others are reluctant due to conflicting findings in recent studies. We present our experience in a 36year-old male with CRAO. Based on the patient’s clinical presentation, we planned to perform selective intraarterial ophthalmic thrombolysis via the ophthalmic artery. When angiography demonstrated that the retina was not supplied by the ophthalmic artery, but by a meningo-ophthalmic artery branching from the internal maxillary artery, we instead administered thrombolytic agents via the meningo-ophthalmic artery. The patient’s vision recovered completely, with visual acuity and visual field examination at 30 day follow up comparable to his pre-treatment status. This case emphasizes the need for external carotid artery examination in cases of nonvisualization of the ophthalmic artery. In addition, it illustrates the successful use of the meningo-ophthalmic artery to perform selective intraarterial thrombolysis for CRAO. Ó 2011 Elsevier Ltd. All rights reserved.
1. Introduction Total and subtotal central retinal artery occlusion (CRAO) presents a grim visual prognosis if managed with conventional conservative methods.1 Several open-label clinical studies using continuous infusion of thrombolytic agents have suggested that local intra-arterial fibrinolysis is efficacious in the treatment of CRAO,1,2 however, a recent multicenter randomized trial showed conflicting findings.3 Adequate patient selection, procedure timing and technical aspects are only a part of the ongoing debated issues on CRAO therapy. The therapeutic goal is to restore the retinal blood flow as soon as possible before permanent and extended visual damage occurs, allowing for significant visual recovery. This goal can be achieved by rapid selective infusion of fibrinolytic agents through ophthalmic artery proximal to the origin of the central retinal and ciliar arteries. We present an unusual case of CRAO that was successfully managed with ophthalmic artery fibrinolysis performed through the meningo-ophthalmic artery.
2. Case presentation A 36-year-old-male with a history of valvular heart disease was found to have a CRAO in his left eye. He presented due to a sudden, ⇑ Corresponding author. Address: Department of Neurosurgery , Hadassah University Medical Center, P.O. Box 12000, Jerusalem 91120, Israel. Tel.: +972 2 6777092; fax: +972 2 6416281. E-mail address: [email protected] (J.E. Cohen).
painless, complete monocular loss of vision twelve hours before admission to the ophthalmology ward. Upon examination, the pupil responded poorly to direct light but constricted briskly when the contralateral eye was illuminated (relative afferent pupillary defect). Fundoscopy showed retinal edema, a cherry-red macular spot, and sluggish circulation through the retinal vessels, confirming the diagnosis of CRAO. 2.1. Endovascular procedure Under local anesthesia, a 6F introducer sheath was placed in the right femoral artery. A diagnostic angiogram of the left internal carotid artery (ICA) demonstrated absence of the ophthalmic artery from the ICA and no visualization of the choroidal blush (Fig. 1A). Selective angiogram of the left external carotid artery (ECA) demonstrated a meningo-ophthalmic artery arising from the left middle meningeal artery (MMA), just before it crosses the sphenoid ridge on the lateral view, contributing supply to the orbit (Fig. 1B). Intravenous heparin was given to obtain an activating clotting time (ACT) of 280–320 seconds. A guiding catheter was placed at the origin of the left ECA. Coaxially, a Prowler 10 microcatheter (Codman & Shurtleff, Raynham, MA, USA) was navigated through the distal MMA under road mapping and placed at the meningoophthalmic artery (Fig. 1C and D). Thrombolysis was performed by administering 250,000 units of urokinase over 30 minutes, injected within 13.5 hours after the CRAO. Following thrombolysis, the left ECA angiogram showed improved angiographic visualization of the choroidal blush (Fig. 1E and F); however, there is usually
Case Reports / Journal of Clinical Neuroscience 19 (2012) 462–464
463
Fig. 1. Central retinal artery occlusion in a 36-year-old male. (A) Left internal carotid artery (ICA) angiogram (lateral view) demonstrates absence of the ophthalmic artery from the ICA and lack of a choroidal blush. (B) Left external carotid artery (ECA) angiogram (lateral view) demonstrates a meningo-ophthalmic artery arising from the left middle meningeal artery (MMA) just before it crosses the sphenoid ridge, contributing blood supply to the orbit. Note the sluggish choroidal blush. (C) The microcatheter is navigated under road mapping through the MMA into the meningo-ophthalmic artery. (D) Selective microangiography of the meningo-ophthalmic artery. (E and F) Left ECA angiogram (lateral view, early and late phases) obtained after the thrombolytic infusion demonstrates a more intense choroidal blush. Usually, there is no correlation between treatment efficacy and choroidal-retinal angiographic changes.
no correlation between treatment efficacy and choroidal-retinal angiographic changes. Following the procedure, the patient showed a rapid and marked improvement of his left eye vision, with increased retinal flow on immediate postprocedural fundoscopic evaluation. A complete ophthalmological examination was performed the following day, including visual acuity, visual field test, slit lamp examination, fundoscopic examination and fluorescein angiography. The patient’s vision recovered completely and fluorescein angiography confirmed total retinal vessel recanalization. The 30 day clinical follow-up examination showed a complete recovery of visual acuity and visual fields. 3. Discussion Intraarterial fibrinolysis has been used primarily in the treatment of thromboembolic occlusion of the cerebral arteries, with
good results.4 Early applications in the ophthalmic territory produced a high rate of recanalization of the central retinal artery, with better outcomes than achieved with conservative treatment.5,6 Selective fibrinolysis primarily acts by relieving of the embolic occlusion or the central retinal artery. A timely revascularization may save the retina at risk (penumbra), however, CRAO due to nonembolic causes such as subintimal hemorrhage, intimo-intimal intussusception, or dissection of the central retinal artery will not improve after fibrinolysis. The central retinal artery (retinal artery) branches from the ophthalmic artery, running inferior to the optic nerve, within its dural sheath, and pierces the optic nerve close to the eyeball, sending branches over the internal surface of the retina. These terminal branches are the only blood supply to a vast retinal area. The central retinal artery typically originates together with or close to the posterior ciliary arteries (either the medial or lateral branches) from the ophthalmic artery; thus choroidal blush, best seen on the lateral
464
Case Reports / Journal of Clinical Neuroscience 19 (2012) 464–466
angiographic view in the capillary and early venous phases, is often used as a landmark to identify the retinal artery origin.7 In approximately 20% of the population, there is a cilio-retinal artery that supplies the retina between the macula and the optic nerve, including nerve fibers from the foveal photoreceptors. If this artery is present, central vision may be preserved even in cases of CRAO. Hayreh et al.8 showed that the retina of elderly, atherosclerotic, hypertensive rhesus monkeys suffered no detectable damage with CRAO of 97 min duration, but beyond that limit, damage became more extensive and irreversible with increasing CRAO duration. The study suggested that CRAO lasting for about 240 min results in massive irreversible retinal damage. In contrast to investigation in animal models, fluorescein angiography in humans has shown that in CRAO, a partial retinal blood flow exists that may extend the therapeutic window for revascularization procedures in most situations.1 Some authors have thus reported the achievement of marked visual recovery when therapy is performed within the first 4–5 hours after onset of visual impairment,9 and others, as in the presented case, have shown similar results even many hours after this window.2,3 Among the several potential orbital collateral routes from the ECA to the ophthalmic artery, the most frequently encountered is the meningo-ophthalmic artery.10 This artery is the extreme variation, in which the remnant of the embryologic stapedial artery (i.e. the MMA and the distal internal maxillary artery) takes over the entire orbital supply from the primitive ophthalmic artery.11 In this case, the distal ophthalmic artery, including the central retinal artery and ciliary arteries, is supplied only from the MMA as the remnant of the stapedial system. Important clues that suggest this variation are nonvisualization of the ophthalmic artery from the ICA and choroidal blush upon ECA injection (Fig. 1A–D). In this setting, even proximal occlusion of the MMA carries a high risk of visual impairment, because the MMA is the sole supply to the distal ophthalmic artery and must be avoided.
In our patient, the meningo-ophthalmic artery was the path used by the embolus causing CRAO as well as the path used for selective thrombolysis infusion. This case emphasizes the need for ECA examination in cases of nonvisualization of the ophthalmic artery, to identify collaterals or anastomoses to the ophthalmic artery. In addition, this case illustrates the use of the meningo-ophthalmic artery to perform selective intraarterial thrombolysis for CRAO. References 1. Schmidt DP, Schulte-Monting J, Schumacher M. Prognosis of central retinal artery occlusion: local intraarterial fibrinolysis versus conservative treatment. AJNR Am J Neuroradiol 2002;23:1301–7. 2. Aldrich EM, Lee AW, Chen CS, et al. Local intraarterial fibrinolysis administered in aliquots for the treatment of central retinal artery occlusion: the Johns Hopkins Hospital experience. Stroke 2008;39:1746–50. 3. Schumacher M, Schmidt D, Jurklies B, et al. Central retinal artery occlusion: local intra-arterial fibrinolysis versus conservative treatment, a multicenter randomized trial. Ophthalmology 2010;117:1367e1–75e1. 4. Cohen JE, Itshayek E, Moskovici S, et al. State-of-the-art reperfusion strategies for acute ischemic stroke. J Clin Neurosci 2011;18:319–23. 5. Schmidt D, Schumacher M, Wakhloo AK. Microcatheter urokinase infusion in central retinal artery occlusion. Am J Ophthalmol 1992;113:429–34. 6. Schumacher M, Schmidt D, Wakhloo AK. Intra-arterial fibrinolytic therapy in central retinal artery occlusion. Neuroradiology 1993;35:600–5. 7. Geibprasert S, Pongpech S, Armstrong D, et al. Dangerous extracranialintracranial anastomoses and supply to the cranial nerves: vessels the neurointerventionalist needs to know. AJNR Am J Neuroradiol 2009;30:1459–68. 8. Hayreh SS, Zimmerman MB, Kimura A, et al. Central retinal artery occlusion. Retinal survival time. Exp Eye Res 2004;78:723–36. 9. Padolecchia R, Puglioli M, Ragone MC, et al. Superselective intraarterial fibrinolysis in central retinal artery occlusion. AJNR Am J Neuroradiol 1999;20:565–7. 10. Hayreh SS. Orbital vascular anatomy. Eye (Lond) 2006;20:1130–44. 11. Lasjaunias P, Berenstein A, terBrugge K. Surgical neuroangiography. Clinical vascular anatomy and variations, vol. 1. Berlin: Springer-Verlag; 2001.
doi:10.1016/j.jocn.2011.06.010
Headache after substance abuse: A diagnostic dilemma A.S. Kamat ⇑, A.F. Aliashkevich, J.R. Denton, T.P. Fitzjohn Department of Neurosurgery, Wellington Regional Hospital, Wellington South, Wellington, New Zealand
a r t i c l e
i n f o
Article history: Received 18 July 2011 Accepted 23 July 2011
Keywords: Aneurysm Chronic Herbal highs Subarachnoid haemorrhage
a b s t r a c t An 18-year-old man inhaled a substance containing synthetic cannabinoids and 1 hour later developed a severe global headache. Imaging revealed a perimesencephalic subarachnoid haemorrhage. An angiogram suggested that a small superior cerebellar artery aneurysm was the culprit. This report discusses the, as yet undefined, relationship between ‘‘herbal highs’’ and intracranial haemorrhage. Crown Copyright Ó 2011 Published by Elsevier Ltd. All rights reserved.
1. Case Report An 18-year old man claimed that he purchased two 1.25-g packets of a substance known as ‘‘Kronic Purple Haze’’ and ⇑ Corresponding author. Address: 8D/39 Taranaki Street, Te Aro, Wellington 6011, New Zealand. Tel.: +64 21 21 747 21. E-mail address: [email protected] (A.S. Kamat).
subsequently rolled it into two ‘‘joints’’ and smoked them over a period of 2 hours. The patient denied consumption of alcohol, tobacco or any other recreational substances. One hour post-consumption, he developed a global headache, nausea, vomiting and visual disturbances. The patient also developed slurred speech, confusion and somnolence. He awoke the next morning with a worsening occipital headache. Although confused, his speech remained normal and he
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Case Reports
Selective thrombolysis performed through meningo-ophthalmic artery in central retinal artery occlusion José E. Cohen a,b,⇑, Samuel Moscovici a, Michael Halpert c, Eyal Itshayek a a
Department of Neurosurgery, Hadassah-Hebrew University Medical Center, P.O.Box 12000, Jerusalem 91120, Israel Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel c Department of Ophthalmology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel b
a r t i c l e
i n f o
Article history: Received 23 June 2011 Accepted 29 June 2011
Keywords: Amaurosis Central retinal artery occlusion Ophthalmic artery Stroke Thrombolysis
a b s t r a c t The poor natural history of central retinal artery occlusion (CRAO) is usually not modified with conventional, conservative management techniques. Guidelines for selective intraarterial ophthalmic thrombolysis are still lacking. While many centers continue to perform this procedure with promising results, others are reluctant due to conflicting findings in recent studies. We present our experience in a 36year-old male with CRAO. Based on the patient’s clinical presentation, we planned to perform selective intraarterial ophthalmic thrombolysis via the ophthalmic artery. When angiography demonstrated that the retina was not supplied by the ophthalmic artery, but by a meningo-ophthalmic artery branching from the internal maxillary artery, we instead administered thrombolytic agents via the meningo-ophthalmic artery. The patient’s vision recovered completely, with visual acuity and visual field examination at 30 day follow up comparable to his pre-treatment status. This case emphasizes the need for external carotid artery examination in cases of nonvisualization of the ophthalmic artery. In addition, it illustrates the successful use of the meningo-ophthalmic artery to perform selective intraarterial thrombolysis for CRAO. Ó 2011 Elsevier Ltd. All rights reserved.
1. Introduction Total and subtotal central retinal artery occlusion (CRAO) presents a grim visual prognosis if managed with conventional conservative methods.1 Several open-label clinical studies using continuous infusion of thrombolytic agents have suggested that local intra-arterial fibrinolysis is efficacious in the treatment of CRAO,1,2 however, a recent multicenter randomized trial showed conflicting findings.3 Adequate patient selection, procedure timing and technical aspects are only a part of the ongoing debated issues on CRAO therapy. The therapeutic goal is to restore the retinal blood flow as soon as possible before permanent and extended visual damage occurs, allowing for significant visual recovery. This goal can be achieved by rapid selective infusion of fibrinolytic agents through ophthalmic artery proximal to the origin of the central retinal and ciliar arteries. We present an unusual case of CRAO that was successfully managed with ophthalmic artery fibrinolysis performed through the meningo-ophthalmic artery.
2. Case presentation A 36-year-old-male with a history of valvular heart disease was found to have a CRAO in his left eye. He presented due to a sudden, ⇑ Corresponding author. Address: Department of Neurosurgery , Hadassah University Medical Center, P.O. Box 12000, Jerusalem 91120, Israel. Tel.: +972 2 6777092; fax: +972 2 6416281. E-mail address: [email protected] (J.E. Cohen).
painless, complete monocular loss of vision twelve hours before admission to the ophthalmology ward. Upon examination, the pupil responded poorly to direct light but constricted briskly when the contralateral eye was illuminated (relative afferent pupillary defect). Fundoscopy showed retinal edema, a cherry-red macular spot, and sluggish circulation through the retinal vessels, confirming the diagnosis of CRAO. 2.1. Endovascular procedure Under local anesthesia, a 6F introducer sheath was placed in the right femoral artery. A diagnostic angiogram of the left internal carotid artery (ICA) demonstrated absence of the ophthalmic artery from the ICA and no visualization of the choroidal blush (Fig. 1A). Selective angiogram of the left external carotid artery (ECA) demonstrated a meningo-ophthalmic artery arising from the left middle meningeal artery (MMA), just before it crosses the sphenoid ridge on the lateral view, contributing supply to the orbit (Fig. 1B). Intravenous heparin was given to obtain an activating clotting time (ACT) of 280–320 seconds. A guiding catheter was placed at the origin of the left ECA. Coaxially, a Prowler 10 microcatheter (Codman & Shurtleff, Raynham, MA, USA) was navigated through the distal MMA under road mapping and placed at the meningoophthalmic artery (Fig. 1C and D). Thrombolysis was performed by administering 250,000 units of urokinase over 30 minutes, injected within 13.5 hours after the CRAO. Following thrombolysis, the left ECA angiogram showed improved angiographic visualization of the choroidal blush (Fig. 1E and F); however, there is usually
Case Reports / Journal of Clinical Neuroscience 19 (2012) 462–464
463
Fig. 1. Central retinal artery occlusion in a 36-year-old male. (A) Left internal carotid artery (ICA) angiogram (lateral view) demonstrates absence of the ophthalmic artery from the ICA and lack of a choroidal blush. (B) Left external carotid artery (ECA) angiogram (lateral view) demonstrates a meningo-ophthalmic artery arising from the left middle meningeal artery (MMA) just before it crosses the sphenoid ridge, contributing blood supply to the orbit. Note the sluggish choroidal blush. (C) The microcatheter is navigated under road mapping through the MMA into the meningo-ophthalmic artery. (D) Selective microangiography of the meningo-ophthalmic artery. (E and F) Left ECA angiogram (lateral view, early and late phases) obtained after the thrombolytic infusion demonstrates a more intense choroidal blush. Usually, there is no correlation between treatment efficacy and choroidal-retinal angiographic changes.
no correlation between treatment efficacy and choroidal-retinal angiographic changes. Following the procedure, the patient showed a rapid and marked improvement of his left eye vision, with increased retinal flow on immediate postprocedural fundoscopic evaluation. A complete ophthalmological examination was performed the following day, including visual acuity, visual field test, slit lamp examination, fundoscopic examination and fluorescein angiography. The patient’s vision recovered completely and fluorescein angiography confirmed total retinal vessel recanalization. The 30 day clinical follow-up examination showed a complete recovery of visual acuity and visual fields. 3. Discussion Intraarterial fibrinolysis has been used primarily in the treatment of thromboembolic occlusion of the cerebral arteries, with
good results.4 Early applications in the ophthalmic territory produced a high rate of recanalization of the central retinal artery, with better outcomes than achieved with conservative treatment.5,6 Selective fibrinolysis primarily acts by relieving of the embolic occlusion or the central retinal artery. A timely revascularization may save the retina at risk (penumbra), however, CRAO due to nonembolic causes such as subintimal hemorrhage, intimo-intimal intussusception, or dissection of the central retinal artery will not improve after fibrinolysis. The central retinal artery (retinal artery) branches from the ophthalmic artery, running inferior to the optic nerve, within its dural sheath, and pierces the optic nerve close to the eyeball, sending branches over the internal surface of the retina. These terminal branches are the only blood supply to a vast retinal area. The central retinal artery typically originates together with or close to the posterior ciliary arteries (either the medial or lateral branches) from the ophthalmic artery; thus choroidal blush, best seen on the lateral
464
Case Reports / Journal of Clinical Neuroscience 19 (2012) 464–466
angiographic view in the capillary and early venous phases, is often used as a landmark to identify the retinal artery origin.7 In approximately 20% of the population, there is a cilio-retinal artery that supplies the retina between the macula and the optic nerve, including nerve fibers from the foveal photoreceptors. If this artery is present, central vision may be preserved even in cases of CRAO. Hayreh et al.8 showed that the retina of elderly, atherosclerotic, hypertensive rhesus monkeys suffered no detectable damage with CRAO of 97 min duration, but beyond that limit, damage became more extensive and irreversible with increasing CRAO duration. The study suggested that CRAO lasting for about 240 min results in massive irreversible retinal damage. In contrast to investigation in animal models, fluorescein angiography in humans has shown that in CRAO, a partial retinal blood flow exists that may extend the therapeutic window for revascularization procedures in most situations.1 Some authors have thus reported the achievement of marked visual recovery when therapy is performed within the first 4–5 hours after onset of visual impairment,9 and others, as in the presented case, have shown similar results even many hours after this window.2,3 Among the several potential orbital collateral routes from the ECA to the ophthalmic artery, the most frequently encountered is the meningo-ophthalmic artery.10 This artery is the extreme variation, in which the remnant of the embryologic stapedial artery (i.e. the MMA and the distal internal maxillary artery) takes over the entire orbital supply from the primitive ophthalmic artery.11 In this case, the distal ophthalmic artery, including the central retinal artery and ciliary arteries, is supplied only from the MMA as the remnant of the stapedial system. Important clues that suggest this variation are nonvisualization of the ophthalmic artery from the ICA and choroidal blush upon ECA injection (Fig. 1A–D). In this setting, even proximal occlusion of the MMA carries a high risk of visual impairment, because the MMA is the sole supply to the distal ophthalmic artery and must be avoided.
In our patient, the meningo-ophthalmic artery was the path used by the embolus causing CRAO as well as the path used for selective thrombolysis infusion. This case emphasizes the need for ECA examination in cases of nonvisualization of the ophthalmic artery, to identify collaterals or anastomoses to the ophthalmic artery. In addition, this case illustrates the use of the meningo-ophthalmic artery to perform selective intraarterial thrombolysis for CRAO. References 1. Schmidt DP, Schulte-Monting J, Schumacher M. Prognosis of central retinal artery occlusion: local intraarterial fibrinolysis versus conservative treatment. AJNR Am J Neuroradiol 2002;23:1301–7. 2. Aldrich EM, Lee AW, Chen CS, et al. Local intraarterial fibrinolysis administered in aliquots for the treatment of central retinal artery occlusion: the Johns Hopkins Hospital experience. Stroke 2008;39:1746–50. 3. Schumacher M, Schmidt D, Jurklies B, et al. Central retinal artery occlusion: local intra-arterial fibrinolysis versus conservative treatment, a multicenter randomized trial. Ophthalmology 2010;117:1367e1–75e1. 4. Cohen JE, Itshayek E, Moskovici S, et al. State-of-the-art reperfusion strategies for acute ischemic stroke. J Clin Neurosci 2011;18:319–23. 5. Schmidt D, Schumacher M, Wakhloo AK. Microcatheter urokinase infusion in central retinal artery occlusion. Am J Ophthalmol 1992;113:429–34. 6. Schumacher M, Schmidt D, Wakhloo AK. Intra-arterial fibrinolytic therapy in central retinal artery occlusion. Neuroradiology 1993;35:600–5. 7. Geibprasert S, Pongpech S, Armstrong D, et al. Dangerous extracranialintracranial anastomoses and supply to the cranial nerves: vessels the neurointerventionalist needs to know. AJNR Am J Neuroradiol 2009;30:1459–68. 8. Hayreh SS, Zimmerman MB, Kimura A, et al. Central retinal artery occlusion. Retinal survival time. Exp Eye Res 2004;78:723–36. 9. Padolecchia R, Puglioli M, Ragone MC, et al. Superselective intraarterial fibrinolysis in central retinal artery occlusion. AJNR Am J Neuroradiol 1999;20:565–7. 10. Hayreh SS. Orbital vascular anatomy. Eye (Lond) 2006;20:1130–44. 11. Lasjaunias P, Berenstein A, terBrugge K. Surgical neuroangiography. Clinical vascular anatomy and variations, vol. 1. Berlin: Springer-Verlag; 2001.
doi:10.1016/j.jocn.2011.06.010
Headache after substance abuse: A diagnostic dilemma A.S. Kamat ⇑, A.F. Aliashkevich, J.R. Denton, T.P. Fitzjohn Department of Neurosurgery, Wellington Regional Hospital, Wellington South, Wellington, New Zealand
a r t i c l e
i n f o
Article history: Received 18 July 2011 Accepted 23 July 2011
Keywords: Aneurysm Chronic Herbal highs Subarachnoid haemorrhage
a b s t r a c t An 18-year-old man inhaled a substance containing synthetic cannabinoids and 1 hour later developed a severe global headache. Imaging revealed a perimesencephalic subarachnoid haemorrhage. An angiogram suggested that a small superior cerebellar artery aneurysm was the culprit. This report discusses the, as yet undefined, relationship between ‘‘herbal highs’’ and intracranial haemorrhage. Crown Copyright Ó 2011 Published by Elsevier Ltd. All rights reserved.
1. Case Report An 18-year old man claimed that he purchased two 1.25-g packets of a substance known as ‘‘Kronic Purple Haze’’ and ⇑ Corresponding author. Address: 8D/39 Taranaki Street, Te Aro, Wellington 6011, New Zealand. Tel.: +64 21 21 747 21. E-mail address: [email protected] (A.S. Kamat).
subsequently rolled it into two ‘‘joints’’ and smoked them over a period of 2 hours. The patient denied consumption of alcohol, tobacco or any other recreational substances. One hour post-consumption, he developed a global headache, nausea, vomiting and visual disturbances. The patient also developed slurred speech, confusion and somnolence. He awoke the next morning with a worsening occipital headache. Although confused, his speech remained normal and he