Reversible cerebral vasoconstriction syndrome (RCVS) manifests with a thunderclap headache and reversible vascular abnormalities. Red blood cell transfusions have not been well identified as a risk factor for RCVS. We report a rare case of acute brain injury resulting from RCVS after a packed red blood cell (PRBC) transfusion. A 49-year-old female with a history of menorrhagia initially presented with generalized weakness. She was found to have a hemoglobin (Hgb) of 1.7 g/dL in the setting of a fundal fibroid for which she received five units of PRBCs. Post transfusion, she complained of several days of thunderclap headache and later returned with new-onset seizures. She was admitted to the neurocritical care unit for the treatment of status epilepticus. Metabolic, infectious and toxic work-up were unremarkable except for an elevated lactate. MRI of the brain with contrast showed extensive bilateral hemispheric and cerebellar white matter T2-weighted fluid-attenuated inversion recovery (T2/FLAIR) hyperintensities with areas of enhancement. A diagnostic cerebral angiogram was performed to evaluate for a vascular etiology and revealed focal segmental stenoses in bilateral A1 segments of the anterior cerebral arteries and in branches of the bilateral middle cerebral arteries. These findings were suggestive of RCVS. Clinicians should have a high degree of suspicion for RCVS in patients presenting with neurological manifestations, such as thunderclap headache or seizures after recent transfusion. The window for injury may be longer than that seen in other organs, such as in transfusion-related acute lung injury (TRALI).
Purpose
To describe a patient whose diagnosis of gliomatosis cerebri was delayed for one year due mostly to dexamethasone.
Patients and Methods
A 78-year-old woman was followed in clinic for a year with a brain lesion suspicious but not definitive for glioma, whose clinical course and neuroimaging varied with use of dexamethasone. A first biopsy and MR spectroscopy did not find evidence of malignancy.
Results
A second biopsy demonstrated the correct diagnosis when the patient was on a very low dexamethasone dose. Hypercellularity and a positive KI-67 immunostaining confirmed a grade II astrocytoma, although the rapid and aggressive course without dexamethasone suggested a higher grade tumor.
Conclusion
As in primary CNS lymphoma, the diagnosis of gliomatosis cerebri can be unnecessarily delayed with dexamethasone use. Every effort should be made to biopsy these lesions before or shortly after the addition of dexamethasone.
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