Correspondence
Case 27-1993: Cerebral Vasculitis
N Engl J Med 1994; 330:67-68January 6, 1994
- Article
To the Editor:
Case 27-1993 (July 8 issue)1 was interesting and informative. However, I would have to disagree with the anatomical diagnosis of cerebral vasculitis. The description of the microscopical examination and the lesions shown in Figures 2 and 3 indicate swollen endothelial cells and transmural migration by leukocytes in small blood vessels that appear to be venules. In my experience, this type of vascular change is a reaction to injury and is not indicative of vasculitis. In Table 4, two cases reported in the literature described lymphocytic infiltration of small vessels. The vessels are not described as arteries.
What are the minimal criteria for the diagnosis of vasculitis? Does lymphocytic venulitis deserve to be classified as vasculitis, with its serious therapeutic implications?
I must also confess that this letter is prompted by a feeling of guilt. If the lesions depicted are truly those of vasculitis, then I am responsible for countless misdiagnoses.
1 ReferencesAnthony D'Agostino, M.D.
Oregon Health Sciences University, Portland, OR 972011
Case Records of the Massachusetts General Hospital (Case 27-1993)
Full Text | Web of Science | Medline
To the Editor:
In the Case Records of the Massachusetts General Hospital for July 8, a patient presented with an intracerebral hemorrhage that enlarged during hospitalization. Nitroglycerin and nitroprusside were given on the patient's arrival at the hospital. Both drugs affect platelet function and could have contributed to the bleeding.1
1 ReferencesSalvatore J. Scialla, M.D.
Scranton-Temple Residency Program, Scranton, PA 185101
Schafer AI ,Alexander RW ,Handin RI . Inhibition of platelet function by organic nitrate vasodilators. Blood 1980;55:649-654
Web of Science | Medline
Author/Editor Response
A discussant and the patient's physician reply:
To the Editor: The comments of Dr. D'Agostino are appreciated and are certainly relevant to the case record. Although some of his disagreements are partially semantic, the diagnosis of vasculitis is unequivocal. The presence of neutrophils, lymphocytes, and macrophages within the walls of small blood vessels, including venules, is characteristic of a hypersensitivity vasculitis1. Lymphocytes may be the principal cell type recognized, or the only one. The pattern helps in distinguishing the features of this condition from those of other types of vasculitis, such as infectious periarteritis nodosa, Wegener's granulomatosis, giant-cell arteritis, Takayusu's arteritis, Buerger's disease, and the like. In addition, primary granulomatous angiitis of the central nervous system primarily involves small vessels and frequently involves venules2. The vessels in question were certainly small, and many were venules. In addition, as noted in the case record, actual destruction of the vessel wall was recognized. In this case the vasculitis was mild, yet the inflammation within the vessel walls was inescapable and out of proportion to the reaction of the surrounding tissue, indicating a primary problem with the blood vessels. The therapeutic implications of the various types of vasculitis certainly differ and are not an appropriate topic for discussion here.
2 ReferencesJeffrey A. Golden, M.D.
Brigham and Women's Hospital, Boston, MA 021151
Golitz LE. The inflammatory dermatoses. In: Silverberg SG, ed. Principles and practice of surgical pathology. New York: Churchill Livingstone, 1988:139-46.
2
Cravioto H ,Feigin I . Noninfectious granulomatous angiitis with a predilection for the nervous system. Neurology 1959;9:599-609
Web of Science | Medline
Author/Editor Response
Dr. Scialla correctly states that nitroglycerin and nitroprusside have been found to increase bleeding time or platelet aggregation in a number of studies. We are not aware of any studies, however, that correlate this finding with clinically important bleeding. These agents are routinely used to control blood pressure in patients with intraparenchymal and subarachnoid hemorrhage and in patients at high risk for bleeding from gastric varices, aortic aneurysm, or postoperative sites. Given the present data, we think the benefit of exact blood-pressure control afforded by these agents outweighs their effects on the bleeding time. Dr. Scialla's letter underscores the need for more information, however. What is the clinical relation between the use of nitroglycerin and nitroprusside and bleeding complications in relevant groups of patients? In this regard, there has been an interesting report that the alternative use of infusions of trimethaphan to control blood pressure in patients undergoing cardiac surgery is not associated with an alteration in platelet function1. Is trimethaphan associated with a lower risk of postoperative bleeding than nitroprusside?
Despite this uncertainty, it is important to emphasize that pharmacologic control of mean systemic blood pressure (SBP) with concomitant maintenance of adequate cerebral perfusion pressure (CPP) is considered the most important goal in patients with intraparenchymal hemorrhage and high intracranial pressure (ICP) (CPP = SBP - ICP)2. This is especially important in the case of cocaine-associated intracranial hemorrhage, because acute cocaine use causes a severe hypertensive surge that we think precipitates bleeding from arterioles affected by cocaine-induced vasculitis. Infusions of nitroglycerin and nitroprusside allow the physician carefully to lower the pressure differential across the defective arteriole while monitoring neurologic function, intracranial pressure, or both to ensure that cerebral perfusion is not threatened by the lowered blood pressure.
2 ReferencesWalter J. Koroshetz, M.D.
Massachusetts General Hospital, Boston, MA 021141
Hines R . Preservation of platelet function during trimethaphan infusion. Anesthesiology 1990;72:834-837
CrossRef | Web of Science | Medline2
Borges LF. Management of nontraumatic brain hemorrhage. In: Ropper AH, ed. Neurological and neurosurgical intensive care. 3rd ed. New York: Raven Press, 1993:279-89.
- Citing Articles (1)
Citing Articles
1
Kazuhiko Kibayashi, Angeline R Mastri, Charles S Hirsch. (1995) Cocaine induced intracerebral hemorrhage: Analysis of predisposing factors and mechanisms causing hemorrhagic strokes. Human Pathology 26:6, 659-663
CrossRef
