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A focal reduction in the caliber of the basal vessels and their proximal branches is a well-known complication of subarachnoid hemorrhage, as described on page 718 Vasospasm has also been implicated in migraine and migrainous stroke and as an explanation for TIAs, but with little supportive evidence Some degree of attenuation of large cerebral vessels is observed in hypertensive encephalopathy, in eclampsia, and with adrenergic drug use (eg, phenylpropanolamine, cocaine, triptan drugs used for the treatmnet of migraine), but the role of the vascular changes in causing strokes has never been clear A related condition of cerebral vasculitis caused by sympathomimetic drugs is discussed further on, with other vasculitides The problem of stroke with migraine, which has a complex and uncertain relationship to vasospasm, is discussed on page 151 In addition to these disorders of known causation, Call and colleagues have described a striking idiopathic widespread segmental vasospasm of cerebral vessels characterized by severe headache and uctuating TIA-like episodes (all cases drawn from our hospital services; termed Call-Fleming syndrome in some publications) The middle cerebral artery and its branches are mainly affected; the angiographic appearance may be mistaken for arteritis A number of similar cases have been described, and we have seen several that resulted in a small stroke There may be a posterior leukoencephalopathy that is similar to the imaging appearance in hypertensive encephalopathy Sometimes the headache is minimal The nature of this condition of idiopathic diffuse vasospasm is unknown A relationship to hypertensive encephalopathy or to delayed postpartum eclampsia has been suggested, because of the aforementioned white matter changes and the observation of widespread vasospasm in eclamptic women The patients we have seen with this process, after several weeks of dramatically uctuating focal neurologic symptoms and disabling headache, have recovered completely or nearly so In all likelihood, several disorders cause this type of vasculopathy Calcium channel blockers or corticosteroids have been prescribed, but their effectiveness cannot be determined There are clinical similarities to the syndrome of migraine, transient focal de cits, and CSF pleocytosis described on page 152; the spinal uid in the vasospasm cases is, however, normal It has recently been brought to attention by Singhal and colleagues and others that the use of serotonergic drugs may produce a similar syndrome of reversible multifocal vasospasm, severe headache, and stroke One of their three patients was using the antimigraine medicine sumatriptan; the other two were using serotonin reuptake inhibitor antidepressants and, in addition, had taken over-the-counter cold remedies that included pseudophedrine and dextromethorphan; we are aware of other similar cases These authors proposed that in these cases a serotonin syndrome had occurred, similar to what has been seen with overdoses of this class of antidepressants It has been suspected that the same sort of vasculopathy is produced by sympathomimetic drugs alone, such as ephedra in health food supplements, phenylpropanolamine, pseudophedrine,.

In ammatory diseases of the blood vessels of infectious origin and their effects upon the nervous system have been considered in detail in Chap 32 There it was pointed out that meningovascular syphilis, tuberculous meningitis, fungal meningitis, and the subacute (untreated or partially treated) forms of bacterial meningitis may be accompanied by in ammatory changes and occlusion of the cerebral arteries or veins Occasionally, in syphilitic, cryptococcal, and tuberculous meningitis, a stroke may be the rst clinical sign of meningitis, but more often it develops well after the meningeal symptoms are established The nature of the cerebral vasculitis that may rarely accompany AIDS is unknown Typhus, schistosomiasis, mucormycosis, malaria, and trichinosis are rare causes of in ammatory arterial disease, which, unlike the above, is not secondary to meningeal infections In typhus and other rickettsial diseases, capillary and arteriolar changes and perivascular in ammatory cells are found in the brain; presumably they are responsible for the seizures, acute psychoses, cerebellar syndromes, and coma characterizing the neurologic disorder in these diseases The internal carotid artery may be occluded in diabetic patients as part of the orbital and cavernous sinus infections with mucormycosis In trichinosis, the cause of the cerebral symptoms has not been established Parasites have been found in the brain; in one of our patients the cerebral lesions were produced by bland emboli arising in the heart and related to a severe myocarditis In cerebral malaria, convulsions, coma, and sometimes focal symptoms appear to be due to the blockage of capillaries and precapillaries by masses of parasitized red blood corpuscles Schistosomiasis may implicate cerebral or spinal arteries These diseases are discussed further in Chap 32

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