Question: I have had artery stenoses all over my brain come and go, and lacunar strokes near these arteries over a four year period. The doctors are unable to find out why. Differential diagnoses are: intermittent arterial spasms, cerebral vasculitis, showers of embolic clots. Atherosclerosis has been ruled out. Can you see any obvious pattern or cause?

I have had artery stenoses all over my brain come and go, and lacunar strokes near these arteries over a four year period. The doctors are unable to find out why. Differential diagnoses are: intermittent arterial spasms, cerebral vasculitis, showers of embolic clots. Atherosclerosis has been ruled out. Can you see any obvious pattern or cause?

I have uploaded images of my stenosis history and stroke history. Also a couple of MRI and MRA descriptions of strokes and stenosis, showing they occur in multiple places at once, which is highly unusual. Anything jump out at you regarding a possible cause?

I have uploaded images of my stenosis history and stroke history. Also a couple of MRI and MRA descriptions of strokes and stenosis, showing they occur in multiple places at once, which is highly unusual. Anything jump out at you regarding a possible cause?

An IR angiogram done last July said “very mild narrowing is noted at the origin of the A1 segment, mid M1 segment and also proximal inferior M2 segment. tortuosity is noted in the proximal V1 segment of the vertebral artery. Mild narrowing is noted at the distal basilar artery. Mild irregularity is noted in the course and caliber of the right P1 segment and also left P2 segment.”

I am currently having TIAs several times a month, but no new strokes. My blood pressure varies from 60/30 to 225/110.

An IR angiogram done last July said “very mild narrowing is noted at the origin of the A1 segment, mid M1 segment and also proximal inferior M2 segment. tortuosity is noted in the proximal V1 segment of the vertebral artery. Mild narrowing is noted at the distal basilar artery. Mild irregularity is noted in the course and caliber of the right P1 segment and also left P2 segment.”

I am currently having TIAs several times a month, but no new strokes. My blood pressure varies from 60/30 to 225/110.

Another doctor has said these are the various possibilities to explain my recurrent ischemic episodes: heart, migraine, anxiety, bp, or some intermittent allergic reactions of the cerebral arteries to some allergen. What do you think?

Another doctor has said these are the various possibilities to explain my recurrent ischemic episodes: heart, migraine, anxiety, bp, or some intermittent allergic reactions of the cerebral arteries to some allergen. What do you think?

Thank you for your answer.

My personal neurologist at UCLA thinks I have cerebral vasculitis, currently in remission. I had blood tests which showed positive ANA 1:80, lupus and Sjogrens disease. I had an IR cerebral angiogram which I presume used digital subtraction angiography since it was done on a fluoroscopy table. The study concluded that vasculitis could not be ruled out. Here is the impression on the report:

IMPRESSION:
1. Mild narrowing and irregularity is noted in multiple intracranial large vessels as described above including the left middle cerebral and bilateral posterior cerebral arteries. These findings are nonspecific and might suggest intracranial
atherosclerotic disease given her history of hypertension and diabetes; however, CNS vasculitis is not completely excluded. Clinical correlation is recommended.
2. Right transverse sinus is hypoplastic.

I sought a second opinion at XXXXXXX Clinic and they did a Testla 3 MRI with special sequences which confirmed the narrowings seen in the IR angiogram. The XXXXXXX Clinic neurologist ruled out vasculitis because the MRI contrast did not light up the narrowings. He said if inflammation were present, it would have lighted up. My UCLA neurologist said that interpretation was not widely recognized and he did not agree with it to rule out vasculitis. So, who do I believe? Should I get a third opinion at another hospital to break the tie? Should I have another IR angiogram?

I have taken multiple blood pressure medicines since the strokes started in 2015 to control my intermittent high blood pressure. Nothing has worked. I continued to have strokes and TIAs. I started verapimil today. Maybe that will work. It is supposed to relax the blood vessels.

What could be the cause of high blood pressure? The stroke symptoms start when my blood pressure is slightly elevated (140-160). As the symptoms progress, my blood pressure rapidly skyrockets within a half hour to 160, 170, 180, 190, 200. Then I have hemiparesis or hemiparalysis and dysarthria, and my blood pressure is 200-225. It seems to me the escalating blood pressure is a reaction to the TIA, not the cause.

Please explain why you have ruled out intermittent arterial spasms, showers of embolic clots and atherosclerosis as causes.

Thank you for your answer.

My personal neurologist at UCLA thinks I have cerebral vasculitis, currently in remission. I had blood tests which showed positive ANA 1:80, lupus and Sjogrens disease. I had an IR cerebral angiogram which I presume used digital subtraction angiography since it was done on a fluoroscopy table. The study concluded that vasculitis could not be ruled out. Here is the impression on the report:

IMPRESSION:
1. Mild narrowing and irregularity is noted in multiple intracranial large vessels as described above including the left middle cerebral and bilateral posterior cerebral arteries. These findings are nonspecific and might suggest intracranial
atherosclerotic disease given her history of hypertension and diabetes; however, CNS vasculitis is not completely excluded. Clinical correlation is recommended.
2. Right transverse sinus is hypoplastic.

I sought a second opinion at XXXXXXX Clinic and they did a Testla 3 MRI with special sequences which confirmed the narrowings seen in the IR angiogram. The XXXXXXX Clinic neurologist ruled out vasculitis because the MRI contrast did not light up the narrowings. He said if inflammation were present, it would have lighted up. My UCLA neurologist said that interpretation was not widely recognized and he did not agree with it to rule out vasculitis. So, who do I believe? Should I get a third opinion at another hospital to break the tie? Should I have another IR angiogram?

I have taken multiple blood pressure medicines since the strokes started in 2015 to control my intermittent high blood pressure. Nothing has worked. I continued to have strokes and TIAs. I started verapimil today. Maybe that will work. It is supposed to relax the blood vessels.

What could be the cause of high blood pressure? The stroke symptoms start when my blood pressure is slightly elevated (140-160). As the symptoms progress, my blood pressure rapidly skyrockets within a half hour to 160, 170, 180, 190, 200. Then I have hemiparesis or hemiparalysis and dysarthria, and my blood pressure is 200-225. It seems to me the escalating blood pressure is a reaction to the TIA, not the cause.

Please explain why you have ruled out intermittent arterial spasms, showers of embolic clots and atherosclerosis as causes.

Dr. XXXXXXX

My neurologist says I do not have arteriosclerosis in my large vessels because there are no plaques present in the usual places, such as where two arteries split. Also, the narrowings have come and gone on their own, which arteriosclerosis plaques would not do, right?

I've spent the day going through my old test results, and found that emboli were monitored for and never found.

So it appears that vasculitis is the most logical answer. It did further analysis of my stroke history, and concluded that there was a 12-month period during 5/1/2015-5/21/2016 when I had continual new strokes, until they slowed down then stopped altogether. I'm wondering if that represents a vasculitis flare up, due to a lupus flare? Then, for the past three years I have had continual TIAs only, and the arteries have settled down into permanent mild stenosis of my distal basilar artery, left ACA A1, left MCA M1, left MCA M2, and right PC. I will wait and hope I never have another flare of lupus or vasculitis.

Another possibility I researched is that it is caused by small vessel disease, which is is more severe for my age than would be suspected. I read that SVD can cause lacunar strokes. But would that cause stenosis in my major vessels?

I had a test for CADASIL and waiting for the results.

Deborah

Dr. XXXXXXX

My neurologist says I do not have arteriosclerosis in my large vessels because there are no plaques present in the usual places, such as where two arteries split. Also, the narrowings have come and gone on their own, which arteriosclerosis plaques would not do, right?

I've spent the day going through my old test results, and found that emboli were monitored for and never found.

So it appears that vasculitis is the most logical answer. It did further analysis of my stroke history, and concluded that there was a 12-month period during 5/1/2015-5/21/2016 when I had continual new strokes, until they slowed down then stopped altogether. I'm wondering if that represents a vasculitis flare up, due to a lupus flare? Then, for the past three years I have had continual TIAs only, and the arteries have settled down into permanent mild stenosis of my distal basilar artery, left ACA A1, left MCA M1, left MCA M2, and right PC. I will wait and hope I never have another flare of lupus or vasculitis.

Another possibility I researched is that it is caused by small vessel disease, which is is more severe for my age than would be suspected. I read that SVD can cause lacunar strokes. But would that cause stenosis in my major vessels?

I had a test for CADASIL and waiting for the results.

Deborah

Thank you I will let you know.

Thank you I will let you know.