Rheumatoid meningitis presenting with a stroke-like attack treated with recombinant tissue plasminogen activator: a case presentation

Abstract

Background: Rheumatoid meningitis presenting with a stroke-like attack (RMSA) is a rare manifestation of rheumatoid arthritis (RA). When the patients arrive within the time-window for recombinant tissue plasminogen activator (rt-PA) infusion therapy, no diagnostic protocol has been established.

Case presentation: A 55-year-old woman was brought by ambulance to our hospital with complaints of sudden-onset dysarthria and left arm numbness. The National Institutes of Health Stroke Scale (NIHSS) score was 5, and the Alberta Stroke Program Early CT Score was 8. She was diagnosed with acute embolic stroke. At 4 h, 6 min after onset, intravenous administration of rt-PA (alteplase, 0.6 mg/kg) was started. Her neurological deficits improved rapidly, and her NIHSS score was 1. Brain MRI was then performed. There was no hemorrhagic transformation, but the MRI findings were not compatible with ischemic stroke. She had a past history of RA diagnosed 6 months earlier, and she had been treated with methotrexate (10 mg daily). She was diagnosed with RMSA, and continuous infusion of methylprednisolone 1000 mg daily was started for 3 days. The high signal intensity on the FLAIR image disappeared.

Conclusion: CT-based decision-making for rt-PA injection is reasonable, but MRI is needed for the early diagnosis of RMSA. In this case, it is particularly important that neither adverse events nor bleeding complications were observed, suggesting the safety of CT-based thrombolytic therapy in RMSA.

Keywords: Recombinant tissue plasminogen activator (rt-PA); Rheumatoid meningitis; Stroke mimics.

Fig. 1

Brain CT images (a, b) do not show a hypodense area at admission, but equivocal findings of effacement in the right temporoparietal region (ASPECT score, 8). CT angiography (c) shows no vascular occlusion or stenosis. CT = computerized tomography, ASPECTS = Alberta Stroke Program Early CT Score

Fig. 2

MRI findings at day 1. DWI (a) demonstrates a linear high-intensity lesion in the right frontotemporal cortex. Reduced ADC of this lesion is seen on the ADC map (b), and this cortical lesion appears as a high-intensity lesion on the FLAIR image (c). MRI = magnetic resonance imaging, DWI = diffusion-weighted imaging, ADC = apparent diffusion coefficient, FLAIR = fluid attenuated inversion recovery

Fig. 3

MRI images at day 3. The abnormal findings at day 1 have disappeared on DWI (a) and the ADC image (b), but the high-intensity area remains on the FLAIR image (c) at day 3. There is no definite enhancement of the lesion on gadolinium-enhanced T1-weighted imaging (d). MRI = magnetic resonance imaging, DWI = diffusion-weighted imaging, ADC = apparent diffusion coefficient, FLAIR = fluid attenuated inversion recovery