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Comment & Response |

Nitric Oxide Deficiency Triggering Strokelike Episodes

Josef Finsterer, MD, PhD1; Sinda Zarrouk-Mahjoub, PhD2
[+] Author Affiliations
1Krankenanstalt Rudolfstiftung, Vienna
2Genomics Platform, Pasteur Institute of Tunis, Tunisia
JAMA Neurol. 2016;73(8):1029-1030. doi:10.1001/jamaneurol.2016.1646.
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To the Editor With interest we read the article by Koenig et al1 about the management of strokelike episodes (SLEs) by early administration of the nitric oxide precursors l-arginine or citrulline. We have the following comments and concerns.

We do not agree with the statement that the neurological status continuously deteriorates after the first SLE.1 There are several examples in the literature that patients experiencing a SLE can completely recover. Furthermore, strokelike lesions (SLLs), which are the morphological equivalent of a SLE on magnetic resonance imaging and are characterized by hyperintense diffusion-weighted imaging and apparent diffusion coefficient in the acute phase, may completely resolve in some cases. In other cases, clinical manifestations of a SLE may improve but remnants of the SLL may remain on magnetic resonance imaging.2 Additionally, there are several reports about recurrent SLEs.


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May 1, 2016
Mary Kay Koenig, MD; Lisa Emrick, MD; Amel Karaa, MD; Mark Korson, MD; Fernando Scaglia, MD; Sumit Parikh, MD; Amy Goldstein, MD
1Departments of Pediatrics and Neurology, The University of Texas Medical School at Houston, Houston
2Department of Pediatrics, Baylor College of Medicine and Texas Children’s Hospital, Houston
3Department of Genetics and Metabolism, Massachusetts General Hospital, Harvard Medical School, Boston
4Genetic Metabolic Center for Education, Salem, Massachusetts
5Department of Molecular and Human Genetics, Baylor College of Medicine and Texas Children’s Hospital, Houston
6Center for Pediatric Neurology, Neurosciences Institute, Cleveland Clinic, Cleveland, Ohio
7Department of Pediatrics, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
JAMA Neurol. 2016;73(5):591-594. doi:10.1001/jamaneurol.2015.5072.
August 1, 2016
Mary Kay Koenig, MD
1The University of Texas Medical School at Houston
JAMA Neurol. 2016;73(8):1030. doi:10.1001/jamaneurol.2016.1649.
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