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.
Finsterer J, Zarrouk-Mahjoub S. Nitric Oxide Deficiency Triggering Strokelike Episodes. JAMA Neurol. 2016;73(8):1029-1030. doi:10.1001/jamaneurol.2016.1646