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Issue: Issue 1 (2014) – Supplement 1

Case Report

Bilateral steno-occlusive disease of the middle cerebral artery: a case report with clinical-hemodynamic mismatch

Helena Rocha, Pedro Castro, Rosa Santos, Elsa Azevedo, and Marta Carvalho
Background: Bilateral steno-occlusive disease of middle cerebral artery (MCA) in young adults raises significant issues regarding etiology and treatment. The potential concomitance of hypoperfusion in the affected territories is of particular clinical relevance.

Case report: A 37-year-old man was admitted for a right MCA transient ischaemic attack. He was smoker, obese, dyslipidaemic, with previous history of heroin addiction and cured B and C hepatitis virus infections. Brain magnetic resonance and cardiac evaluation were normal. Transcranial color-coded sonography (TCCS) showed >50% proximal right MCA stenosis and distal left MCA occlusion. Treatment with aspirin and statin was started. Three months later, TCCS revealed >70% right MCA stenosis and left MCA occlusion. Selective angiography confirmed the steno-occlusive disease. Cerebrospinal fluid analysis revealed increased protein levels and a normal cell count. Corticotherapy was started, but the patient did not complied. Bilateral occlusion of MCA was noticed on TCCS, one month later, being the patient asymptomatic. Pulsed arterial spin labelling (PASL) revealed a severe decrease of cerebral blood flow in the distal part of both MCA territories.

Conclusions: The etiology of this progressive steno-occlusive disease remains unknown. Atherosclerosis may be a possible mechanism, however other potential etiologies must be considered giving the rapidly progressive character of the disorder. As it seems to be now stabilized, we wonder if it can be due to the vascular risk factors control and antithrombotic treatment or to a non-identified inflammatory monophasic cause. Serial TCCS played a major role in the assessment of disease progression.

Keywords: Progressive intracranial stenosis, Brain hypoperfusion, Transcranial color-coded sonography, Pulsed arterial spin labeling.

International Journal of Clinical Neurosciences and Mental Health 2014; 1(Suppl. 1):S26

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