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The Periodical Second Issue, November 2002

Editors Note	SAGAS Objectives	SAGAS News	Stroke Risk Factors: An Overview
A Need For A World Stroke Federation	International Article Review	The Periodical Quiz	The Periodical Case

The Periodical Case

A Case of Moyamoya

22 year old Saudi single private male

First ever:

Sudden and mild, left upper limb weakness with facial tilt

Negative history for:

Headache, LOC, seizures, speech difficulties, diplopia, dysphagia, sensory changes, sphincters loss, abnormal movements and head or neck trauma

No risk factors and no drug abuse

Negative family history

Negative systemic inquiry

Examination:

Obese young man, who is slightly dull with mild left hemiparesis. No other abnormalities

Neuro-psychological testing:

Below average performance at school and later at work. Impaired attention and concentration with mild depressive symptoms

IQ:

Verbal IQ 87

Performance IQ 90

Full IQ 88

Memory:

Verbal, mild deterioration

Visual, normal

Global memory function 85%

Work up

CT scan of the brain shows oval hypodensity in the right frontal watershed area, which is not enhancing with contrast

CXR, ECG, ECHO and TEE are normal.

Hemogram, biochemistry, inflammatory reactants, lipid profile, pyruvate and lactate and all hypercoaguble parameters are normal

Sickle cell and autoimmune screen are negative

CSF examination is normal

Evoked potentials are normal

TCD

Bilateral ICA distal severe stenosis and severe stenosis of both ACA and MCA bilaterally with plenty of collaterals and normal posterior circulation (suggesting moyamoya disease)

EEG

Shows rebuild of frontal high amplitude delta wave, 2 minutes following stopping hyperventilation.

Angiography

Severe stenosis of distal internal carotid artries bilaterally, with severe stenosis of both middle cerebral and anterior cerebral arteries bilaterally with compensated dilated lentriculo-striatal arteries (moyamoya phenomena, stage III-IV). The basialr artery is normal.

AP view