Abstract
BackgroundThe intracranial localization of large artery disease is recognized as the main cause of ischemic stroke in the world, considering all countries, although its global burden is widely underestimated. Indeed it has been reported more frequently in Asians and African-American people, but the finding of intracranial stenosis as a cause of ischemic stroke is relatively common also in Caucasians. The prognosis of patients with stroke due to intracranial steno-occlusion is strictly dependent on the time of recanalization. Moreover, the course of the vessel involvement is highly dynamic in both directions, improvement or worsening, although several data are derived from the atherosclerotic subtype, compared to other causes.Case descriptionWe report the clinical, neurosonological and neuroradiological findings of a young woman, who came to our Stroke Unit because of the abrupt onset of aphasia during her work. An urgent neurosonological examination showed a left M1 MCA stenosis, congruent with the presenting symptoms; magnetic resonance imaging confirmed this finding and identified an acute ischemic lesion on the left MCA territory. The past history of the patient was significant only for a hyperinsulinemic condition, treated with metformine, and a mild overweight. At this time a selective cerebral angiography was not performed because of the patient refusal and she was discharged on antiplatelet and lipid-lowering therapy, having failed to identify autoimmune or inflammatory diseases. Within 1 month, she went back to our attention because of the recurrence of aphasia, lasting about ten minutes. Neuroimaging findings were unchanged, but the patient accepted to undergo a selective cerebral angiography, which showed a mild left distal M1 MCA stenosis.During the follow-up the patient did not experienced any recurrence, but a routine neurosonological examination found an unexpected evolution of the known MCA stenosis, i.e. left M1 MCA occlusion. Neuroradiological imaging did not identify new lesions of the brain parenchyma and a repeated selective cerebral angiography confirmed the left M1 MCA occlusion.ConclusionsRegardless of the role of metabolic and/or inflammatory factors on the aetiology of the intracranial stenosis in this case, the course of the vessel disease was unexpected and previously unreported in the literature at our knowledge.
Highlights
The intracranial localization of large artery disease is recognized as the main cause of ischemic stroke in the world, considering all countries, its global burden is widely underestimated
Regardless of the role of metabolic and/or inflammatory factors on the aetiology of the intracranial stenosis in this case, the course of the vessel disease was unexpected and previously unreported in the literature at our knowledge. It has been known since several years that ischemic stroke related to large intracranial arteries steno-occlusion has a poor prognosis, if the vessel recanalization does not occur within 1 hour [1]
The neurological evaluation reported a mild aphasia with prevalent anomic and paraphasic alterations, without motor deficits; the National Institute of Health Stroke Scale (NIHSS) score was 1
Summary
It has been known since several years that ischemic stroke related to large intracranial arteries steno-occlusion has a poor prognosis, if the vessel recanalization does not occur within 1 hour [1]. The neurological evaluation reported a mild aphasia with prevalent anomic and paraphasic alterations, without motor deficits; the National Institute of Health Stroke Scale (NIHSS) score was 1 At this point an urgent neurosonological study was performed both in the extracranial and intracranial vessels, showing a normal appearance of the extracranial carotid and vertebral axis and a suspected left distal M1 MCA stenosis, by using unenhanced Transcranial Colour-Coded Sonography (TCCS). A left M1-M2 MCA occlusion was diagnosed, with a large early branch, arising from the M1 MCA segment just before the stop (Figure 1, row C) This findings were really unexpected and a brain MRI and MRA were performed, showing respectively the lack of new brain parenchymal lesions with a normal perfusional status, and an absent flow signal in the left M1M2 MCA. Neuropsychological testing was normal and the patient was treated with a Serotonine Selective Reuptake Inhibitor, because of an associated post-stroke depression
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