Delayed-onset cerebral infarction after cosmetic facial injection using hyaluronic acid

Abstract

A 25-year-old woman without any known systemic disease reported experiencing a sudden onset of right eye blindness after hyaluronic acid injection into the nose, and a delayed course of left upper limb weakness developed 9 hours later. Initially, the patient was brought to our emergency department for right eye blindness. The fundus revealed right central retinal artery occlusion (Figures 1A and 1B). Nine hours later, acute onset of left upper limb weakness with muscle power Grade 4 in the left elbow, wrist, and hand and Grade 5 in the left shoulder and other three extremities was noted. Brain magnetic resonance imaging (MRI) revealed many small acute infarcts, mainly in the right middle cerebral artery territory (Figure 1C). The survey of young stroke was within the normal limit, except transesophageal echocardiography showed an atrial septal defect (ASD) with a size of 2.7 cm. Finally, the visual loss and left upper limb weakness remained after discharge. Cosmetic facial injection using hyaluronic acid as a filler is often performed because of its convenience, ease