P 166 Case presentation – apoplex due to partial occlusion of the medial cerebral artery with sinistral hemiparesis, word-finding disorder, memory impairment and writing disorder

Abstract

Anamnesis S. had helped her sister to move. She experienced dizziness and everything went black. She choked on something to drink. Then she went out on the balcony, fell due to weakness of her right leg, and she could not move the right half of the body (right arm, right leg). The right angle of his mouth hung slightly with saliva, and she slurred her speech. She was put down. Then she was unconscious for about 5 min and was hospitalised by the emergency physician with suspicion of epilepsy. Additional anamnestic data collected later: Was frequently beaten by a violent friend. After separation, day-hospital and then stationary child and adolescent psychiatric treatment for 3 months for depression and self-injury followed. HWS- and BWS-distorsion, left-convex rotation-scoliosis in the proximal BWS-region, broad-base discrete disc protrusion in the disc compartment C5/ 6 with contact to the thekal tube with initial spinal constriction, diagnosed after an accident on trampoline 9 months ago by MRT. Varicella with 3 years. Drug history: fluoxetine for about 2–3 weeks, melatonin for 2 months, Jubrele since about 1 year. Clinical findings 14 year old girl, in a somnolent state, eyes open from time to time, but can not adequately speak. Coarse motor system normal, fine motor system disturbed. Cannot write. Left forearm with fresh and old scratches. Sensorium intact. Reflexes slowed. Other clinical examination normal. With suspected apoplex because of incomplete hemiparesis an MRI was immediately performed, which showed a fresh ischemia in the region of the artery cerebri media on the left side, a disturbed perfusion in the basal ganglia and in the insular region, swelling of the frontal and frontoparietal brain region and an incomplete occlusion of the artery cerebri media, suggesting a hemorrhagic transformation and occlusion of peripheral vessels. A standard lysis therapy with Actilyse followed by secondary prophylaxis with thrombocyte aggregation inhibitors was performed. Duplex sonography showed a high-grade ACM stenosis on the left in the M1 segment. After 20 h, S. became more somnolent and showed no linguistic activities at the time. A new MRI examination showed a high-grade stenosis in the M1 segment on the left and peripherally a markedly reduced perfusion with increasing infarction. On the third day of treatment rudimentary communication returned. On the 4th day duplex sonography showed worsening of hemodynamics in the left arteria cerebri media and the EEG showed a light focus on the left temporal side, no signs of hyperexcitability. Then development of complete paresis of the right arm and progression of aphasia. The MRI proved an increase in the ischemic areas in the region supplied by the left arteria cerebri media and showed a frontoparietal substantial ischemic area as well as changes in the vascular area, which would be compatible with vasculitis. Laboratory chemistry: no elevated inflammation parameters, no coagulation disorder, no signs of an autoimmune process. Since the radiologists of the MHH Hanover considered an interventional therapy to be possible, but wanted to see the patient on the spot, the patient was transferred with helicopter to Hannover in a stable condition. Unfortunately, no additional interventional therapy was possible.