P199 – 2588: A case report of left internal carotid artery stenosis in an eight yrs old child with mild hyperhomocysteinemia

Abstract

Objective The connection between hyperhomocysteinemia and cerebral arterial stenosis. Case report: The boy was admitted at 6 yrs at the Neurology division of the Paediatrics Department of the Universitary Hospital Center in Tirana in August 2010, complaining of strong left side headache, vomiting, right side hemyparesis and dysarthria. Normal Physical Examination (except overweight), hemocoagulative tests. Brain angio MR, Brain angiography showed total left internal carotid artery stenosis, right internal carotid artery with normal flux. Acute phase therapy included Warfarin 2 mg per 2 days, Aspirin 2 mg/kg/day, Mannitol 20% i/v, Dexamethasone 0.2 mg/kg/day for four days, Cephtriaxon i/v. The child condition improved without neurological deficits. At dimisson the child continued anticoagulant therapy. In September 2011 the child was admitted in our hospital with prolonged 4 hours aphasia. EEG showed left hemisphere paroxystic anomaly T-P. The child was treated with Carbamazepin 400 mg/day. In March 2014 the child was transferred at “S. Maria della Misericordia Hospital”, Udine Italy. The results of the Hemodynamic Imaging Examination such as Selective Arteriography, Brain MRI, Transcranial Echo Doppler at this hospital confirmed the diagnosis while Brain MRI showed temporal and peritrigonal avascular porencephalic lesion. Complete Blood Count was normal while the analysis of the hemocoagulative tests showed plasma homocysteine level-10.9 mmol/l (Optimal homocysteine levels are considered below 10 mmol/l) and the Complete DNA analysis showed a mutation of the MTHFR (heterozygous state). The neurosurgical consultation decided to perform bypass intra and extracranial between left temporal artery and M4 left media cerebral artery. After intervention the child was conscious with normal hematic control and without neurological deficits. Maintainance therapy: Acetylsalicylic Ac. 75 mg/day, Carbamazepin 400 mg per day. Conclusion Hyperhomocystinemia is one of the causes of arterial and venous stenotic ischemic strokes in children. One of the treatment methods of the stenosis of internal carotid artery consists of internal and extracranial bypass.