SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Moyamoya disease is a rare chronic cerebrovasculopathy of unknown etiology characterized by progressive stenosis of the internal carotid artery and it is main proximal branches. This stenosis leads to growth of small collateral circulation which look like “Puffs of Smoke” known as Moyamoya in Japanese (1). Moyamoya disease was first described in Japan by Takeuchi and Shimizu in 1957(2). CASE PRESENTATION: Our patient is a 41-year-old Caucasian female who presented to our emergency department with new onset of left sided facial droop, left arm weakness, and inability to speak. The patient has a history of Seizure disorder and Moyamoya disease with chronic right MCA stenosis who is currently on Aspirin and Plavix. At time of arrival, vital signs were noted to be stable except blood pressure being elevated. Brain CTA was done which showed chronic narrowing of the right MCA and also what appeared to be an acute embolic event in the right ACA which was felt to be the cause of her symptoms. Review of other labs showed no significant abnormalities. The patient underwent a Cerebral Angiogram but a mechanical thrombectomy was unsuccessful due to report small caliber of the Right A1 segment. Brain MRI was done and confirms acute infarction in the Right posterior frontal cortex along the margin of the primary motor cortex, which is the watershed of the two collateral circulations supplying the Right hemisphere. We treated the patient mainly symptomatic by prevent hypoperfusion by keeping systolic blood pressure around 170S mmHg, continuing aspirin, and switched Plavix to Ticagrelor. DISCUSSION: Moyamoya disease has been recognized as a cause of ischemic and hemorrhagic strokes. It usually exhibits recurrent transient ischemic attacks (TIA) or infarction in the territory of the ICA. AS in our case patient presented with hemi-paresis and expressive aphasia. Even though MRI angiography is used to confirm the diagnosis and to see the anatomy of the vessels involved, CT angiography can also be used to see intracranial stenosis suggesting Moyamoya (3). The process of blockage, once it begins, tends to continue despite any known medical management unless treated with surgery. Since surgery is the only viable option, revascularization procedures are gaining importance as a primary treatment for Moyamoya. A good option for adult symptomatic patients is superficial temporal artery-middle cerebral artery bypass or middle meningeal artery to middle cerebral artery bypass (3). The estimated rate of symptomatic progression is only 2.6% after surgery according to a meta-analysis involving 1156 patients (4). CONCLUSIONS: This case highlights the importance of understanding Moyamoya disease and its prognosis. Moyamoya is a very progressive disease and should have been recognized as a cause of ischemic and hemorrhagic strokes. Surgical revascularization should be considered to prevent complications, mainly stroke. Reference #1: Janda PH, Bellew JG, Veerappan V. Moyamoya disease: case report and literature review. J Am Osteopath Assoc. 2009;109(10):547–53. Reference #2: Takeuchi K. Hypoplasia of bilateral internal carotid arteries. Brain nerve. 1957;9:37–43. Reference #3: Gudepu RK, Qureshi MA, Qureshi IA, Rao L. Case Report: A case report of Moyamoya disease in a 36 year old African American woman. F1000Research. 2014;3. DISCLOSURES: No relevant relationships by MAHMOUD ABOUZID, source=Web Response No relevant relationships by Waiel Abusnina, source=Web Response No relevant relationships by Yonas Raru, source=Web Response No relevant relationships by Fuad Zeid, source=Admin input