Severe hyperthermia caused by four-vessel occlusion of main cerebral arteries

[A 39 years old woman responding to modafinil with bilateral hypothalamic lesion associated with hyperthermia and hypersomnia: a case report]

A 39 years old woman was admitted to our hospital with a status epilepticus, with high fever of 41°C. Magnetic resonance Imaging (MRI) revealed high signal intensities of both sides of thalami and hypothalami in T2 weighted and fluid attenuated inversion recovery (FLAIR) images. A needle biopsy of the thalamic lesion was consistent with neuromyelitis optica spectrum disorder although her serum antibody to aquaporin-4 was negative. The level of orexin in celebrospinal fluid (CSF) was reduced. She presented hypersomnia, which didn't improve even after intravenous methylprednisolone 1 g daily for 3 days. Administration of oral modafinil extended her waking time. There is a number of reports about neuromyelitis optica (NMO) with hypothalamic lesions. We report this case as important suggestion of treatment of these cases.

Occlusion of all aortic arch great vessels: acute revascularization to perform endovascular stroke therapy

BACKGROUND

We present a case of a patient with a left-sided stroke and occlusion of all aortic arch great vessels who was treated successfully with endovascular intervention followed by delayed cardiothoracic revascularization.

CASE REPORT

A 46-year-old man presented with acute onset of dense right hemiparesis, facial droop, and aphasia with an initial National Institute of Health Stroke Score of 15. The patient was taken for emergent angiography after failing intravenous tissue plasminogen activator thrombolysis. Dedicated angiography of the aortic arch revealed occlusion of all great vessels, including the right brachiocephalic, left common carotid, and left subclavian artery. Delayed arterial filling of the right brachiocephalic and left subclavian artery by aberrant collaterals was seen. More distally, flow into the bilateral subclavian arteries, right common carotid artery, and left vertebral artery was appreciated. Serial balloon angioplasty of the left common carotid artery origin reconstituted flow. Subsequent selective angiogram of the left internal carotid artery revealed a proximal middle cerebral artery occlusion. Intra-arterial injection of tissue plasminogen activator followed by mechanical thrombectomy and intracranial stenting restored flow in the middle cerebral artery. Two months later the patient underwent aortic arch reconstruction with bifurcated graft to the brachiocephalic artery and left common carotid artery. At 1-year follow-up, the patient's examination revealed almost complete resolution of right hemiparesis with minimal hand weakness and mild expressive aphasia.

CONCLUSIONS

We report a rare case of occlusion of all aortic arch great vessels. Combined endovascular intervention and surgical revascularization resulted in an excellent durable outcome.