Mowzoon N Flemming Kd Neurology Board Review an Illustrated Study Guide Mayo Clinic
BMJ Case Rep. 2019; 12(2): e228029.
Case Report
Stroke in a young man: a late complexity of radiations therapy
Zhaozhi Jiang
1Graduate Medical Pedagogy, Orange Regional Medical Center, Middletown, New York, USA,
Mitchell Elkind
2Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, United states,
Matthew Lucky
3Graduate Medical Educational activity, Orange Regional Medical Eye, Middletown, New York, USA,
Zoltan Fekete
4Crystal Run Healthcare, Rock Hill, New York, Usa,
Abstract
This 37-year-erstwhile human being presented with left sided facial warmth and numbness associated with new sudden-onset correct hemiparesis. The patient first developed sudden numbness of his left lip and warmth in left ear which travelled to the balance of left face. His past medical history was significant for hypertension, Hodgkin lymphoma treated with radiations therapy at the historic period of 10, and sleeve gastrectomy for obesity 1 twelvemonth ago complicated by bilateral ischaemic cerebral infarctions with residual left hemiparesis. No astute infarcts were found on MRI. Transesophageal echocardiography revealed a circuitous atheroma about the sinotubular junction in ascending aorta.
Keywords: stroke, cardiovascular medicine, radiotherapy
Groundwork
Stroke is the fifth leading cause of decease and the leading cause of long-term disability in the The states. Most, three-quarters of all strokes occur in people over the historic period of 65. Stroke in young patients is relatively rare but increasing.i One of the reasons for stroke in the young can be a belatedly complication of radiations therapy used in treating cancers, such every bit Hodgkin lymphoma.ii We describe a case of stroke in a young survivor of Hodgkin lymphoma treated with radiation therapy at the age of 10.
Case presentation
A 37-year-former human being presented with complaints of left sided facial numbness and sensation of warmth in left face associated with new right-sided hemiparesis. He was working at his computer when he developed sudden numbness of his left lip and simultaneous feelings of right sided weakness. He so began to feel a sensation of warmness of his left face, starting in the ear and travelling to the rest of the confront. On neurological examination, he had correct-sided and left-sided weakness, with no changes in speech communication or mentation. The patient also reported a rash on the abdomen and right elbow for 1 calendar week; he had been in urgent intendance and started on a prednisone taper. He was besides diagnosed with colitis afterward left abdominal pain and was taking ciprofloxacin and metronidazole.
The patient had a history of chronic essential hypertension, hypothyroidism and Hodgkin lymphoma of left side of neck without metastasis at the age of 10, which was treated with radiation of neck and breast equally well equally splenectomy; and sleeve gastrectomy complicated by bilateral ischaemic strokes 1 year ago with balance left arm and leg weakness. He had 180 lb weight loss afterward surgery. Patient was on aspirin 81 mg daily and atorvastatin 40 mg daily since the stroke.
Investigations
On inflow, a head CT without contrast was performed, which revealed 3 chronic infarcts in the right MCA distribution and a chronic infarct involving the left medial occipital cortex, with no acute lesion.
Brain MRI revealed multiple wedge-shaped transcortical areas of encephalomalacia and gliosis bilaterally in the inferolateral right frontal lobe, right posterior frontal lobe, right parietal lobe and medial left occipital lobe, which correlates with his previous CVA (figure 1). MRA of neck showed no left internal carotid avenue stenosis. ECG showed normal sinus rhythm, normal intervals and no ST or T wave changes. Continuous telemetric monitoring of the patient demonstrated normal sinus rhythm throughout the hospitalisation. Transthoracic echocardiography revealed balmy aortic stenosis with mitral valve calcification. Transoesophageal echocardiography (TEE) institute a complex atheroma, large, ulcerated and mobile, measuring ix-mm thickness most the sinotubular junction in ascending aorta. Hypercoagulability evaluation, including antiphospholipid antibodies, was negative.
Differential diagnosis
The exact crusade of his stroke-like symptoms was unclear. I possibility was cardiogenic ischaemic stroke. Some other possibility was hypercoagulable country due to history of lymphoma. The third possibility was aortic stenosis secondary to radiations therapy. Seizure and migraine were the other two possibilities. SMART syndrome,3 iv which stands for stroke-like migraine attacks afterwards radiation therapy, can also be a possible diagnosis but unlikely since the patient had no headache, only received chest radiation, no brain radiations therapy and the MRI of the brain without and with contrast revealed onetime chronic strokes and not SMART syndrome.
Treatment
The patient was given aspirin 325 mg and his symptoms resolved within a couple hours. The patient started rivaroxaban and rosuvastatin for secondary prevention of cardioembolic stroke after complex aortic atheroma was found on TEE.
Outcome and follow-up
The patient was readmitted 2 months afterwards with identical complaints of left facial numbness. MRI of the encephalon again revealed no astute stroke. Patient was discharged on aspirin 81 mg daily, rivaroxaban twenty mg daily and rosuvastatin 5 mg daily. Anticoagulation was subsequently stopped. Electroencephalogram was done to exclude seizures, and showed no epileptiform abnormalities. He started levetiracetam to prevent possible seizures.
Discussion
Young adults business relationship for 10%–15% of all stroke cases.five Approximately 20%–30% of cerebral infarctions in a general population are the event of a cardioembolic source, while approximately 15%–20% of strokes are secondary to extracranial big vessel disease.6 Large-artery atherosclerosis has been shown to exist an infrequent crusade of ischaemic stroke in young adults, bookkeeping for less than 10% of cases.5 Other common reasons for stroke in young adults include pocket-sized vessel illness, hypercoagulability and miscellaneous other causes. The nearly common risk factors include smoking, dyslipidaemia and hypertension.vii Other less common causes of stroke in young adults include non-atherosclerotic angiopathies, hematologic conditions, genetic diseases and inflammatory and infectious atmospheric condition.v
Our patient was establish to have a complex atheroma measuring 9-mm thickness near the sinotubular junction, which is possibly a belatedly complication of radiations. Other chance factors for atheroma include smoking, hypercholesterolaemia, hypertension, obesity and diabetes.
Aortic plaque 4 mm or larger is an contained run a risk factor for ischaemic stroke. Stroke gamble is greater for complex, mobile plaques larger than five mm.6 TEE is the preferred test for diagnosis of aortic atherosclerosis. Although atherosclerosis tin can exist seen in young patients, the clinical presentations are usually not seen until patients are older. Young patients without conventional cardiac take a chance factors who received mediastinal irradiation for Hodgkin lymphoma can nowadays with coronary avenue affliction (CAD) in their 20s.2
Radiation therapy, an essential method to treat Hodgkin lymphoma, helped improved the overall prognosis, but tin can be associated with serious complications. There is a 5- to 17-fold greater risk of cerebrovascular events (stroke or transient ischaemic attack) in patients with head and neck cancer who are treated with RT compared with matched non-RT treated controls.8 A multi-institutional cohort report of more than than 5-year cancer survivors diagnosed between 1970 and 1986 showed survivors of childhood Hodgkin disease are at increased risk of stroke. The incidence of tardily-occurring stroke among Hd survivors was 83.6 per 100 000 person-years, significantly higher than expected range of 10–23 per 100 000 person-years in adults aged 18–44 years in the general population.9 Another retrospective study showed among 415 Hodgkin lymphoma survivors treated with radiation therapy, 42 patients (10.iv%) developed coronary artery disease at a median of 9 years after treatment, 30 patients (vii.4%) developed carotid and/or subclavian artery disease at a median of 17 years after treatment, and 25 patients (6.2%) developed clinically significant valvular dysfunction at a median of 22 years.10 Nevertheless, there is no evidence of aortic disease in the to a higher place studies.
Radiations-induced arterial injury may involve any arteries exposed to radiation. We speculate that in our case, radiation therapy contributed to development of a circuitous aortic atheroma. The exact mechanism of radiation therapy causing aortic atheroma remains unclear. It is widely accepted that neck and chest radiations tin can atomic number 82 to carotid atherosclerosis and coronary atherosclerosis, thus increases the chance of stroke. The review by Xu and Cao suggests endothelial dysfunction, injury and occlusion of vasa vasorum and accelerated atherosclerosis be the virtually likely crusade of carotid stenosis.11 The review past Jaworski et al reveals endothelial dysfunction is a precipitating factor in the evolution of radiations induced cardiac illness.12 The review by Darby et al suggests radiation induced coronary artery disease results from intimal proliferation of myofibroblasts with lipid-containing macrophages forming atherosclerotic plaques.two Radiation induced aortic atheroma, as a process of aortic atherosclerosis, is probable caused by endothelial damage with plaque formation, thus causes embolic stroke. The study past Stewart et al suggests ionising radiations accelerates the development of macrophage-rich and inflammatory atherosclerotic lesions in ApoE−/− mice; lesions developed in the aortic roots of irradiated mice were macrophage rich and lipid filled, whereas lesions in non-irradiated mice were collagenous and but minimal macrophage infiltration.13
Management of cerebrovascular disease associated with radiation-induced vascular injury still needs further study. Testify-based guidelines for the direction of asymptomatic and symptomatic (medium- and large-artery) radiation vasculopathy are lacking.14
In patients who had a stroke with large-artery atherosclerosis or small-vessel affliction, antiplatelet drugs are recommended. Acetylsalicylic acid (ASA) should be a first-choice antiplatelet drug in secondary prevention.5 15 ASA in combination with dipyridamole or clopidogrel monotherapy can also be used as the get-go-line treatment.fifteen The combination of ASA and clopidogrel tin can reduce the take a chance of stroke in the kickoff 90 days and does non increment the risk haemorrhage.xvi
Cheers to Emmanuel Obeng Nketiah MD for doing and interpreting the TEE.
Footnotes
Contributors: ZJ, ME and ZF contributed to the design of the instance study. ZJ drafted the manuscript. ME, ML and ZF revised the manuscript for important intellectual content. ZF contributed to the final approval of the version to be published. ML obtained the informed consent from the patient.
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-turn a profit sectors.
Competing interests: None alleged.
Patient consent for publication: Obtained.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6441249/
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