Welcome to the WSC 2022 Interactive Program

Background and Aims

Introduction :

Behcet's disease (BD) is a multisystem relapsing inflammatory disorder. Neurological involvement is well known but ischaemic stroke is unusual.

Methods

Case description :

A 42-year-old male patient with hypertension, obstructive sleep apnea syndrome, chronic sinusitis, presented with acute left hemiparesis. Cranial magnetic resonance (MR) imaging showed a right junctional anterior stroke and multiple segmental stenosis of the arteries of the polygone of Willis were seen on angiography. There was no clinical or serological evidence in favour of cerebral vascularitis. One year after, he developed recurrent oral and genital aphthosis, pseudofolliculitis and erythema nodosum. A diagnosis of BD with cerebral vasculitis was made and immunosuppressive therapy was started.

Results

Discussion :

Neurological involvement in BD has two common features: parenchymal involvement and non-parenchymal involvement like intracranial hypertension, sinus thromboses and aseptic meningitis. BD has the propensity to affect the venous rather than the arterial side and can rarely lead to cerebral vasculitis.

Conclusions

Conclusion :

BD should be considered in young patients who had brain infarction and cerebral vasculitis.

Background and Aims

Sjogren’s syndrome (SS) is a multi-systemic autoimmune disorder with a myriad of clinical presentations.

Methods

We report a rare case of acute ischaemic stroke as the sole initial presentation of Sjogren’s syndrome with secondary antiphospholipid syndrome (APS).

Results

A previously well 45-year old Chinese female was admitted for acute onset right hemispheric syndrome. Magnetic Resonance Imaging (MRI) of the brain showed a right middle cerebral artery (MCA) infarct (image 1). Further stroke evaluation revealed a raised ESR(75mm/hr), positive ANA, and markedly elevated anti-Ro antibodies(185RU/ml). Lupus anticoagulant was strongly positive and anti-cardiolipin antibodies were elevated (46GPL units). She was diagnosed with Sjogren’s syndrome with secondary APS. She was started on anticoagulation and hydroxychloroquine, remained well and was transferred to a rehabilitation facility.

Interestingly, the CTA and MRA showed moderate to severe stenosis of the right carotid siphon (image 2) with concomitant mild stenosis of the right common carotid dartery (CCA) and MCA and its branches. MRI Black blood vessel-wall imaging with contrast done about a week later showed resolution of the stenoses of the right CCA and MCA but persistent carotid siphon stenosis remained. No enhancement of the vessel walls was noted. Cerebrospinal fluid studies showed mild pleocytosis (7 cells) attributable to the infarction. These findings indicate the unusual presence of concomitant large vessel vasculopathy which could contribute to the mechanism of stroke in Sjogren’s syndrome with APS.

Conclusions

Cerebrovascular disease may be the initial presenting feature of Sjogren’s syndrome. Large vessel vasculopathy may be present in the context of Sjogren’s syndrome with APS.

Background and Aims

Intracranial bleeding increased mortality among patients diagnosed with hematologic malignancy. Low platelet count associated with bone marrow failure increased the risk of hemorrhagic complications. The role of blood count for predicting intracranial bleeding is still poorly understood. This study investigated the association between complete blood count and intracranial bleeding risk in patient with hematologic malignancy.

Methods

Case control study was conducted in General Hospital Dr. Sardjito Yogyakarta from May 2021 to April 2022. 52 patients with low platelet count were selected and divided into two groups, control group and intracranial bleeding group. Demographic data, complete blood count, type of hematologic malignancy and intracranial bleeding incidence during hospitalization were collected. Bivariate analysis with spearman test was performed and followed by multivariate analysis with logistic regression.

Results

From 52 samples, AML was the most type of hematologic malignancy. Intracranial bleeding etiology were intracerebral hemorrhage (76%), subdural hemorrhage (19%) and epidural hemorrhage (5%). Spearman test showed leukocyte count (p 0.000), neutrophil count (p 0.027), eosinophil count (p 0.038), PTT (p 0.011) and APTT (p 0.014) were significantly correlated with intracranial bleeding. Logistic regression test showed higher leukocyte count was associated with higher risk of intracranial bleeding (OR 4.346 [95% CI 0.915-0.997]).

Conclusions

Our study implies leukocyte count had positive correlation and represent a predictor for intracranial bleeding risk in patient with low platelet count caused by hematologic malignancy.

Background and Aims

About one-quarter to one-third of ischemic stroke have no established etiology after standard investigations and are classified as embolic stroke of undetermined source (ESUS). Active malignancy is also an important risk factor of embolic stroke which is important to diagnose and not to be missed. It is increasingly recognized that stroke, particularly ESUS, can be the initial presentation of cancer.

Hereby, we describe a case of ESUS who was subsequently diagnosed to have metastatic gallbladder cancer. Management of this case including antithrombotic for secondary stroke prevention for cancer-associated ischemic stroke will be discussed.

Methods

A 42 year-old lady without past medical history presented sudden onset of blurring of vision. Examination showed left homonymous hemianopia. Blood test on admission showed mildy elevated alkaline phosphatase (ALP) and bilirubin. MRI brain showed right occipital lobe acute infarct and bilateral cerebral scattered infarcts. D-dimer was elevated. Young stroke work up was normal. CT thoracic/abdomen/pelvis showed gallbladder mass with hepatic metastasis.

Results

She was started on low molecular weight heparin (LMWH) and referred to surgeon and oncologist for surgical treatment and chemotherapy. LMWH was subsequently changed to rivaroxaban for stroke prevention.

Conclusions

This case report highlights the importance of high index of suspicion in evaluating young patients with ischemic stroke without significant cardiovascular risk factors. Comprehensive young stroke work up including malignancy screening should be considered. The optimal antithrombotic treatment strategy for cancer-related ESUS remains uncertain, especially because of the high risk of bleeding in these patients. Consequently, there is an need for randomized clinical trials in this population.