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22. European Stroke Conference 165 Interesting and challenging cases Bilateral dissection of carotid arteries as a first sign of unknown fibromuscular dysplasia in a young male A.D. Athanasopoulos1, V Fardis2, E Papageorgiou3, M Gryllia4, S Tsiara5 Neurology department of G.N.A “G.GENNIMATAS”, Athens, GREECE1, Neurology depart-ment of G.N.A “G.GENNIMATAS”, Athens, GREECE2, Neurology department of G.N.A “G.GEN-NIMATAS”, Athens, GREECE3, Neurology department of G.N.A “G.GENNIMATAS”, Athens, GREECE4, Neurology department of G.N.A “G.GENNIMATAS”, Athens, GREECE5 Background: A young male (34) comes to the ED - conscious with left hemiparesis and blurred vi-sion of the right eye presented at awakening. His individual and family medical history for cerebro-vascular events, hypertension and connective tissue disorders is free. Drug abuse was denied. The patient reported that he lifted heavy object under considerable pressure 24 hours before .His vital signs were normal. No malformations of the body or skin were reported or detected. Brain CT scan was performed which showed infract of RMCA territory. He underwent duplex ultrasound of neck arteries that showed right internal carotid artery dissection. The myocardial ultra sound and ECG were normal. His chest X-ray, biochemical and blood tests were also normal. Brain CTA was also performed which showed bilateral dissection of carotid arteries and severe stenosis of RVA. These findings were confirmed with magnetic resonance and digital subtraction angiography and addition-ally these tests gave the diagnosis of FMB. Laboratory findings were negative for connective tissue disease or vasculitis. For 4 days he received i.v. heparine 22.000 IU and subsequently ASA He re-covered within 3 days and he was released after 7 days Conclusion: Internal carotid artery dissection is a common cause of stroke in young patients with-out vascular risk factor, but bilateral is uncommon. Whilst some dissections occur in patients with known genetic predisposing factors ( Marfin’s syndrome, Ehlers-Danlos syndrome, polycystic kid-neys, FMB, Lob stein syndrome) many are either caused by direct neck trauma or precipitated by an event involving head or neck movement. FMB often occurs in young Caucasian women and as a first symptom is hypertension. So bilateral dissection as a first symptom of FMB in an asymptomatic man patient is even less common. 370 © 2013 S. Karger AG, Basel Scientific Programme 166 Interesting and challenging cases Successful repeated IV thrombolysis (r-tPA) in a nonagenarian F. Chaudery1, N.M. Lobo2, F. Gergely3, T. Webb4, I. Balogun5, D. Hargroves6 William Harvey Hospital, Ashford, Kent, TN24 0LZ, Ashford, UNITED KINGDOM1, William Harvey Hospital, Ashford, Kent, TN24 0LZ, Ashford, UNITED KINGDOM2, William Harvey Hos-pital, Ashford, Kent, TN24 0LZ, Ashford, UNITED KINGDOM3, William Harvey Hospital, Ash-ford, Kent, TN24 0LZ, Ashford, UNITED KINGDOM4, William Harvey Hospital, Ashford, Kent, TN24 0LZ, Ashford, UNITED KINGDOM5, William Harvey Hospital, Ashford, Kent, TN24 0LZ, Ashford, UNITED KINGDOM6 Trial evidence from IST-3 now supports the use of IV r-tPA for stroke in patients over the age of 80. Concerns about possible increased risk of haemorrhage and reduced benefit in older people with stroke continue however, especially in significantly older individuals. We report a 94 year old lady who presented twice in one year with contralateral acute ischaemic strokes and was successfully treated with IV r-tPA on both occasions. A 94 year old lady initially presented with right-sided facial droop and expressive dysphasia (NIHSS 8). CT perfusion showed evidence of mismatch within the left middle cerebral artery territory and frontal lobe region. She was treated with IV r-tPA at a standard dose of 0.9 mg/kg with good effect (NIHSS 0 on discharge). Her resting ECG was sinus. One year later she re-presented, this time with left-sided weakness and drift. Initial examination re-vealed a mild deficit (NIHSS 2). She was admitted to the acute stroke unit for close observation. 8 hours later she deteriorated with the weakness in her left arm becoming more evident. CT perfusion demonstrated a clear mismatch suggestive of a right MCA ischaemic penumbra. IV r-tPA at a dose of 0.9 mg/kg was again given with good effect and no significant complications (NIHSS 3 on dis-charge). The patient was discharged with clopidogrel and simvastatin as secondary stroke prevention, pend-ing extensive investigations into possible underlying paroxysmal AF with repeated 7 day heart mon-itoring. This case demonstrates that repeated IV r-tPA may be carried out successfully in nonagenarians. The benefit of multimodal cranial imaging, in this case CT perfusion and angiography, to aid selec-tion for IV r-tPA treatment appears promising but requires further evaluation.


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