22. European Stroke Conference 608 © 2013 S. Karger AG, Basel Scientific Programme 28 Interesting and challenging cases SMART: a Reversible Stroke Mimic M. Bhandari1, M. Ingle2, S. Khan3, A.C. Pereira4 Department of Neurology, St. George’s Hospital, London, UNITED KINGDOM1, Department of Neurology, St. George’s Hospital, London, UNITED KINGDOM2, Department of Neurology, St. George’s Hospital, London, UNITED KINGDOM3, Department of Neurology, St. George’s Hospi-tal, London, UNITED KINGDOM4 Background A 50 year- old estate agent presented to the Stroke Unit with abrupt onset blindness (perceiving only movement) and disorientation. He was surprisingly able to eat, drink and manoeuvre round the ward without mishap. The difference in expected and observed visual behaviour suggested a psychogen-ic problem. He had suffered a similar but milder attack a year previously where migraine headache predominated. He suffered from episodic migraine with visual aura and had one seizure in the past. In childhood, he survived acute lymphoblastic leukaemia treated with chemotherapy and crucially, prophylactic whole brain radiotherapy. Methods Blood tests, LP, & VEP were normal. EEG identified non specific cerebral dysfunction. MRI showed occipital cortex gyriform swelling and restricted diffusion, suggesting a potentially vascular (vasospasm) pathological process. However, CT angiography was normal, effectively excluding a post radiation vasculopathy. Results Complete recovery occurred over 12 days with supportive care and Topirimate. The MRI changes resolved. When recovered, he recalled being aware of his surroundings in an extraordinary halluci-natory, dystopic, unreal world. Disorientation and colour hallucinations predominated. He thought he had been kidnapped. Conclusion The diagnosis here is ‘Stroke-like Migraine Attacks after Radiation Therapy (SMART)’, a rare long term consequence of brain irradiation. Radiotherapy commonly causes a vasculopathy but here the pathology was reversible metabolic cortical oedema. This probably decreased the excitability thresh-old of neuronal ion channels causing spreading depression similar to that previously described in hemiplegic migraine. FIGURE The figure shows the T2 and FLAIR images of a representative slice during the illness and after re-covery. Notice the resolution of the cortical oedema in the occipital cortex. 27 Interesting and challenging cases Acute ischaemic stroke in a male-to-female transsexual using high dose oestrogen therapy. G. Cumming1, J. Godfrey2 Crosshouse Hospital, Kilmarnock, UNITED KINGDOM1, Crosshouse Hospital, Kilmarnock, UNITED KINGDOM2 Background: Stroke associated with oestrogen use is uncommon. We present a patient with a middle cerebral artery (MCA) stroke who had been receiving oestrogen therapy for 9 years after gender re-assignment surgery. No conventional vascular risk factors were present. Case report: A 41 year old male-to-female transsexual patient presented with sudden onset of right hemiparesis and right facial droop. Examination also confirmed a right visual field deficit and a marked expressive and receptive dysphasia. Her CT brain showed a thrombosed left MCA and MRI head with DWI confirmed an acute left MCA infarct. She had a normal carotid MR angiogram. Laboratory tests showed a normal full blood count, coagulation screen, bone biochemistry, electro-lytes, liver and thyroid function tests. She had a glucose of 5.0, total cholesterol of 6.8 and ESR of 6. Her electrocardiogram was sinus rhythm and her CXR and echocardiogram were normal. A throm-bophilia screen was normal. Her 24 hour cardiac monitor was normal. Her HIV status was negative. She underwent Gender Reassignment with feminising genitoplasty in 2003 and was taking oral oes-trogen, Prognova (oestradiol valerate) 2mg TID. She has no family history of vascular disease and is an ex-smoker. She has Hodgkin’s lymphoma diagnosed in December 2011 and underwent AVBD chemotherapy. She was on dexamethasone 2mg daily. Conclusion: Oestrogen therapy after gender reassignment surgery should be considered as a cause of stroke. Oestrogens may be associated with vascular disease in defined groups of patients and dos-es used by male-to-female transsexuals are about 2-3 times greater than those of standard hormone replacement therapy. Transsexual patients treated with hormone therapy should have their vascular risk factors assessed and addressed and should be monitored for venous thrombotic, emboli and cerebrovascular events.
Karger_ESC London_2013
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