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London, United Kingdom 2013 Poster Session Red Cerebrovasc Dis 2013; 35 (suppl 3)1-854 373 170 Interesting and challenging cases A case report: Sneddon’s Syndrome S. Karanovic1, P. Martin2 Addenbrooke’s Hospital, Cambridge, UNITED KINGDOM1, Addenbrooke’s Hospital, Cam-bridge, UNITED KINGDOM2 A 32 year old female developed a net-like rash involving the upper and lower limbs and six weeks later presented with a left hemi-paresis. An episode of right upper limb weakness and speech dis-turbance occurred seven years later. She had a miscarriage in early adulthood and suffers from oc-casional migraines. An MRI confirmed infarction in the MCA territory. She was referred to Adden-brooke’s Hospital for a diagnostic opinion. Cerebral angiography did not reveal ischemia related angiogenesis and skin biopsy showed focal peri-vascular chronic inflammation. This case illustrates Sneddon’s syndrome(SS), first described by Champion and Rook in 1960(1). SS may occur in about 1/2000 stroke patients(2,3). It is characterised by ischemic cerebrovascular le-sions with livedo racemosa, caused by a small vessel arterioapthy. Unlike livedo reticularis, it has a widespread distribution and irregular shape, with characteristic vascular abnormalities(4). The diagnosis is based on skin biopsy, neurological examination and/or MRI(5). The diagnostic val-ue of skin biopsies is illustrated by the histological proof of arteriole occlusion by intimal prolifer-ation( 6). A similar process may be occurring in the cerebral vessels with inflammation, thrombosis and re-canalisaiton(5). However, a negative biopsy does not exclude SS and results should be inter-preted in conjunction with clinical and laboratory findings(7,8). Our patient remains stable on Clopi-dogrel. Therapeutic options include Cyclophosphamide and most recently intravenous thrombolysis has been tried with neurological improvement(9). Further research will be invaluable in clarifying diagnostic and therapeutic guidelines, including the relevance of skin biopsies in early diagnosis, before neurological manifestations occur. As illustrat-ed, it is important to remember that a negative biopsy does not rule out underlying disease. A thor-ough inspection of the skin constitutes a vital part of the examination of younger stoke patients. 171 Interesting and challenging cases An interesting case of gastro-oesophageal reflux occurring post percutaneous gastrostomy (PEG) S. Keeling1, A. Schofield2, P. O’Mahony3, P. Youd4, V. Jones5 St Helier Hospital, London, UNITED KINGDOM1, St George’s Hospital Medical School, Lon-don, UNITED KINGDOM2, St Helier Hospital, London, UNITED KINGDOM3, St Helier Hospital, London, UNITED KINGDOM4, St Helier Hospital, London, UNITED KINGDOM5 A 72 year old female with diabetes, hypertension, and previous stroke presented with a total left an-terior circulation infarct at 2.5 hours. She was not thrombolysed due to severe hypertension, and be-cause of acute infarction on CT scan. CT angiogram and perfusion scan showed occlusion of the left internal carotid artery (ICA) and left middle cerebral artery hypoperfusion so she underwent emer-gency thrombectomy. Follow up CT brain scan showed total left ICA infarct. She remained totally dependent requiring enteral feeding via a nasogastric tube (NGT) without ca-pacity to make decisions about her treatment. At one month post stroke, a plan for percutaneous en-doscopic gastrostomy (PEG) was discussed with family. As they did not agree the patient remained NG fed for almost 3 months despite repeated discussions, opinions from gastroenterology and stroke physicians and exploration of the legal implications of proceeding. Eventually after family agreement and a successful PEG procedure, the patient experienced daily recurrent episodes of vomiting, which had not occurred pre-PEG. A PEG-ogram demonstrated sig-nificant gastro-oesophageal reflux (GOR). The following efforts were made to alleviate this: slower feed rate, medication (acid suppression, anti-emetics, motility agents), percutaneous endoscopic je-junostomy (PEJ) extension and subsequent re-positioning of this, elemental feed. Two PEJ-ograms showed persistence of GOR, although this was less after successful positioning of the tube beyond the D3/4 flexure. Vomiting subsequently resolved almost completely, sufficient to facilitate dis-charge home. The case gave us an interesting dilemma with reluctance from family to proceed with PEG and then the onset of GOR. GOR is reported as occurring in up to 1/8 of neurological patients post PEG (1,2). The case questions whether we should routinely present it as a potential complication to patients and carers. Clinicians may also need to consider that duration of NG feeding could increase the risk (by weakening gastro-oesophageal sphincter function?). Further research into this possible association would be interesting. 1)Gut 2003;52 Suppl7:1-12 2)Ann Intern Med 1981;95:67–68


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