Methods

Based on the history and clinical examinations, stroke due to an embolic event, moyamoya disease as a provisional diagnosis, along with multiple sclerosis and vascular malformation. Since the absence of optic neuritis or specific sensory disturbances further reduces the likelihood of MS, blood investigations and imaging were done to narrow it further. Laboratory tests revealed increased leukocyte count of 13,200/cmm [Normal: 4,000-11,000/cmm] with a neutrophil predominance of 87.2% [ Normal: 45-75%], C-reactive protein (CRP) quantitative was positive (+++), ESR (Capillary Photometric) of 17 mm/hr [Normal: 0-15 mm/hr] and haemoglobin level of 13.3 gm% [Normal: 13.5-18.0 gm%]. Laboratory investigation was sent with serum sodium of 138 mEq/l [Normal: 135-146 mEq] and potassium with 3.8 mEq/l [Normal: 3.5-5.2 mEq]. Her biochemical profile includes alanine aminotransferase (ALT) 59 U/L [ Normal: 7 to 56 units per litre], aspartate aminotransferase (AST) 7 U/L [Normal: 8 to 33 U/L], triiodothyronine (fT3): 4.21 pmol/L (2.4-6.0), thyroxine (fT4): 16.2 pmol/L (9-19), TSH: 1.26 uIU/ml (0.35-4.94), HDL Cholesterol (Direct): 1.0 mmol/L (0.8-1.6) and LDL Cholesterol (Direct): 3.7 mmol/L (less than 4). Additionally, the serological investigation was sent for HIV, Syphilis, Hepatitis B antigen, Hepatitis C antigen and Lupus, antinuclear antibody (ANA), and IFA human epithelial cell line (HEP-2) endpoint titre and was negative. Normal serological tests rule out other causes of vasculitis. Radiological investigation was conducted, and Magnetic Resonance Imaging of the Brain with magnetic resonance angiogram found T2/FLAIR high signal intensity involving the grey and white matter of the right frontoparietal temporal lobe, as well as the right lentiform nucleus, caudate head, and internal capsule, along with a mass effect. (Figure 1) Fronto-parietal temporal lobe as well as lentiform nucleus, caudate nucleus and internal capsule shows diffuse restriction in DWI. (Figure 2) Magnetic resonance venography suggested the right frontal, parietal, temporal lobe, basal ganglia and internal capsule acute/ subacute infarct, mainly proper middle cerebral artery territory with mass effect with loss of flow void in left transverse sinus in T2 image with loss of flow signal. (Figure 3) CT angiogram of the head and neck was sent for further investigation, which suggested a subacute infarct involving the right frontal, temporal, parietal lobe with mass effect and midline shift, abrupt and smooth long segment narrowing of vertical segment of the bilateral internal carotid artery (left> suitable) through its course with collateral vessels around a clinoid segment of the bilateral internal carotid artery and bilateral middle cerebral artery territory- features are likely of vasculitis suggested of MMD. Further, echocardiography and electrocardiography were done, and normal findings were revealed.