Rapid Progression of Cerebral Infarction after Intraventricular Hemorrhage in Adult Moyamoya Disease
A healthy 39-year-old woman visited our hospital with sudden headache and a decreased level of consciousness. On admission, she was drowsy with mild tetraparesis [manual muscle testing (MMT) score 4/5] and dysarthria. Her blood pressure was 230/100 mm Hg. Magnetic resonance imaging (MRI) revealed IVH on diffusion-weighted imaging in addition to small cerebral infarction in the bilateral frontal lobe (), and MR angiography revealed bilateral occlusion at the terminal of the ICA (). There was asymptomatic, old cerebral infarction in the left frontal lobe on fluid-attenuated inversion recovery imaging (). No old hemorrhage was detected on T2-star-weighted imaging (). Routine laboratory tests were normal. We diagnosed that ischemic-type moyamoya disease had changed into hemorrhagic-type. After admission, the patient underwent conservative treatment with edaravone, a free radical scavenger. Anti-platelet therapy was not performed because of the possibility of progression of IVH. Because there was old cerebral infarction, dehydration might occur ischemia. Hence, hyperosmotic agent such as glycerol was not given. To maintain adequate cerebral hemodynamics, her systolic blood pressure was kept at 180-200 mm Hg, and she received hypervolemia and hemodilution. Her body temperature was around 37.0℃, and her urine output was adequate. Nevertheless, on the second hospital day, the right hemiparesis deteriorated (MMT score 1/5) with motor aphasia, and the infarction area continued to expand without progression of IVH (). On the 7th day, the left hemiparesis deteriorated (MMT score 1/5) and she became apallic. On the 14th day, repeated MRI revealed massive cerebral infarction in the bilateral frontal lobes and expansion of the cerebral infarction stopped at last ().