No abstract

A previously healthy 16-year-old girl presented to a local emergency room with intense headache, severe nausea, and vision loss. The week before, she had intermittent headaches and nonspecific visual changes that resolved with acetaminophen or NSAIDs and rest. On admission to the hospital, she was found to be extremely hypertensive and had bilateral occipital hypodensities consistent with infarcts on noncontrast computed tomography. On transfer to the regional pediatric hospital, she had severe vision loss (light perception only), and magnetic resonance imaging showed bilateral infarctions, especially affecting the posterior circulation and occipital lobes (Figure 1). Magnetic resonance perfusion revealed severe bilateral hemispheric hypoperfusion, and magnetic resonance imaging fluid-attenuated inversion-recovery sequence demonstrated linear hyperdensities along sulci-the ivy sign often seen in moyamoya. Cerebral angiography revealed complete occlusion of the bilateral internal carotid arteries distal to the anterior choroidal arteries with dense moyamoya collaterals and extreme attenuation of the posterior cerebral artery circulation, also with moyamoya collaterals (Figure 2). Biochemical, hemostatic, and genetic evaluations were normal, with the exception of a significantly elevated D-dimer level (1850 ng/ mL; normal range: 0-543 ng/µL). Apart from her mother experiencing a deep venous thrombosis during pregnancy, the patient's family history was unremarkable for coagulopathies. The patient was admitted to the pediatric intensive care unit, where she was started on aspirin. Deterioration in her neurological examination coincided with a relative decrease in blood pressure. Her neurological examination improved with pressors, which were eventually weaned. The patient remained on daily aspirin and had no subsequent strokes, but her cortical blindness persisted. The patient was discharged home with follow-up for surgical planning. Several weeks after the patient's initial stroke, her neuroophthalmologic testing remained notable for light-only perception in both eyes. Both pupils were 4 mm and reactive on

Endometriosis is a relatively common condition among women, and pancreatic endometriosis has been reported on rare occasions. Such pancreatic lesions are difficult to diagnose and distinguish from other cystic lesions of the pancreas preoperatively. This report describes a case of pancreatic endometriosis in a 51-year-old female patient. Imaging demonstrated an enlarging cyst with findings concerning for a mucinous neoplasm. The patient underwent robotic distal pancreatectomy and splenectomy. Histopathology revealed an endometriotic cyst. Pancreatic endometriosis can be difficult to distinguish from other lesions of the pancreas. Surgical resection should be undertaken in cases where malignancy is suspected.