Acute progressive stroke with middle cerebral artery occlusion caused by idiopathic hypereosinophilic syndrome: a case report

Abstract

Background Idiopathic hypereosinophilic syndrome (IHES) is associated with various organ system dysfunctions. Neurologic abnormalities have been previously noted in this syndrome. Cerebral infarction secondary to occlusion of large cerebral artery is rarely reported. Here we described a patient with IHES presented progressive multiple cerebral infarctions caused by bilateral middle cerebral artery occlusion. Case presentation A 55-year-old Chinese woman presented to our hospital with acute onset of right limbs weakness and slurred speech. Laboratory tests showed a significant eosinophilia of 5.29 × 109/L (normal, < 0.5), 49.9% of leukocytes. Brain magnetic resonance imaging (MRI) revealed multiple acute cerebral ischemic lesions. Magnetic resonance angiography (MRA) demonstrated stenosis in horizontal segment of right middle cerebral artery. A pretibial skin biopsy revealed eosinophilic infiltration around the capillaries in deep dermis and adipose tissue. The patient was given oral dual anti platelet agents and intravenous methylprednisolone. However, one week later, the patient presented significant neurological deterioration with right-sided hemiparesis and totally motor aphasia. Brain MRI and computed tomography perfusion (CTP) demonstrated new acute cerebral ischemia in left hemisphere. Digital subtraction angiography (DSA) revealed left middle cerebral artery completely occluded. The patient received a high-dose of intravenous methylprednisolone 500 mg per day and the eosinophil count quickly fell to normal within 2 days. She was transferred to a rehabilitation center and her neurological symptoms improved with modified Ranking Scale from 4 to 2. Conclusions IHES is one of the rare causes of acute ischemic stroke with large cerebral artery occlusion. An early high-dose of corticosteroids therapy should be considered in cases of IHES patients. Our case study is benefit to clinical diagnosis and treatment of cerebral infarction with IHES.

Hypereosinophilic syndrome presenting as acute ischemic stroke, myocardial infarction, and arterial involvement: A case report

“…Chang et al [ 10 ] reported a 43-year-old male patient with HES presenting with ischemic stroke and segmental stenosis of the right posterior cerebral artery resulting from direct eosinophilic toxicity. Li et al [ 11 ] described a middle-aged woman with idiopathic HES presenting with bilateral middle cerebral artery occlusion and progressive multiple cerebral infarction. Our patient suffered from multiple arterial vascular damage involving the left common carotid artery, vertebral arteries, posterior cerebral artery, and coronary artery.…”

Mechanisms and Neuroimaging Patterns of Hypereosinophilia-related Ischemic Stroke: A Narrative Review through Three Cases

“…We report three patients with stroke as presenting symptom of hypereosinophilia from three different causes, two of them fulfilling the criteria for HES. The pathophysiological mechanisms of stroke in the context of hypereosinophilia may produce a composite pattern on neuroimaging studies, ranging from a large vessel occlusion (or territorial) pattern [8] to multiple scattered lesions in several different vascular territories, and in particular in border zones [5,6,9,11]. These last ones may be considered a hallmark of HESrelated stroke, in particular without evidence of hemodynamic unfavorable conditions, being caused by a direct toxic effect of the increased number of circulating eosinophils to the endothelium of small cerebral vessels.…”

“…Neurologic involvement is not uncommon in HES and it typically consists in peripheral neuropathy, encephalopathy, and stroke [3]. Previous reports of stroke in the context of HES involved either large vessel occlusion (or territorial) pattern and border zone pattern; the pathophysiological mechanisms, even if not completely understood, might be related to hypercoagulable state, probably due to the cytotoxic effect of eosinophil-produced mediators and subsequent endothelial damage and thromboembolism caused by cardiac involvement [4,5,6,7,8,9]. In this setting we report three cases of ischemic lesions as the first main clinical expression of different types of HES.…”

Imaging patterns of cerebral ischemia in hypereosinophilic syndrome: case report and systematic review

“…An intracardial thrombus was found in 25% of patients, which on its own does not explain the border zone distribution of ischemia. Several mechanisms were proposed to cause ischemia in HES patients, namely direct eosinophile-induced endothelial toxicity and subsequent local thrombogenicity [ 6 ], eosinophilic vasculitis [ 7 ], prothrombotic state and hypercoagulability [ 8 ], and/or cardiac microembolism [ 9 ]. An interesting mechanism which may explain the border zone pattern was proposed by Aida et al [ 10 ].…”