Subacute Stroke in a Young Female: A Case of Moyamoya Syndrome Initially Anchoring with Anxiety, 2019, Chaughtai et al

[Andy]

Moyamoya disease is an arterial disorder causing stroke in a young patient. This is a chronic condition causing progressive cerebrovascular disease due to bilateral stenosis and occlusion of the arteries around the circle of Willis, with prominent arterial collateral circulation. It was first described in Japan and subsequently reported in other Asian countries, but infrequently found in the Western world. Interestingly, there may be racial differences in the presentation and subsequent prognostication of treatment of moyamoya. It is diagnosed with classic angiographic findings of stenosis or occlusion of the circle of Willis vessels.

Here, we describe a 28-year-old Caucasian female who was initially diagnosed with anxiety when she presented with symptoms of impaired concentration and fatigue. After the development of remitting slurred speech and facial droop, magnetic resonance imaging and cerebral angiogram yielded the discovery of high-grade stenosis of the origin of the left middle cerebral artery with associated thrombosis in that area. She did well after getting surgery and rehabilitation. This demonstrates a unique presentation of prominent psychiatric symptoms initially thought to be anxiety and culminated in the finding of ischemic stroke in an adult patient with moyamoya.

Open access, https://www.hindawi.com/journals/crim/2019/7919568/

 

[Hutan]

Here, we describe a 28-year-old Caucasian female who was initially diagnosed with anxiety when she presented with symptoms of impaired concentration and fatigue.

It is noteworthy that primarily psychiatric symptoms as the presentation of moyamoya is quite unique. Other case reports have described rare instances of patients initially presenting with anxiety, psychosis, prominent depression, and insomnia [6]. The significance of our case lies in the fact that our patient presented with prominent psychiatric symptoms of impaired concentration, anxiety, and fatigue. She was initially diagnosed as anxiety as her symptoms were associated with a prominent psychiatric component, and she was instructed to follow-up outpatient. She subsequently developed remitting facial droop and slurred speech and had an outpatient MRI done showing evidence of moyamoya.

Since her facial droop and slurred speech were remitting, it is also easy for the provider to miss the fact that it was a stroke. Maheswari et al. mentioned in their case report that their patient had remitting symptoms of hemichorea and hemiparesis which was finally diagnosed after 3 months as being moyamoya [7]. So, it is important to know symptoms may remit and relapse.

Moyamoya disease is an unusual cause of stroke in a young adult. Early diagnosis of this rare disease can be complicated by psychiatric manifestation and anchoring bias, like in our case. The clinician should consider this rare condition while evaluating a young patient with stroke in appropriate clinical settings.

Thanks to the authors for helping to make medical professionals less likely to write off people with this condition as just being anxious.

It's a shame when being concerned enough about symptoms of impaired concentration and fatigue to consult a doctor is so readily seen as evidence of the symptom of 'anxiety'. And having the symptom 'anxiety' and no immediately obvious physical issues is enough for an explanatory diagnosis of 'Anxiety'.

 

[rvallee]

prominent psychiatric symptoms

Rather suggesting that the reliability of what are considered psychiatric symptoms is essentially a crapshoot. "Diagnosed with anxiety" says a lot. There is no such thing as a diagnosis of anxiety, it's a vague symptom, there is no test for it and it has a vague nonspecific description, which usually bothers physicians but somehow here doesn't. It's never more than a possible option and as this case makes clear, is often made off-hand with zero effort and only as a means to disappear a "difficult" patient.

Really revealing that the entire specialty is just a big mess, like that drawer in everyone's kitchen that is just a mix of random things that don't fit anywhere else. Maybe at the extremes, but this fad of pathologizing small superficial changes in behavior as absolutely being 100% guaranteed to be psychogenic is just about the most idiotic thing medicine has done since, well, doing exactly that many times before. Always the same assumptions and beliefs, always failure.

Way past time to examine unhelpful beliefs about illness in the medical profession. This thing is out of control.