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Table of Contents    
CASE REPORT
Year : 2021  |  Volume : 69  |  Issue : 4  |  Page : 1032-1033

Transient Ischemic Attack after Eating Spicy Foods in Children: Think of Moya Moya Disease


1 Department of Neurology, St. John's Medical College Hospital, Sarjapura Road, Bangalore, Karnataka, India
2 Department of Neuroradiology, St John's Medical College Hospital, Hospital, Bangalore, Karnataka, India

Date of Submission25-May-2018
Date of Decision26-Mar-2020
Date of Acceptance16-Jun-2020
Date of Web Publication2-Sep-2021

Correspondence Address:
Thomas Mathew
Department of Neurology, St. Johns Medical College Hospital, Bangalore - 560 034, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.325347

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 » Abstract 


Moya Moya disease is an important cause for childhood strokes and morbidity. An early diagnosis and treatment can prevent strokes and disability. Here we report the case of an eight-year-old boy who had transient episodes of headache and hemiparesis secondary to Moya Moya disease. He was misdiagnosed as hemiplegic migraine, seizure disorder, paroxysmal non-kinesigenic dyskinesia and dissociative disorder during the past three years. The diagnosis was significantly delayed as an important clinical cue was overlooked. A detailed history showed that symptoms were precipitated on eating spicy food. This clinical pointer prompted evaluation for Moya Moya disease. MRI and MR angiogram confirmed Moya Moya disease.


Keywords: Moya Moya disease, Spicy foods, hyperventilation, transient ischemic attack, transient neurological deficit
Key Message: Transient neurological dysfunction after eating spicy foods may point to the presence of Moya Moya disease. Hyperventilation caused by spicy foods results in hypocarbia and vasoconstriction in cerebral vasculature, leading to transient neurological deficits.


How to cite this article:
Mathew T, Souza DD, John SK, Sharath Kumar G G. Transient Ischemic Attack after Eating Spicy Foods in Children: Think of Moya Moya Disease. Neurol India 2021;69:1032-3

How to cite this URL:
Mathew T, Souza DD, John SK, Sharath Kumar G G. Transient Ischemic Attack after Eating Spicy Foods in Children: Think of Moya Moya Disease. Neurol India [serial online] 2021 [cited 2021 Sep 18];69:1032-3. Available from: https://www.neurologyindia.com/text.asp?2021/69/4/1032/325347




Here we are reporting the case of a child with Moya Moya disease presenting with headache and transient neurological deficits after eating spicy foods. The child was misdiagnosed as dissociative attacks, seizures, paroxysmal non-kinesigenic dyskinesia and hemiplegic migraine for three years before arriving at the correct diagnosis.


 » Case Report Top


An eight-year-old boy presented with history of transient right hemicranial headache and hemiparesis precipitated by eating spicy foods. The patient and his parents noticed that when he ate spicy food, spicy chicken, or fish curries he developed headache which was moderate to severe in intensity. The headache was right hemicranial not associated with any other autonomic features. Within 30 to 40 seconds of the onset of headache patient would develop a right sided weakness. He was often not able to stand and would sway to the right side on attempting to walk. He was unable to hold things in his right hand during the episode. The episodes resolved in 3 to 4 minutes with complete recovery of weakness and headache. Patient would immediately ask for some water or sweet complaining that the food had been spicy. There was no history of any involuntary jerky movements or impaired consciousness, no history of dysarthria or facial deviation. Some of the episodes were more pronounced after prolonged state of fasting when patient was very hungry. One episode was seen after an overnight travel when patient had been without food or water for 14 hours. Parents reported about 4 to 6 episodes per year since the last three years. The child had normal milestones and was doing academically well in school. There was no other significant medical history. On examination, the patient had normal blood pressure and all peripheral pulses were well felt. His head circumference was 49 cm. His fundus examination was normal. Power was normal in both upper and lower limbs. There was no pronator drift. Deep tendon reflexes were normal and plantars were flexor.

Routine laboratory investigations including hemogram, renal and liver functions, fasting blood sugar, and lipid profile were normal. MRI brain was done which showed bilateral T2 flair hyperintensities along the cortical sulci suggestive of increased leptomenigeal collaterals [Figure 1]. There was no evidence of acute or chronic infarcts or hemorrhage. MR angiogram showed severe stenosis of bilateral distal ICA and well-developed collateral vessels of Moya Moya type [Figure 2].
Figure 1: MRI Brain FLAIR image showing increased leptomeningeal collaterals “ Ivy sign” (white arrows)

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Figure 2: MR Angiogram showing occlusion of both distal ICA and proximal MCA and ACA territories with collateral formation

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Moya Moya disease is an important cause of strokes in children. Patients usually present with stroke, transient ischaemic attacks, seizures, cognitive impairment, headaches, or movement disorders.[1] Intracranial hemorrhage is more common in adults. TIAs in children are often precipitated by events that cause a change in the hemodynamics of the cerebral vasculature. TIAs are often reported with crying spells, blowing, playing wind instruments, exertion, fasting, and dehydration.[2],[3] There is a case report of acute chorea following intake of hot noodles in a 17-year-old female with Moya Moya disease by Jung et al.[2] When hot food is consumed there is a tendency to hyperventilate. Hyperventilation has been found to reduce cerebral blood flow by reducing PaCo2 which results in vasoconstriction and vasospasm. This resulted in transient headache and hemiparesis. The patient had more pronounced attacks after fasting. Prolonged fasting results in dehydration and reduced systemic pressures with reduced cerebral blood flow resulting in neurological dysfunction.[1] This coupled with hyperventilation induced hypocarbia due to spicy food precipitated the ischemic attacks. The patient had been to several doctors before he was correctly diagnosed. He was misdiagnosed with seizure disorder, paroxysmal kinesigenic dyskinesia, dissociate attacks, and hemiplegic migraine before the correct diagnosis was reached. The important clinical pointer of spicy food triggering TIAs in Moya Moya shouldn't be overlooked and patient should be investigated with CT or MR angiogram for an early diagnosis and treatment.

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Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Scott RM, Smith ER. Moyamoya Disease and Moyamoya Syndrome. N Engl J Med 2009;360:1226-37.  Back to cited text no. 1
    
2.
Jung HY, Lee JE, Kang I, Kim YB, Park H, Kim J. Acute chorea onset after hot food consumption in a patient with Moyamoya disease. J Mov Disord 2016;9:50-2.  Back to cited text no. 2
    
3.
Fukui M, Kono S, Sueishi K, Ikezaki K. Moyamoya disease. Neuropathology 2000;20(Suppl):S61-4.  Back to cited text no. 3
    


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