Intermittent Hemiplegia in a Boy with Primary Moyamoya Disease: A Case Report from Iran

How to Cite This Article: Bidaki R, Zarepur E. Intermittent Hemiplegia in A Boy With Primary Moyamoya Disease; A Case Report from Iran. Iran J Child Neurol. Spring 2017; 11(2):65-68. AbstractMoyamoya is a rare chronic progressive occlusive cerebrovascular disease. Its manifestation varies from stroke, progressive learning impairment and transient ischemic attack to headache and seizure. There is no accepted medical treatment and surgery usually, is needed. We report here a case of 8 yr old boy referred to psychiatrist outpatient. An eight yr old boy with intermittent hemiplegia was brought to Imam Ali Clinic, Yazd, Iran in 2015 because his headache and medical problem began from 6 yr old. Stress and excitement exacerbated his condition. His first attack was at the age of 6 yr old. During attack, he had incontinence, severe headache, alogia, pallor, claudication and left hemiplegia (Left lower limb). Magnetic resonance angiography (MRA) was done and our diagnosis was moyamoya disease. Moyamoya is a mysterious disease and psychiatrists should consider it in differential diagnosis of alogia and plegia. Acute management of this disease is mainly symptomatic. Nowadays, surgery is a good choice and early diagnosis of this disease can change our patient’s life. References 1. Hallemeier CL, Rich KM, Grubb RL, Chicoine MR, Moran CJ, Cross DT, et al. Clinical features and outcome in North American adults with moyamoya phenomenon. Stroke 2006;37(6):1490-6.2. Suzuki J, Takaku A. Cerebrovascular “moyamoya” disease. Disease showing abnormal net-like vessels in base of brain. Arch Neurol 1969;20(3):288-99.3. Wakai K, Tamakoshi A, Ikezaki K, Fukui M, Kawamura T, Aoki R, et al. Epidemiological features of moyamoya disease in Japan: findings from a nationwide survey. Clin Neurol Neurosurg 1997;99 Suppl 2:S1-5.4. Duan L, Bao XY, Yang WZ, Shi WC, Li DS, Zhang ZS, et al. Moyamoya disease in China: its clinical features and outcomes. Stroke 2012;43(1):56-60.5. Im SH, Cho CB, Joo WI, Chough CK, Park HK, Lee KJ, et al. Prevalence and epidemiological features of moyamoya disease in Korea. J Cerebrovasc Endovasc Neurosurg 2012;14(2):75-8.6. Lutterman J, Scott M, Nass R, Geva T. Moyamoya syndrome associated with congenital heart disease. Pediatrics 1998;101(1 Pt 1):57-60.7. Peerless SJ. Risk factors of moyamoya disease in Canada and the USA. Clin Neurol Neurosurg 1997;99 Suppl 2:S45-8.8. Abuzayed B, Khreisat W, Maaiah W, Agailat S. Supratentorial primitive neuroectodermal tumor presenting with intracranial hemorrhage in adult. J Neurosci Rural Pract 2014;5(2):176-9.9. Yamauchi T, Houkin K, Tada M, Abe H. Familial occurrence of moyamoya disease. Clin Neurol Neurosurg 1997;99 Suppl 2:S162-7.10. Kim JS. Moyamoya Disease: Epidemiology, Clinical Features, and Diagnosis. J Stroke 2016;18(1):2-11.11. Smith ER, Scott RM. Surgical management of moyamoya syndrome. Skull Base 2005;15(1):15-26.12. Yamada I, Suzuki S, Matsushima Y. Moyamoya disease: comparison of assessment with MR angiography and MR imaging versus conventional angiography. Radiology 1995;196(1):211-8.13. Nakakita K, Tanaka S, Fukuda A, Fujii C, Kohama A, Miyasato H. [Nontraumatic acute subdural hematoma caused by the rupture of transdural anastomotic vessels in moyamoya disease]. No Shinkei Geka 1994;22(6):561-5.14. Mughal DK, Nissirios KS, Puri MR. A 30-Year-Old Female with Moyamoya Disease and Associated Depression. Psychiatr Ann 2014;44(12):549-551.15. Kim T, Oh CW, Bang JS, Kim JE, Cho WS. Moyamoya Disease: Treatment and Outcomes. J Stroke 2016;18(1):21-30.

Intravenous versus Subcutaneous Midazolam Using Jet-injector in Pediatric Sedation; a Randomized Clinical Trial

Introduction: The quality of interventions in children is largely dependent on their control. Hence, this study compared the sedative effects of subcutaneous (SC) and intravenous (IV) Midazolam in pediatric sedation induction. Methods: This randomized clinical trial was conducted on children aged 1-6 years presenting to emergency departments of Shahid Sadoughi and Shahid Rahnemoon Hospitals, Yazd, Iran. Participants were randomly assigned to IV or SC midazolam using a jet injector and success rate, degree of sedation, and satisfaction of parents and physician were compared between groups.Results: 60 cases with the mean age of 3.15±1.43 (1-6) years were randomly assigned to the SC (30 cases) or IV (30 cases) groups (56.7% female). SC and IV groups were similar regarding the mean age (p = 0.165) and sex (p = 0.121).Depth of sedation (p=0.900), control of child (p=0.711), in-charge physician’s satisfaction (p=0.467), successful sedation and need for rescue dose (p=0.519) were not different between groups. IV midazolam group had a significantly shorter recovery time (about 10 minutes; p=0.040) and SC midazolam group had a significantly higher level of parent satisfaction (p=0.001).Conclusion: The findings indicate no significant difference in depth of sedation, control of child, in-charge physician’s satisfaction, successful sedation (reaching stage 1 of sedation or higher), and need for rescue dose of SC and IV midazolam. Parents’ satisfaction was significantly greater with SC administration and IV injection had shorter recovery time

Functional Neurological Symptom Disorder:Mismanagement, Misdiagnosis, Chronic Cough Following Sexual Abuse: A Rare Case Report

How to Cite This Article: Bidaki R, Zarepur E, Akrami M, Nadi Sakhvidi M. Functional Neurological Symptom Disorder: Mismanagement, Misdiagnosis, Chronic Cough Following Sexual Abuse; A Rare Case Report. Iran J Child Neurol. Spring 2016; 10(2):90-92.AbstractObjectiveConversion disorder (CD) is a mental disorder in which patient displays neurological symptoms such as blindness, mutism, paralysis and seizure. It starts when our mind converts our mental stress into a physical symptom. A 15-year-old single white female with chronic cough, which had begun 5 months ago, was brought to our clinic. She had no history of hospitalization. His daily cough was without sputum production or fever, rhinorrhea and stopped during sleep. There was no recent exposure to tobacco smoke or a person with a chronic productive cough. Laboratory tests were normal. She had engaged 4 months ago.Doing sex during engagement is prohibited in her culture but and had anal sex, because of her spouse’s trend. Psychotherapy was done and complete recovery was accomplished. ReferencesFeinstein A. Conversion disorder: advances in our understanding. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne. 2011 May 17;183(8):915-20. PubMed PMID: 21502352. Pubmed Central PMCID: 3091899.Pehlivanturk B, Unal F. Conversion disorder in children and adolescents: a 4-year follow-up study. Journal of psychosomatic research. 2002 Apr;52(4):187-91. PubMed PMID: 11943237.Ozsungur B, Foto-Ozdemir D, Ozusta S, Topcu M, Topaloglu H. Treatment of a severe conversion disorder in a 10-year-old boy: a case study and overview. The Turkish journal of pediatrics. 2012 Jul-Aug;54(4):413-8. PubMed PMID: 23692724.Kozlowska K, Nunn KP, Rose D, Morris A, Ouvrier RA, Varghese J. Conversion disorder in Australian pediatric practice. Journal of the American Academy of Child and Adolescent Psychiatry. 2007 Jan;46(1):68-75. PubMed PMID: 17195731.Singh SP, Lee AS. Conversion disorders in Nottingham: alive, but not kicking. Journal of psychosomatic research. 1997 Oct;43(4):425-30. PubMed PMID: 9330242.Haydour Q, Alahdab F, Farah M, Barrionuevo P, Vertigan AE, Newcombe PA, et al. Management and diagnosis of psychogenic cough, habit cough, and tic cough: a systematic review. Chest. 2014 Aug;146(2):355-72. PubMed PMID: 24833061.Mastrovich JD, Greenberger PA. Psychogenic cough in adults: a report of two cases and review of the literature. Allergy and asthma proceedings : the official journal of regional and state allergy societies. 2002 Jan-Feb;23(1):27-33. PubMed PMID: 11894731.Sobot V, Ivanovic-Kovacevic S, Markovic J, Misic-Pavkov G, Novovic Z. Role of sexual abuse in development of conversion disorder: case report. European review for medical and pharmacological sciences. 2012 Feb;16(2):276-9. PubMed PMID: 22428482.Amirsalari S, Radfar S, Ajallouyean M, Saburi A, Yousefi J, Noohi S, et al. Prevalence of epileptiform discharges in children with sensori-neural hearing loss and behavioral problems compared to their normal hearing peers. Iranian journal of child neurology. 2014 Spring;8(2):29-33. PubMed PMID: 24949048. Pubmed Central PMCID: 4058062.Voon V, Lang AE. Antidepressant treatment outcomes of psychogenic movement disorder. The Journal of clinical psychiatry. 2005 Dec;66(12):1529-34. PubMed PMID: 16401153.Tocchio SL. Treatment of conversion disorder. A clinical and holistic approach. Journal of psychosocial nursing and mental health services. 2009 Aug;47(8):42-9. PubMed PMID: 19681521.

Intravenous Haloperidol versus Midazolam in Management of Conversion Disorder; a Randomized Clinical Trial

Introduction: Conversion disorder is a condition in which the patient shows psychological stress in physical ways. This study aimed to compare the effects of haloperidol versus midazolam in patients with conversion disorder.Methods: This double-blind randomized clinical trial was conducted on patients with conversion disorder who had presented to the emergency department, throughout 2015. Patients were randomly divided into two groups and were either treated with 2.5 mg of intravenous (IV) haloperidol or 2.5 mg of IV midazolam. Recovery rate, time to recovery, and side effects of both drugs 1 hour, 24 hours, and 1 week after treatment were compared using SPSS19.Results: 140 patients were divided into two groups of 70. There were no significant differences between the groups regarding the baseline characteristics. 12 (17.1%) patients who were treated with IV haloperidol experienced drug side effects within 1 hour and 12 (17.1%) within 24 hours, while only 3 (4.3%) patients in IV midazolam experienced side-effects within 1 hour after drug administration (p = 0.026).  The symptoms of the disease subsided in 45 (success rate: 64.3%) patients in midazolam and in 64 (success rate: 91.5%) participants in haloperidol group (P<0.001). Mean recovery time was 31.24 ± 7.03 minutes in IV midazolam and 30.53 ± 7.11 minutes in IV haloperidol group (p = 0.592). Absolute risk reduction (ARR) of treating patients with haloperidol compared to midazolam is about 27%.Conclusion: The response of patients to treatment with haloperidol is clearly better than midazolam. Although more transient and minor side-effects were observed in the group treated with haloperidol compared to midazolam group, serious side-effects were rare for both treatments

The relationship between ultra processed food consumption and premature coronary artery disease: Iran premature coronary artery disease study (IPAD)

BackgroundUltra-processed foods (UPF) consumption may affect the risk of PCAD through affecting cardio metabolic risk factors. This study aimed to evaluate the association between UPFs consumption and premature coronary artery disease (PCAD).MethodsA case–control study was conducted on 2,354 Iranian adults (≥ 19 years). Dietary intake was assessed using a validated 110-item food frequency questionnaire (FFQ) and foods were classified based on the NOVA system, which groups all foods according to the nature, extent and purposes of the industrial processes they undergo. PCAD was defined as having an stenosis of at least single coronary artery equal and above 75% or left main coronary of equal or more than 50% in women less than 70 and men less than 60 years, determined by angiography. The odds of PCAD across the tertiles of UPFs consumption were assessed by binary logistic regression.ResultsAfter adjustment for potential confounders, participants in the top tertile of UPFs were twice as likely to have PCAD compared with those in the bottom tertile (OR: 2.52; 95% CI: 1.97–3.23). Moreover, those in the highest tertile of the UPFs consumption had more than two times higher risk for having severe PCAD than those in the first tertile (OR: 2.64; 95% CI: 2.16–3.22). In addition, there was a significant upward trend in PCAD risk and PCAD severity as tertiles increased (P-trend < 0.001 for all models).ConclusionHigher consumption of UPFs was related to increased risk of PCAD and higher chance of having severe PCAD in Iranian adults. Although, future cohort studies are needed to confirm the results of this study, these findings indicated the necessity of reducing UPFs intake

Study of the Relationship between Meconium Passage and Newborns Birth Weight and its related factors in Pregnant Women

Background: Previous studies have shown that meconium staining of the amniotic fluid may affect maternal and neonatal outcomes. In this study, we aimed to investigate the relationship between birth weight and meconium passage and its related factors in pregnant women.Materials and Methods: This matched case control study was conducted on a total of 200 newborns (100 as cases and 100 as controls) in Imam Reza and Valiasr hospitals in Qom city- Iran in 2014 and 2015. A questionnaire was used to collect required data including the passage or non-passage of meconium, newborn's birth weight, gestational age, maternal age, newborn gender, maternal weight, comorbidities, type of delivery, and history of abortion or stillbirth. Data were analyzed by SPSS using independent t- test, Fisher exact test, and Chi-square test.Results: Based on the results of this study, there was a significant difference between the two groups in terms of birth weight (P=0.001). So, the birth weight was higher in the cases than in the controls. There was also a significant differences between the two groups in terms of the relationship between newborns gender and meconium passage (P=0.04). In addition, there was a significant difference between the two groups in terms of gestational age (P=0.035). Moreover, a significant difference was observed between the two groups in terms of birth height (P=0.003).Conclusion: The newborns birth weight associated meconium passage. Therefore, meconium passage must be monitored and controlled through examination and screening during the period of pregnancy

Congenital adrenal hyperplasia and vanishing testis: rare case of male pseudohermaphroditism

Background: Congenital adrenal hyperplasia (CAH) and vanishing testes are uncommon diseases that can result from hormonal and mechanical factors. Classic CAH is determined by ambiguous genitalia and increase in amount of 17-Hydroxyprogesterone. Simultaneous occurrence of CAH and vanishing testes is a rare condition. Case: A 22-year-old boy, known case of CAH who was diagnosed as female pseudohermaphroditism due to ambiguous genitalia, was referred to Shahid Sadoughi Hospital, Yazd, Iran with colicky abdominal pain and hematuria. Ultrasonography has been performed and prostate tissue was reported. Karyotyping was done because of uncertainty in primary diagnosis, which revealed 46XY. For finding location of testes, ultrasonography and MRI were done and nothing was found in abdomen, inguinal canal or scrotum. Inhibin B serum level was measured to find out whether testis tissue was present in the body, which was <1 pg/ml and vanishing testis was confirmed. Conclusion: Early diagnosis and treatment are essential to prevent further sequels and karyotyping for all patients with CAH is recommended. Lifelong treatment with synthetic glucocorticoid replacement is necessar

Adenosine Preconditioning versus Ischemic Preconditioning in Patients undergoing Off-Pump Coronary Artery Bypass (OPCAB)

Background: During off-pump coronary artery bypass (OPCAB), the heart is subjected to ischemic and reperfusion injury. Preconditioning is a mechanism that permits the heart to tolerate myocardial ischemia. The aim of this study was to compare the effects of Adenosine preconditioning with ischemic preconditioning on the global ejection fraction (EF) in patients undergoing OPCAB. Methods: In this single-blind, randomized controlled trial, sixty patients undergoing OPCAB were allocated into three equally-numbered groups through simple randomization: Adenosine group, ischemic group, and control group. The patients in the Adenosine group received an infusion of Adenosine. In the ischemic group, ischemic preconditioning was induced by the temporary occlusion of the left anterior descending coronary artery twice for a 2-minute period, followed by 3-minute reperfusion before bypass grafting of the first coronary vessel. The control group received an intravenous infusion of 0.9% saline. Blood samples at different times were sent for the measurement of creatine kinase isoenzyme MB (CK-MB) and cardiac troponin I (cTnI). We also recorded electrocardiographic indices and clinical parameters, including postoperative use of inotropic drugs and preoperative and postoperative EF. Results: History of myocardial infarction, hyperlipidemia, diabetes mellitus, kidney disease, preoperative arrhythmias, and utilization of postoperative inotrope was the same between the three groups. The incidence of postoperative arrhythmias was not significant between the three groups. Also, there were no significant differences in preoperative and postoperative EF and the serum levels of enzymes (cTnI and CK-MB) between the groups. Conclusion: Based on the findings of this study, there was no significant difference in the postoperative EF between the groups. Although the incidence of arrhythmias was higher in the ischemic preconditioning group than in the other groups, the difference between the groups did not constitute statistical significance

Efficacy of Preoperative Color Doppler Sonography of Lower Extremity Veins on Postoperative Outcomes in Candidates of Saphenectomy: A Randomized Clinical Trial

Background: Doppler sonography is a type of sonography used for imaging the blood flow in the vessels and heart. This technique uses ultrasound waves with high frequency. In some patient candidates for venous graft, the identification of the suitable vein is not possible with clinical examination. Objective: This study compared the effects of preoperative color Doppler sonography of lower extremity veins on the postoperative outcomes of saphenectomy. Methods: This randomized clinical trial was conducted on 100 candidates of an off-pump coronary artery bypass graft (CABG) hospitalized in Afshar Hospital in Yazd in 2015. Patients were divided into two groups: 50 patients in the study group and 50 patients in the control group. Patients in the study group underwent color Doppler sonography of lower extremity veins using the Medison 8000 Live device. Patients in the control group were assessed preoperatively by routine venous examination without undergoing color Doppler sonography. The prepping and draping methods and also the preoperative antibiotics were the same for both groups. The patients were assessed for wound infection, edema, hematoma, and DVT 2 days, 1 week, and 1 month after surgery. Data were analyzed by SPSS version 16 using t-test, Chi-square, and Fisher’s exact test. Results: The length of incision for saphenectomy was 29.20 ± 3.71 cm in the Doppler group and 28.98 ± 3.72 cm in the non-Doppler group with no significant difference between the two groups (p=0.768). The two groups were not significantly different with respect to age, gender, diabetes, hypertension, hyperlipidemia, smoking, and history of peripheral vessels disease, postoperative infection, postoperative organ edema, postoperative hematoma, and postoperative DVT. Conclusion: Preoperative color Doppler sonography of the saphenous vein before saphenectomy has no effect on reducing the postoperative complications, and saphenectomy on the basis of intraoperative examination of the vein course by the surgeon has acceptable consequences. Clinical trial registration: The trial was registered at the Thai Clinical Trials Registry (TCTR) (http://www.clinicaltrials.in.th) with the TCTR ID: TCTR20160708001. Funding: The authors received no financial support for the research, authorship, and/or publication of this articl

Rare Presentation of MoyaMoya Disease with Sub acute Presentation: A Case Report from Iran

AbstractMoyamoya disease is  a  chronic  progressive  vascular  disease of  brain  has  been characterized  by  bilateral  stenosis or occlusion  of   the  arteries  around  the  circle of   Willis with prominent  arterial  collateral  circulation. We introduce  a  patient  with  Moyamoya  that  was  been   misdiagnosed.We report  a  16-year-old  female  from  northeast  of  Iran  who complained  left hemiparesis  and  was diagnosed  Moyamoya disease  by  brain and cervical CT-Angiography. There is still great difficulty in the diagnosis of diffuse white matter lesions and our case shows that moyamoya disease should be considered in differential diagnoses especially among young patients presenting with unexplained cerebrovascular syndromes. The   CT-Angiography  showed   bilateral  internal  carotid  stenosis   with  "puff of smoke" collateralization  arising  from  the  circle of Willis, therefore  Moyamoya disease was raised.The   clinical  diagnosis  of  Moyamoya  is  challenging   and   misdiagnosis   is    probable. Therefore,   the  physicians    should  know  this   disease   and   think  about  it  in  patients   with   Juvenile   stroke