Bilateral Anterior Circulation Infarctions in the Setting of Moyamoya Syndrome in a Young Non-verbal Adult with Down’s Syndrome: A Case Report

Case Diagnosis: Acute Bilateral Anterior Circulation Infarctions in the Setting of Underlying Moyamoya Syndrome.

Case Description or Program Description: A 28-year-old female with a past medical history of Down's syndrome, type 1 diabetes mellitus, and hypothyroidism was admitted to Geisinger Medical Center (GMC) for community-acquired pneumonia and COVID-19. At baseline, the patient was mute and independent with activities of daily living (ADL). Prior to admission, she required increasing assistance with ADLs and ambulation. After a fall, she presented to GMC ED and was diagnosed with community-acquired pneumonia, given chest x-ray findings in the clinical context. The patient was admitted, started on antibiotics. Subsequent computed tomography head scan was concerning for new acute bilateral (B/L) anterior cerebral artery (ACA) infarctions. The patient was medically stabilized and subsequently discharged to an acute rehabilitation facility.

Setting: Tertiary Care Comprehensive Stroke Center.

Assessment/Results: Follow-up magnetic resonance imaging of her brain during acute care admission confirmed late acute/early subacute B/L ACA ischemic infarctions with findings consistent with Moyamoya syndrome.

Discussion (relevance): This case demonstrates some unique challenges and considerations physiatrists manage in complex patients in the acute rehabilitation setting. It emphasizes the importance of obtaining a thorough history, functional status baseline, and collaboration with families, particularly those who are non-verbal.

Conclusions: Patients with Down's syndrome are at increased risk for numerous co-morbidities that significantly affect their quality of life. Additionally, lack of verbal communication poses unique challenges for the rehabilitation team, requiring careful disposition planning and inter-disciplinary collaboration to ensure the highest quality and non-biased care. Physiatrists should maintain a low threshold for pursuing a comprehensive workup for acute changes in clinically complex patients.