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Introduction Strokes secondary to large vessel occlusions (LVO) are frequently caused by either atherosclerotic or thromboembolic sources (1). Both genetic and acquired etiologies can lead to elevated serum homocysteine levels causing LVO as recognized in our patient (2). Measuring homocysteine levels and vitamin B12, B6, and folate replacement can reduce the future risk of stroke by ∼25% (3). Methods A 42‐year‐old male with acute onset right‐sided facial droop, ataxia, gait instability, nausea, and vomiting. PMH: 11 weeks preterm with subtotal colectomy and short gut syndrome, and mild hypertension. No family h/o blood clots. LKW: >24 hours, initial NIHSS 6, required rapid sequence intubation with repeat NIHSS 28, decreased responsiveness, non‐reactive pupils, and ventilatory compromise. PE: decreased arousal and depressed mentation, facial asymmetry, flaccid right upper and lower extremity. Results Non‐contrast head CT: a hyperdense basilar artery (fig 1). CT angiogram of head and neck: Left vertebral artery stenosis with diminutive basilar artery. A diagnostic cerebral angiogram with mechanical thrombectomy was performed with TICI 2b recanalization (fig 2). A subsequent MRI brain further confirmed an acute bi‐cerebellar and left pontine ischemic infarct with diffusion restriction on DWI and ADC reversal (fig 1). Lab work: B12 < 50, homocysteine 50.08, methylmalonic acid 38,038, and folate wnl. A transthoracic, transesophageal ECHO with bubble study and a lower extremity doppler ruled out peripheral sources of stroke. He developed malignant cerebral edema requiring decompressive sub‐occipital craniectomy with external ventricular drain (EVD) placement and remained in the Neuro ICU until discharge. Conclusions •A build‐up of hcy (an intermediate product of methionine and cysteine metabolism) can occur de novo via or iatrogenically •This can cause arterial occlusion leading to ischemic strokes and venous thrombosis as seen in our patient. •Serial monitoring of Hcy, MMA, and replacing the deficient vitamins like B12, B6, and folate in these patients can help prevent the chance of ischemic CNS injuries |
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