Stroke Presenting as a Complication of Sarcoidosis in an Otherwise Asymptomatic Patient

Abstract

A stroke occurring in young patients in the absence of common risk factors needs a thorough investigation of the underlying cause to prevent its recurrence. Herein, we discuss a case of stroke with rare etiology in a 28-year-old male presenting within 30 minutes of speech difficulty and right-sided weakness. The initial triage workup showed an abnormal configuration of the P wave in the 12 lead echocardiograph (ECG) and his chest x-ray (CXR) showed mediastinal widening. His echocardiogram and chest computed tomography (CT) confirmed bilateral enlargement with restrictive cardiomyopathy and mediastinal lymphadenopathy, raising a suspicion of sarcoidosis. A cardiac positron emission tomography (PET) scan confirmed the diagnosis by showing a non-caseating granuloma. The patient was put on intravenous (IV) tissue plasminogen activator (TPA) and his National Institute of Health Stroke Scale (NIHSS) came down from 14 on admission to zero within 48 hours. Cardiac involvement in sarcoidosis is not uncommon but it presenting as stroke is extremely rare. For a young, previously healthy patient presenting as a stroke without risk factors, sarcoidosis should be considered as a differential diagnosis.

Keywords: biatrial enlargement; bihilar lymphadenopathy; implantable cardioverter-defibrillator device; lt. middle cerebral artery; restrictive cardiomyopathy.

Figure 1. CT head showing a left hyperdense middle cerebral artery sign

Computed tomography (CT) head with a left hyperdense middle cerebral artery sign

Figure 2. CT angiogram showing the cut-off of blood supply at the M2 part of the left middle cerebral artery

Computed tomography angiogram (CT) showing the cut-off of blood supply at the M2 part of the left middle cerebral artery

Figure 3. Twelve lead ECG showing septal hypertrophy V2, 3, 4, bifid P wave in lead II, V3

Twelve lead echocardiogram (ECG) showing septal hypertrophy V2, 3, 4, bifid P wave in lead II, V3

Figure 4. CT chest showing bihilar lymphadenopathy

Computed tomography (CT) chest showing bihilar lymphadenopathy