Preprint Review Version 1 Preserved in Portico This version is not peer-reviewed

Mechanisms and Neuroimaging Patterns of Hypereosinophilia-related Ischemic Stroke: A Narrative Review through Three Cases

Version 1 : Received: 24 July 2022 / Approved: 27 July 2022 / Online: 27 July 2022 (05:30:13 CEST)

How to cite: Cioclu, M.C.; Cavallieri, F.; Napoli, M.; Moratti, C.; Pascarella, R.; Valzania, F.; Zedde, M. Mechanisms and Neuroimaging Patterns of Hypereosinophilia-related Ischemic Stroke: A Narrative Review through Three Cases. Preprints 2022, 2022070412 (doi: 10.20944/preprints202207.0412.v1). Cioclu, M.C.; Cavallieri, F.; Napoli, M.; Moratti, C.; Pascarella, R.; Valzania, F.; Zedde, M. Mechanisms and Neuroimaging Patterns of Hypereosinophilia-related Ischemic Stroke: A Narrative Review through Three Cases. Preprints 2022, 2022070412 (doi: 10.20944/preprints202207.0412.v1).

Abstract

Background: Hypereosinophilic syndromes (HES) are a group of relatively rare disorders in which neurological manifestations are not uncommon including ischemic stroke. The hypothesized pathophysiological mechanisms are hypercoagulability, cardioembolism (mainly mediated by myocardial involvement) and damage to the endothelium. A variable ischemic pattern has been described, including an association of territorial and border zone ischemic stroke. Methods: Three patients who presented to our department with acute stroke were selected aiming to show these three different mechanisms inferred from the stroke pattern on brain Magnetic Resonance Imaging (MRI) and to simultaneously illustrate the three main causes of HES. Results and Discussion: The first patient is a 55-year-old man with an abrupt onset of aphasia due to an acute ischemic stroke involving the left parietal lobule and the angular gyrus; recent lab test had shown hypereosinophilia. An extensive workup excluded primary and secondary causes of hy-pereosinophilia so a diagnosis of idiopathic hypereosinophilia was formulated and he was treated with high doses of steroids. The second patient had severe hypereosinophilia and developed multiple small scattered ischemic lesions, mainly in watershed zones. The history of severe asthma and recurrent sinusitis supported the diagnosis of EGPA (Eosinophilic Granulomatosis with Polyangiitis); considering the severe clinical conditions and the presumptive role of hypereo-sinophilia in determining her symptoms, steroid treatment was promptly started, with good clinical response. The third patient also presented with multiple metachronous ischemic lesions, both in cortical and watershed distribution and marked eosinophilia; the diagnostic work-up found an ovarian cancer. She was treated with steroids and then underwent surgery and adjuvant chemotherapy. Conclusions: HES should be considered in stroke etiological evaluation, although it is a rare disorder, and border zones pattern on neuroimaging is quite suggestive. A thorough research of the sources of hypereosinophilia should be performed to select the appropriate therapy.

Keywords

stroke; hypereosinophilia; hypereosinophilic syndrome (HES); brain MRI; embolic pattern; border zone stroke

Subject

MEDICINE & PHARMACOLOGY, Clinical Neurology

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