A 23-month-old full-term Moroccan baby boy born to a non-consanguineous couple was referred to our hospital with the complaint of sudden onset left-sided hemiparesis evolving for 2 days. There was no history of fever, seizure, head injury, ear discharge, headache, visual disturbances, or vomiting. No family history of early stroke, ischemic heart disease, or autoimmune disease was reported. At presentation, he was conscious and well orientated. There was no dysmorphism, no neurocutaneous markers, and he had normal growth parameters. He was afebrile with a pulse of 110 beats per minute and a respiratory rate of 26 breaths per minute. On neurological examination, there were no signs of meningeal irritation, his gait was hemiplegic, tone was decreased over left side, power was 2/5 over left upper and lower limb using Medical Research Council (MRC) muscle strength scale, and deep tendon reflexes were exaggerated. There were no abnormalities on cardiac auscultation or hepatosplenomegaly. Brain computed tomography (CT) showed a low density area in the right cortical and subcortical frontotemporoparietal regions and right insular cortex representing ischemic lesions in the right middle cerebral artery (MCA) territory (Fig. ). Laboratory investigations, including hemogram, prothrombin, partial thromboplastin, erythrocyte sedimentation rate (ESR), fibrinogen, proteins C and S, antithrombin III activity, and antinuclear antibody tests were all within limits. Renal ultrasonography with Doppler flow study showed no evidence of renal artery stenosis. Electroencephalography revealed no epileptic discharges, only a diffuse slow rhythm over the left hemisphere with slow waves at the temporal regions.\nOur patient was booked for cerebral angiography with contrast, which revealed a proximal obliteration in his MCA with a fine anastomotic moyamoya network and typical “puff of smoke” appearance (Fig. ). Urine for metabolic screening, including homocysteine levels, was normal. A normal hemoglobin electrophoresis ruled out sickle cell disease. An electrocardiogram and echocardiogram revealed no abnormalities. He was finally diagnosed as a case of MMD.\nWe treated our patient conservatively with acetylsalicylic acid 5 mg/kg per day. He showed slight improvement in power over left side (3/5). He was then discharged to follow-up with pediatric neurosurgeon. Cerebral revascularization surgery using encephaloduroarteriosynangiosis (EDAS) was performed. At 8-month follow-up, his hemiparesis was improved and no further ischemic events had occurred.
A 12-year-old male patient reported to the Department of Pedodontics and Preventive Dentistry with a chief complaint of broken tooth in the upper front tooth region due to trauma, 1 week back. The patient gave a history of prediagnosed case of MMD with hemiplegia of the right side.\nAt the age of 1½ years, the patient suffered from pulmonary tuberculosis and completed anti-tuberculosis treatment for the same. At the age of 4 years, the patient experienced sudden onset of pain and weakness in the right lower limb, which was associated with difficulty in holding objects with the right hand and raising the right arm above the head. The MRI of brain showed focal right frontal infarct with left cerebral atrophy and an attenuated appearance of intracanal arteries suggestive of effects of MMD. Symptomatic medical treatment was provided to the patient. The patient had no past dental treatment exposure. There is no related family history.\nThe patient appeared underweight with a lean body type. The general physical examination revealed hemiplegia of the right side, affecting both upper and lower limbs ().\nThe extraoral examination revealed a symmetrical face with competent lips and normal mouth opening. On intraoral examination, permanent dentition was present with Angle's Class I malocclusion. Ellis Class I fracture was present in the upper right central incisor whereas Ellis Class II fracture was present in the upper left central incisor ().\nThe dental treatment plan focused on providing preventive as well as restorative care to the patient while simultaneously providing proactive counseling to both the parents and the patient. Behavior management was an integral part of our management. Oral hygiene measures were instructed to the patient and modified angled toothbrush with fluoridated toothpaste was prescribed due to the lack of manual dexterity. Along with this, diet modification was done by recommending intake of noncarious dietary food items such as fibrous food, nuts, and fruits. The medical consent was obtained from the pediatrician following which oral prophylaxis and composite restoration of upper central incisors were done ().