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 ().
A 53-year-old male patient, without relevant personal or family history, was admitted to the emergency room after he suddenly developed severe headache with dysarthria, altered state of consciousness and syncope. At the time of admission, he was found drowsy with global aphasia, stiff neck, right hemiparesis and right Babinski's sign. Kernig's sign was present too. Fundoscopy did not show retinal hemorrhages. Autoimmune diseases, brain tumors, actinic encephalopathy, Von Recklinghausen's disease and Down syndrome were clinically ruled out.\nA non-contrast brain computed tomography revealed bleeding in the subarachnoid space over the left frontal and parietal cortex []. Four-vessel cerebral angiography showed bilateral stenosis of the supraclinoid segment of both internal carotid arteries and multiple tortuous vessels branching from the anterior and middle cerebral arteries (moyamoya vessels). These abnormal vessels were anastomosing with branches from the posterior cerebral and middle meningeal arteries. With this information, MMD diagnosis was made. An extensive search for aneurysms and vascular malformations was done, including a three-dimensional reconstruction from each projection of the four-vessel angiography, with no other abnormalities found []. Taking into account the possibility of an angiographically occult aneurysm, digital subtraction angiography was repeated after 4 weeks and remained without changes from the previous.\nDuring hospitalization, the patient developed a massive pulmonary embolism and subsequently died.