Transient ischaemic attack in a case of a morbidly obese girl associated with metabolic syndrome

Sir, It is well known that transient ischaemic attack (TIA) associated with hypertension occurs in the elderly, but there is scant information available on the incidence of such a condition in children (1). We recently encountered a morbidly obese girl who developed sudden onset of hemiparesis, transient symptoms with no neurological sequelae, and was diagnosed with TIA. Transiently worsened hypertension with a background of metabolic syndrome associated with increased insulin resistance was considered to contribute to the underlying pathogenesis that caused the TIA in the present patient. A 12-year-old girl, who had been suffering from simple obesity since entering elementary school, fell down outside at her home in the morning hours of June, when she was intending to go to school. On that occasion, she felt sudden weakness in her left upper and lower leg, followed by a temporal blackout (several seconds). Her blood pressure was immediately measured by automated sphygmomanometer by her mother, who worked as occupational health nurse, and was unexpectedly elevated to 160 ⁄102 mmHg. The patient was unable to communicate smoothly, but she could complain of mild sensory disturbance on the left side of her body. However, all of these symptoms subsided rapidly (the duration of the symptoms was within 10 min), when she was brought to the emergency visit from the hospital. Upon her arrival at the hospital, her consciousness was clear, and the systolic blood pressure was 150 ⁄ 95mm Hg. Her height was 162 cm (+1.8 SD above the average Japanese girls height for age), and body weight, 75 kg (+3.8 SD). Her BMI (body mass index) was 28.3 (>97th percentile). Her growth chart is shown in the Figure 1. By further detailed questioning, it was confirmed that she had not lost any memory of the entire course of events except for the loss of several seconds. No abnormal neurological signs including the optic fundus were observed except for decreased left grip strength of 12 kg (right grip was not measured). In the family history taken by her parents, antihypertensive medications were indicated for essential hypertension. Ambulatory blood pressure monitoring of the patient during her daily life revealed that the average systolic and diastolic blood pressures were 145 and 85 mmHg, respectively, indicating the persistently elevated blood pressure. As the cause of TIA, brain computed tomography, magnetic resonance (MR) imaging and MR angiography revealed normal parenchymal and vascular imaging: no findings of arteriopathies, including moyamoya disease, vasculitis or dissection, were evident. Laboratory examinations of plasma renin activity, plasma concentrations of electrolytes, ACTH, cortisol, thyroid hormones and catecholamines were all within the normal range. Thus, endocrine diseases responsible for secondary hypertension were ruled out. In the evaluation of the patient’s obesity, increased waist circumference (82.6 cm), associated with elevated serum triglyceride concentration (140 mg ⁄ dL) and elevated blood pressure, met the criteria of metabolic syndrome in Japanese children (2). Serum total cholesterol and high-density lipoprotein– cholesterol (156 and 50 mg ⁄ dL, respectively) levels were normal. The abdominal CT scan showed remarkable fatty changes of the liver and increased visceral fat accumulation [the proportion of visceral fat to subcutaneous fat was notably increased to 23.14%