Cerebral Infarction as a Rare Complication of Wasp Sting 1
123
Payam Moein, MD and Ramin Zand, MD, MPH 1Department
of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, United States (email: [email protected]
2Department
of Neurology, Geisinger Medical Center, Danville, Pennsylvania, United States
3Biocomplexity
Institute, Virginia Tech, Blacksburg, Virginia, United States
Introduction Journal of Vascular and Interventional Neurology, Vol. 9
Wasps, bees, and hornets belong to the order of insects called “Hymenoptera.” Millions of cases of Hymenoptera stings happen every year around the world. Frequently, they are accompanied by local inflammatory reactions. Less commonly, victims develop severe systemic allergic reactions presenting with hypotension or anaphylactic shock, generalized edema, respiratory failure, or even multiple organ failures. Although rare, neurological complications including stroke have been reported (Table 1). In this paper, we present a case of ischemic stroke 30 min after a wasp sting, and a systematic review of the literature.
Case Presentation A 53-year old Caucasian man was stung by a wasp on his right hand while he was working in his garage. Initially, there was just local pain and inflammation without any systemic reaction. Thirty minutes later, while he was sitting on a chair, he noticed that his left upper limb became numb and started moving out of his control. He presented to our emergency department. Past medical history was significant for multiple sclerosis which was diagnosed in 2002 and has been inactive since, coronary artery disease with myocardial infarction and angioplasty in 2012, hypertension, and hyperlipidemia. His home medication included daily lisinopril 20 mg and intermittent use of daily aspirin 81 mg. He denied any history of smoking or alcohol consumption. Family history was negative for stroke. In the emergency department, the examination revealed a slightly overweight man, afebrile, with normal blood pressure and respiratory rate, and mild tachycardia with a normal level of consciousness. Lungs were clear to auscultation and heart was regular rate and rhythm with no adventitious sounds. No carotid bruit was noted.
There were an expected swelling and redness at the sting site on the back of his right hand. The neurological examination was significant for mild dysarthria, uncontrollable movement of the left hand (alien hand syndrome), decreased sensation to touch, pain, and temperature as well as extinction to double simultaneous stimulation in the entire left upper extremity. We also noticed vertical and horizontal nystagmus as well as ataxic gait and impaired tandem gait, which, according to the patient, were chronic symptoms secondary to his multiple sclerosis. His initial blood and imaging workup including cell blood count, complete metabolic and coagulation panel, lipid profile, hemoglobin A1c, cardiac enzymes, electrocardiogram, chest x-ray was unremarkable except for a mildly elevated serum creatinine (1.89 mg/dl) and an elevated serum low-density lipoprotein (160 mg/dl) and triglyceride (329 mg/dl). Initial head computed tomography (CT) scan was negative for any acute finding. The magnetic resonance imaging (MRI) study of the brain, obtained within 6 hours, showed two punctate diffusion lesions in the right frontoparietal area consistent with acute cerebral infarction (Figure 1). A magnetic resonance angiography (MRA) of the head and neck was unremarkable. The Doppler ultrasonography of the lower extremities, transthoracic echocardiography and transesophageal echocardiography, and hypercoagulable and vasculitis panel were all unremarkable. A 4-day inpatient telemetry results did not show any atrial fibrillation or other abnormal cardiac rhythm. He was prescribed aspirin 325 mg and atorvastatin 80 mg daily. The left-hand movement stopped soon after admission; however, there was a mild residual weakness in the left hand. The weakness was completely resolved within 4 days.
Vol. 9, No. 4, pp. 13–16. Published June, 2017. All Rights Reserved by JVIN. Unauthorized reproduction of this article is prohibited
14
Table 1. Case Reports on Ischemic Stroke and Other Associated Neurological Manifestations Following Bee/ Wasp Bite Presentation
Schiffman, et al.[1] Crawley et al. [2]
Riggs et al.[4]
Journal of Vascular and Interventional Neurology, Vol. 9
Rajendiran et al.[5] Wani et al.[6]
57 years old with left homonymous hemianopia followed by unresponsiveness 30-year old with anaphylaxis and respiratory failure after a wasp sting. Right homonymous superior quadrantanopia after 36 hours 52-year old with anaphylactic shock 2 min after a wasp sting followed by slurred speech and left hemiparesis a few hours later 25-year old with left hemiparesis and transient visual loss 40-year old with right hemiparesis, and severe multiorgan dysfunction.
Number of stings and location / Time interval between sting and stroke symptoms 30–40 bee sting on head, face, neck and right arm / 2 days Single wasp sting / 36 hours
Single wasp sting / a few hours
Multiple bee stings on head and neck / not reported >50 wasp stings entire body / 16 hours
Temizoz et al., 60-year old developed a left Multiple bees stings 2009[7] sided hemiplegia and dysentire body / 2 hours arthria Sachdev et al., 2002[8]
40-year old with left hemiplegia and right facial droop
Stalin Viswanathan et al., 2012 [9]
59-year old with dysarthria, Multiple bees sting left sided upper motor neu- entire body / 2 hours ron facial nerve palsy, left hemiplegia and left conjugate gaze palsy
J. MURRAY 36-year old with confusion DAY, 1962[10] and right hemiplegia
Mukund R. Vidhate et al., 2011[11]
Romano JT, et al.,1989[12]
Weeranun Dechyapirom et al.,2010[13] De-Meing Chen et al., 2004[14]
Single wasp sting on face / 10 hours
Imaging findings
Outcome
Other complications
MRI & CT – right occipital ischemic infarct followed with a large right temporo-occipital hemorrhagic infarct CT – left occipital infarction
Partial improvement of visual field loss
Ischemic optic neuropathy, hemorrhagic stroke
Full recovery
Anaphylaxis, respiratory failure
Noto reported
Seizure, anaphylactic shock
Complete motor and vision recovery in 8 months Vegetative state
None
MRI – diffuse bilateral hemisphere stroke MRA – complete right internal carotid artery and near complete left internal carotid artery occlusion MRI – right parietal and basal ganglia infarct MRI – multiple ischemic lesions in bilateral cerebral hemispheres, pons, bilateral thalami, and left parieto-occipital region. MRI – ischemic changes in the frontal lobes, right temporoparietal area, and bilateral centrum semiovale MRI – right ventral pons, and right cerebellum infarction
MRI – right MCA territory infarct
Multiple yellow jackets Not reported stings over the neck, face and arms / 15 minutes
8 years old with left hemiNot reported plegia and altered mental status followed by right hemiplegia, ophthalmoplegia, and partial left ophthalmoplegia
CT: non-hemorrhagic infarcts in left frontoparietal and bilateral subcortical regions and bilateral cavernous sinus thrombosis MRI: infarcts in the left frontoparietal cortex, posterior limb of internal capsule, and right subcortical region 34 months old with dysarth- Single yellow jacket’s CT – left putamen and caudate ria and right hemiparesis sting on the inner side ischemic infarct of his upper lip / 4 days Angiography – left supraclinoid internal carotid artery occlusion 64-year old with left hemi- Multiple bee stings on MRI: Large right MCA terriparesis and heart attack face, neck, chest, and tory ischemic stroke upper extremities / 16 hours 71-year old woman with Multiple wasps entire Arteriography – total occlusion left hemiplegia followed by body / 24 hours of the infrarenal aorta Two paraplegia. weeks later, CT – right MCA territory infarction
Anaphylaxis, multiorgan failure
Residual hemiparesis after three months
None
Complete motor recovery within 5 days. Some improvement of cerebellar function and dysarthria after two months Complete resolution of dysarthria and cranial nerve deficits with significant recovery from the left hemiplegia after two weeks several generalized convulsions and hemodynamic instability within few hours followed by decerebration, intracerebral hemorrhage, and death within 30 hours after the stings resolution of encephalopathy and some improvement in left hemiplegia with persistence right ophthalmoplegia 15 days after admission
None
Seizure
Seizure, intracerebral hemorrhage, and death
Orbital cellulitis, bilateral cavernous sinus thrombosis
NR
None
Complete neurological recovery within a week
Non ST-elevated myocardial infarction
Partial recovery
Infrarenal aortic artery occlusion
Moein and Zand
15
Journal of Vascular and Interventional Neurology, Vol. 9
Figure 1. Diffusion-weighted image (a) and T2-FLAIR (B) brain MRI showed two punctate ischemic lesions in the right
frontoparietal.
Discussion We found 13 other case reports of ischemic stroke following wasp or bee sting in a systematic literature review on articles published prior to July 2015 in PubMed and Google Scholar with the following search topics: “bees or wasps” and “stroke or cerebral infarction” (Table 1). Age at onset ranged from 34 months to 71 years old. Twenty percent of cases had anaphylactic shock preceding their stroke. The time interval between the sting and the stroke ranged from 15 min to 4 days with a median of 16 hours. On the brain MRI, findings were variable. Ischemic infarcts in the territory of middle cerebral artery were commonly reported. Almost half of the patient recovered completely within 4 days to 8 months. One patient developed intracerebral hemorrhage and died. One patient developed multi-organ failure and progressed to a vegetative state. There was one case of cavernous sinus thrombosis reported in an 8-year old toddler. Eight cases had suffered from multiple stings. Several pathophysiologies have been postulated in the development of stroke after wasp or bee stings. The major mechanisms include hypotension and hypoxia related to an anaphylactic reaction, enhanced platelet aggregation, thrombogenesis, or vasoconstriction induced by the release of several inflammatory substances after the wasp sting [1]. These substances include serotonin (5-hydroxytryptamine), histamine, dopamine, acetylcholine, bradykinin, leukotrienes, and thromboxane [2,3]. Intense retrograde stimulation of the superior cervical ganglion resulting in obstruction of the terminal internal carotid artery is also reported to be causing
stroke in the cases of wasp sting to the head and neck area [4]. Our patient’s presentation was consistent with “Alien hand syndrome” that can occur in patients with stroke. Although our workup did not show a definite etiology, the etiology of his small diffusion defect in the right frontoparietal cortex was probably embolic. Nevertheless, the patient had some risk factors for stroke including a history of hypertension, hyperlipidemia, and acute coronary syndrome. The temporal relationship between the wasp sting and the development of neurological deficits is likely related. Since no hypotension or allergic reaction was noted in our patient and he was stung only on his hand, it is unlikely that the stroke was related to the retrograde intense activation of the superior cervical sympathetic ganglion or anaphylactic shock and hypotension. We think that the direct vasogenic and thrombogenic effect of the wasp sting was the most likely mechanism leading to stroke in our case.
References 1. Schiffman JS. Bilateral ischaemic optic neuropathy and stroke after multiple bee stings. Br J Ophthal 2004;88:1596–1597. 2. Crawley F, et al. Cerebral infarction: a rare complication of wasp sting. J Neurol Neurosurg Psychiatry 1999 Apr;66(4): 550–551. 3. Riggs JE, et al. Acute and delayed cerebral infarction after wasp sting anaphylaxis. Clin Neuropharmacol 1994 Aug; 17(4):384–348. 4. Romano JT, et al. Wasp sting-associated occlusion of the supraclinoid internal carotid artery: implications regarding the pathogenesis of moyamoya syndrome. Arch Neurol 1989 Jun;46(6):607–608. 5. Rajendiran C, et al. Stroke after multiple bee sting. J Assoc Physicians India 2012;60:122–124.
16 6. Wani M, et al. Multiple cerebral infarctions with severe multi-organ dysfunction following multiple wasp stings. Ann Indian Acad Neurol 2014;17(1):125–127. 7. Temizoz O, et al. Stroke due to bee sting. Neurologist 2009;15(1): 42–43. 8. Sachdev A, et al. Wasp sting induced neurological manifestations. Neurol India 2002;50(3):319–321. 9. Viswanathan S, et al. Middle cerebral artery infarct following multiple bee stings. J Stroke Cerebrovasc Dis 2012;21(2):148–150. 10. Day JM. Death due to cerebral infarction after wasp stings. Arch Neurol 1962;7:184–186.
11. Vidhate MR, et al. Bilateral cavernous sinus syndrome and bilateral cerebral infarcts: a rare combination after wasp sting. J Neurol Sci 2011;301(1-2):104–106. 12. Romano JT, et al. Wasp sting-associated occlusion of the supraclinoid internal carotid artery: implications regarding the pathogenesis of moyamoya syndrome. Arch Neurol 1989 Jun;46(6):607–608. 13. Dechyapirom W, et al. Concurrent acute coronary syndrome and ischemic stroke following multiple bee stings. Int J Cardiol 2011;151(2):e47–e52.Arch Neurol. 1989;46(6):607–608. 14. Chen DM, et al. Descending aortic thrombosis and cerebral infarction after massive wasp stings. Am J Med 2004;116(8):567–569.
Journal of Vascular and Interventional Neurology, Vol. 9
123
Payam Moein, MD and Ramin Zand, MD, MPH 1Department
of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, United States (email: [email protected]
2Department
of Neurology, Geisinger Medical Center, Danville, Pennsylvania, United States
3Biocomplexity
Institute, Virginia Tech, Blacksburg, Virginia, United States
Introduction Journal of Vascular and Interventional Neurology, Vol. 9
Wasps, bees, and hornets belong to the order of insects called “Hymenoptera.” Millions of cases of Hymenoptera stings happen every year around the world. Frequently, they are accompanied by local inflammatory reactions. Less commonly, victims develop severe systemic allergic reactions presenting with hypotension or anaphylactic shock, generalized edema, respiratory failure, or even multiple organ failures. Although rare, neurological complications including stroke have been reported (Table 1). In this paper, we present a case of ischemic stroke 30 min after a wasp sting, and a systematic review of the literature.
Case Presentation A 53-year old Caucasian man was stung by a wasp on his right hand while he was working in his garage. Initially, there was just local pain and inflammation without any systemic reaction. Thirty minutes later, while he was sitting on a chair, he noticed that his left upper limb became numb and started moving out of his control. He presented to our emergency department. Past medical history was significant for multiple sclerosis which was diagnosed in 2002 and has been inactive since, coronary artery disease with myocardial infarction and angioplasty in 2012, hypertension, and hyperlipidemia. His home medication included daily lisinopril 20 mg and intermittent use of daily aspirin 81 mg. He denied any history of smoking or alcohol consumption. Family history was negative for stroke. In the emergency department, the examination revealed a slightly overweight man, afebrile, with normal blood pressure and respiratory rate, and mild tachycardia with a normal level of consciousness. Lungs were clear to auscultation and heart was regular rate and rhythm with no adventitious sounds. No carotid bruit was noted.
There were an expected swelling and redness at the sting site on the back of his right hand. The neurological examination was significant for mild dysarthria, uncontrollable movement of the left hand (alien hand syndrome), decreased sensation to touch, pain, and temperature as well as extinction to double simultaneous stimulation in the entire left upper extremity. We also noticed vertical and horizontal nystagmus as well as ataxic gait and impaired tandem gait, which, according to the patient, were chronic symptoms secondary to his multiple sclerosis. His initial blood and imaging workup including cell blood count, complete metabolic and coagulation panel, lipid profile, hemoglobin A1c, cardiac enzymes, electrocardiogram, chest x-ray was unremarkable except for a mildly elevated serum creatinine (1.89 mg/dl) and an elevated serum low-density lipoprotein (160 mg/dl) and triglyceride (329 mg/dl). Initial head computed tomography (CT) scan was negative for any acute finding. The magnetic resonance imaging (MRI) study of the brain, obtained within 6 hours, showed two punctate diffusion lesions in the right frontoparietal area consistent with acute cerebral infarction (Figure 1). A magnetic resonance angiography (MRA) of the head and neck was unremarkable. The Doppler ultrasonography of the lower extremities, transthoracic echocardiography and transesophageal echocardiography, and hypercoagulable and vasculitis panel were all unremarkable. A 4-day inpatient telemetry results did not show any atrial fibrillation or other abnormal cardiac rhythm. He was prescribed aspirin 325 mg and atorvastatin 80 mg daily. The left-hand movement stopped soon after admission; however, there was a mild residual weakness in the left hand. The weakness was completely resolved within 4 days.
Vol. 9, No. 4, pp. 13–16. Published June, 2017. All Rights Reserved by JVIN. Unauthorized reproduction of this article is prohibited
14
Table 1. Case Reports on Ischemic Stroke and Other Associated Neurological Manifestations Following Bee/ Wasp Bite Presentation
Schiffman, et al.[1] Crawley et al. [2]
Riggs et al.[4]
Journal of Vascular and Interventional Neurology, Vol. 9
Rajendiran et al.[5] Wani et al.[6]
57 years old with left homonymous hemianopia followed by unresponsiveness 30-year old with anaphylaxis and respiratory failure after a wasp sting. Right homonymous superior quadrantanopia after 36 hours 52-year old with anaphylactic shock 2 min after a wasp sting followed by slurred speech and left hemiparesis a few hours later 25-year old with left hemiparesis and transient visual loss 40-year old with right hemiparesis, and severe multiorgan dysfunction.
Number of stings and location / Time interval between sting and stroke symptoms 30–40 bee sting on head, face, neck and right arm / 2 days Single wasp sting / 36 hours
Single wasp sting / a few hours
Multiple bee stings on head and neck / not reported >50 wasp stings entire body / 16 hours
Temizoz et al., 60-year old developed a left Multiple bees stings 2009[7] sided hemiplegia and dysentire body / 2 hours arthria Sachdev et al., 2002[8]
40-year old with left hemiplegia and right facial droop
Stalin Viswanathan et al., 2012 [9]
59-year old with dysarthria, Multiple bees sting left sided upper motor neu- entire body / 2 hours ron facial nerve palsy, left hemiplegia and left conjugate gaze palsy
J. MURRAY 36-year old with confusion DAY, 1962[10] and right hemiplegia
Mukund R. Vidhate et al., 2011[11]
Romano JT, et al.,1989[12]
Weeranun Dechyapirom et al.,2010[13] De-Meing Chen et al., 2004[14]
Single wasp sting on face / 10 hours
Imaging findings
Outcome
Other complications
MRI & CT – right occipital ischemic infarct followed with a large right temporo-occipital hemorrhagic infarct CT – left occipital infarction
Partial improvement of visual field loss
Ischemic optic neuropathy, hemorrhagic stroke
Full recovery
Anaphylaxis, respiratory failure
Noto reported
Seizure, anaphylactic shock
Complete motor and vision recovery in 8 months Vegetative state
None
MRI – diffuse bilateral hemisphere stroke MRA – complete right internal carotid artery and near complete left internal carotid artery occlusion MRI – right parietal and basal ganglia infarct MRI – multiple ischemic lesions in bilateral cerebral hemispheres, pons, bilateral thalami, and left parieto-occipital region. MRI – ischemic changes in the frontal lobes, right temporoparietal area, and bilateral centrum semiovale MRI – right ventral pons, and right cerebellum infarction
MRI – right MCA territory infarct
Multiple yellow jackets Not reported stings over the neck, face and arms / 15 minutes
8 years old with left hemiNot reported plegia and altered mental status followed by right hemiplegia, ophthalmoplegia, and partial left ophthalmoplegia
CT: non-hemorrhagic infarcts in left frontoparietal and bilateral subcortical regions and bilateral cavernous sinus thrombosis MRI: infarcts in the left frontoparietal cortex, posterior limb of internal capsule, and right subcortical region 34 months old with dysarth- Single yellow jacket’s CT – left putamen and caudate ria and right hemiparesis sting on the inner side ischemic infarct of his upper lip / 4 days Angiography – left supraclinoid internal carotid artery occlusion 64-year old with left hemi- Multiple bee stings on MRI: Large right MCA terriparesis and heart attack face, neck, chest, and tory ischemic stroke upper extremities / 16 hours 71-year old woman with Multiple wasps entire Arteriography – total occlusion left hemiplegia followed by body / 24 hours of the infrarenal aorta Two paraplegia. weeks later, CT – right MCA territory infarction
Anaphylaxis, multiorgan failure
Residual hemiparesis after three months
None
Complete motor recovery within 5 days. Some improvement of cerebellar function and dysarthria after two months Complete resolution of dysarthria and cranial nerve deficits with significant recovery from the left hemiplegia after two weeks several generalized convulsions and hemodynamic instability within few hours followed by decerebration, intracerebral hemorrhage, and death within 30 hours after the stings resolution of encephalopathy and some improvement in left hemiplegia with persistence right ophthalmoplegia 15 days after admission
None
Seizure
Seizure, intracerebral hemorrhage, and death
Orbital cellulitis, bilateral cavernous sinus thrombosis
NR
None
Complete neurological recovery within a week
Non ST-elevated myocardial infarction
Partial recovery
Infrarenal aortic artery occlusion
Moein and Zand
15
Journal of Vascular and Interventional Neurology, Vol. 9
Figure 1. Diffusion-weighted image (a) and T2-FLAIR (B) brain MRI showed two punctate ischemic lesions in the right
frontoparietal.
Discussion We found 13 other case reports of ischemic stroke following wasp or bee sting in a systematic literature review on articles published prior to July 2015 in PubMed and Google Scholar with the following search topics: “bees or wasps” and “stroke or cerebral infarction” (Table 1). Age at onset ranged from 34 months to 71 years old. Twenty percent of cases had anaphylactic shock preceding their stroke. The time interval between the sting and the stroke ranged from 15 min to 4 days with a median of 16 hours. On the brain MRI, findings were variable. Ischemic infarcts in the territory of middle cerebral artery were commonly reported. Almost half of the patient recovered completely within 4 days to 8 months. One patient developed intracerebral hemorrhage and died. One patient developed multi-organ failure and progressed to a vegetative state. There was one case of cavernous sinus thrombosis reported in an 8-year old toddler. Eight cases had suffered from multiple stings. Several pathophysiologies have been postulated in the development of stroke after wasp or bee stings. The major mechanisms include hypotension and hypoxia related to an anaphylactic reaction, enhanced platelet aggregation, thrombogenesis, or vasoconstriction induced by the release of several inflammatory substances after the wasp sting [1]. These substances include serotonin (5-hydroxytryptamine), histamine, dopamine, acetylcholine, bradykinin, leukotrienes, and thromboxane [2,3]. Intense retrograde stimulation of the superior cervical ganglion resulting in obstruction of the terminal internal carotid artery is also reported to be causing
stroke in the cases of wasp sting to the head and neck area [4]. Our patient’s presentation was consistent with “Alien hand syndrome” that can occur in patients with stroke. Although our workup did not show a definite etiology, the etiology of his small diffusion defect in the right frontoparietal cortex was probably embolic. Nevertheless, the patient had some risk factors for stroke including a history of hypertension, hyperlipidemia, and acute coronary syndrome. The temporal relationship between the wasp sting and the development of neurological deficits is likely related. Since no hypotension or allergic reaction was noted in our patient and he was stung only on his hand, it is unlikely that the stroke was related to the retrograde intense activation of the superior cervical sympathetic ganglion or anaphylactic shock and hypotension. We think that the direct vasogenic and thrombogenic effect of the wasp sting was the most likely mechanism leading to stroke in our case.
References 1. Schiffman JS. Bilateral ischaemic optic neuropathy and stroke after multiple bee stings. Br J Ophthal 2004;88:1596–1597. 2. Crawley F, et al. Cerebral infarction: a rare complication of wasp sting. J Neurol Neurosurg Psychiatry 1999 Apr;66(4): 550–551. 3. Riggs JE, et al. Acute and delayed cerebral infarction after wasp sting anaphylaxis. Clin Neuropharmacol 1994 Aug; 17(4):384–348. 4. Romano JT, et al. Wasp sting-associated occlusion of the supraclinoid internal carotid artery: implications regarding the pathogenesis of moyamoya syndrome. Arch Neurol 1989 Jun;46(6):607–608. 5. Rajendiran C, et al. Stroke after multiple bee sting. J Assoc Physicians India 2012;60:122–124.
16 6. Wani M, et al. Multiple cerebral infarctions with severe multi-organ dysfunction following multiple wasp stings. Ann Indian Acad Neurol 2014;17(1):125–127. 7. Temizoz O, et al. Stroke due to bee sting. Neurologist 2009;15(1): 42–43. 8. Sachdev A, et al. Wasp sting induced neurological manifestations. Neurol India 2002;50(3):319–321. 9. Viswanathan S, et al. Middle cerebral artery infarct following multiple bee stings. J Stroke Cerebrovasc Dis 2012;21(2):148–150. 10. Day JM. Death due to cerebral infarction after wasp stings. Arch Neurol 1962;7:184–186.
11. Vidhate MR, et al. Bilateral cavernous sinus syndrome and bilateral cerebral infarcts: a rare combination after wasp sting. J Neurol Sci 2011;301(1-2):104–106. 12. Romano JT, et al. Wasp sting-associated occlusion of the supraclinoid internal carotid artery: implications regarding the pathogenesis of moyamoya syndrome. Arch Neurol 1989 Jun;46(6):607–608. 13. Dechyapirom W, et al. Concurrent acute coronary syndrome and ischemic stroke following multiple bee stings. Int J Cardiol 2011;151(2):e47–e52.Arch Neurol. 1989;46(6):607–608. 14. Chen DM, et al. Descending aortic thrombosis and cerebral infarction after massive wasp stings. Am J Med 2004;116(8):567–569.
Journal of Vascular and Interventional Neurology, Vol. 9
