PMC4727608_01
Non-contrast CT scan brain showing A) and C) no CT signs of acute infarction or hemorrhage. B) Axial image and D) Coronal image showing focal hyper-density at the M2 segment of the left middle cerebral artery (MCA dot sign).
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F1
She had her first CT of the brain carried out at 35 minutes from hospital arrival (Figure 1), which showed a small hyperdense dot sign in the M2 segment of the left MCA with no direct sign of ischemic infarct or hemorrhage.
Magnetic resonance imaging with diffusion-weighted image (DWI), apparent diffusion coefficient (ADC) and axial fluid attenuated inversion recovery (FLAIR) WI showing: A) Acute infarction of the left lentiform nucleus and corona radiata region with high signal on DWI (arrow in A); B) Low signal on ADC (arrow in B); C) FLAIR WI with loss of the normal signal void along the M2 and M3 branches of the left middle cerebral artery (arrow in C) implying slow blood flow.
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F2
The MRI of brain with diffusion weighted imaging (DWI) and magnetic resonance angiography of the cerebral circulation were carried out to document cerebral infarction (Figure 2).
3-D time-of-flight magnetic resonance angiogram (3 hours after stroke onset) showed A) left middle cerebral (MCA) segment with contrast enhancement, B), C), & D) signal attenuation from the M2 segment of the left MCA depicted with arrows graded as partial thrombo-embolic occlusion.
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F3
This showed acute infarction of the left lentiform nucleus and corona radiata region with signal attenuation from the M2 segment of the left MCA graded as partial thrombo-embolic occlusion (Figures 3 & 4).
Maximum intensity projection 3-D time-of-flight magnetic resonance angiogram of the circle of Willis (3 hours and 30 minutes after stroke onset) showing: A and B) thrombo-embolic filling defect at the M2 segment (short white arrows in A and B), narrowing distal M2 segment (short grey arrows in A and B) and pruning of M3 segment branches (long white arrow in A and B) of the left middle cerebral artery.
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F4
This showed acute infarction of the left lentiform nucleus and corona radiata region with signal attenuation from the M2 segment of the left MCA graded as partial thrombo-embolic occlusion (Figures 3 & 4).
Non-contrast CT scan brain (26 hours after stroke [22 hours after IV thrombolysis]) showed: A) previously seen hyperdense left middle cerebral artery dot sign in the M2 segment is less prominent. B), C) and D) showed acute linear infarction at the left lentiform and head of caudate nuclei.
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F5
A repeat CT of brain (Figure 5) the next day showed acute linear infarction at the left lentiform and head of caudate nuclei.
Follow up coronal A) and axial B) maximum intensity projection 3-D time-of-flight magnetic resonance angiogram, axial fluid attenuated inversion recovery [FLAIR] C) and coronal D) T2 WI MRI showing: A) Patent M2 segment of left middle cerebral artery. B) Good filling of M3 segment branches. C) Chronic infarction at left lentiform nucleus. D) Chronic infarction at head of caudate nucleus.
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F6
A clinical diagnosis of SLE with secondary antiphospholipid syndrome presenting with acute MCA ischemic stroke as the first manifestation was made, and after recovery she was started on lifelong oral warfarin anticoagulation with regular INR monitoring. She followed up with us over the next 6 months with no residual deficit. A follow-up MRI brain (Figure 6) plus MRA of cerebral circulation showed patent M2 segment of left MCA, chronic infarction at left lentiform nucleus and head of caudate nucleus.