PMC6521521_01
(a) Axial FLAIR image reveals multiple hyperintensities in watershed territories. (b) Time of Flight MRA shows bilateral MCA occlusions (arrows). (c, d) DSA of the right (c) and left (d) internal carotid arteries verifies the MCA occlusions (white arrows). Proliferation of small abnormal net-like vessels is also noticed. Diffusion Weighted Imaging (e) and Apparent Diffusion Coefficient (ADC) map (f) reveal diffusion restriction in the left MCA territory due to an acute infarct (arrows).
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However, a more thorough analysis of brain MRI revealed that lesions were mainly in the border zone of anterior cerebral artery (ACA) and middle cerebral artery (MCA) with no evidence of restricted diffusion (Figure 1(a)). Brain MRA showed a significant stenosis in the proximal segment of MCA and ACA bilaterally and collateralization mainly around M1 and A1 segments, findings typically seen in MMD (Figure 1(b)). Digital subtraction angiography (DSA) of neck and head confirmed diagnosis (Figures 1(c) and 1(d)). Antiplatelet therapy started, but two days later, she suddenly developed global aphasia and right hemiparesis (National Institutes of Health Stroke Scale/ NIHSS 6) and brain MRI revealed acute infarct in the distribution of the left MCA (Figures 1(e) and 1(f)).