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Images in Neurology |

Late "Spectacular Shrinking Deficit"?

Francisco de Assis Aquino Gondim, MD, PhD; Florian P. Thomas, MA, MD, PhD
Arch Neurol. 2004;61(1):129-130. doi:10.1001/archneur.61.1.129.
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A 56-year-old woman with a history of colon cancer had sudden onset of left hemineglect, dysarthria, left facial weakness, forced right gaze deviation, and left hemianesthesia and hemiparesis with 0/5 (Medical Research Council classification) arm strength and 2/5 leg strength. A head computed tomographic (CT) scan 2 hours after the stroke onset showed minor evidence of ischemia. Magnetic resonance imaging (MRI) and MR angiography on day 2 revealed a malignant middle cerebral artery pattern on diffusion-weighted imaging and fluid-attenuated inversion recovery (Figure 1A) with right middle cerebral artery occlusion (Figure 1B). She was transferred to the intensive care unit because of decreased alertness. A transthoracic echocardiogram revealed a left atrial thrombus and a large thrombotic mass in the descending aorta. A CT scan taken on day 4 (Figure 2A) showed similar results to the MRI. On day 6, the right gaze preference persisted but without forced deviation, and the hemineglect had improved. On day 8, a CT scan showed marked resolution of the stroke with associated luxury perfusion, and strength in the left arm increased to 2/5. The patient developed renal and splenic infarcts and was given heparin intravenously. On day 10, neglect and strength improved further, and a CT scan showed only minimal residual ischemia and luxury perfusion (Figure 2B). Several days later, she was able to ambulate with assistance and was discharged to an inpatient rehabilitation facility.

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Figure 1.

Fluid-attenuated inversion recovery magnetic resonance imaging on day 2 shows a large right hemispheric lesion in the territory of the middle cerebral artery (MCA). B, magnetic resonance angiography reveals a right MCA occlusion.

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Figure 2.

A, The appearance of the stroke by computed tomography (CT) on day 4 resembles that by magnetic resonance imaging on day 2. B, A CT scan on day 10 reveals minimal residual ischemia and luxury perfusion.

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