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Images in Neurology |

Devoid of Flow

Peter E. Turkeltaub, MD, PhD; Sarah M. Kranick, MD; Brett Cucchiara, MD
Arch Neurol. 2009;66(4):536. doi:10.1001/archneurol.2009.7.
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A 55-year-old, previously healthy woman presented with neglect and left hemiplegia 5½ hours after onset of symptoms. Her deficits did not improve, and brain magnetic resonance imaging performed 36 hours after symptom onset revealed a large right subcortical infarction with cortical sparing. T2-weighted sequences showed an apparent flow void in the proximal right middle cerebral artery (MCA), suggesting normal flow (Figure). However, gradient echo sequences demonstrated a hypointense signal in the right MCA consistent with thrombus. Magnetic resonance angiography subsequently confirmed a right MCA occlusion and demonstrated a cervical internal carotid artery dissection, which was the presumed stroke mechanism. At 3-month follow-up, her neglect had resolved, but she had persistent moderate hemiparesis that affected the arm more than the leg. Her modified Rankin scale score was 3.

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. Magnetic resonance images of the middle cerebral artery (MCA). A, False flow void in the right MCA on T2-weighted imaging. T2-weighted hyperintensity in the adjacent brain parenchyma and decreased prominence of the right sylvian fissure are due to acute infarction. Acute thrombus in the right MCA appears mildly hyperintense on T1-weighted imaging (B) and hypointense on the gradient echo sequence (C). D, Right terminal internal carotid artery and MCA occlusion is apparent on magnetic resonance angiography.

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