Symptomatic Intracranial Atherosclerosis With Impaired Distal Perfusion
A Case Study
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An 82-year-old woman with a history of hypertension presented to the emergency department with a 1-week history of 3 episodes of word-finding difficulty and right arm weakness lasting for a few minutes each without any known triggers or associated neurological symptoms.
On arrival, her blood pressure was 174/84 mm Hg. Her general and neurological examination showed mild expressive aphasia. Neuroimaging was immediately undertaken with computerized tomographic angiogram of the brain and neck, demonstrating high-grade proximal left M1 stenosis without cervical artery stenosis (Figure 1). She then underwent magnetic resonance imaging (MRI) of the brain with perfusion imaging with rapid processing of perfusion and diffusion (RAPID), which demonstrated delayed perfusion in the left middle cerebral artery territory and small left hemispheric infarcts (Figure 2, top). She was started on aspirin, clopidogrel, and high-intensity statin therapy and admitted to the stroke unit. A transthoracic echocardiogram was unremarkable, her glycosylated hemoglobin was 5.7%, and low-density lipoprotein was 131 mg/dL. Her stroke was attributed to intracranial atherosclerosis. She was discharged on dual antiplatelet therapy and high-intensity statin therapy with persistent mild expressive aphasia.