Symptomatic Intracranial Atherosclerosis With Impaired Distal Perfusion

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.Figure 1. Computed tomographic angiogram demonstrates critical left proximal middle cerebral artery (M1) stenosis.Figure 2. patient’s sequential rapid processing of perfusion and diffusion (RAPID) magnetic resonance imaging (MRI) demonstrates the evolution of the perfusion deficit. The top of the figure shows the initial RAPID MRI with punctate left hemispheric infarcts and delayed perfusion in the left middle cerebral artery territory with 61-mL volume of brain tissue with T max u003e6-s delay. Middle of figure shows second RAPID MRI with infarct expansion and 61-mL volume of brain tissue with T max u003e6-s delay. The bottom of the figure shows the last RAPID MRI after blood pressure augmentation showing stable left hemispheric infarcts without areas of brain tissue with T max u003e6-s delay. ADC indicates …