Stuttering lacunar infarction captured on serial MRIs

Abstract

A 61-year-old man with a history of untreated hyperlipidemia presented with acute onset of dysarthria and right-sided weakness. His symptoms had improved but not resolved upon arrival at the hospital (NIH Stroke Scale [NIHSS] score was 4). Brain MRI showed a hyperintense lesion in the medial left pons on diffusion-weighted imaging (DWI) with a matching area of hypointensity on apparent diffusion coefficient map. The fluid-attenuated inversion recovery (FLAIR) sequence showed no changes in this area, suggesting a hyperacute lesion. There was no evidence of focal stenosis of the large intracranial vessels (figure 1) or intracranial hemorrhage. Perfusion-weighted imaging demonstrated an area of increased mean transit time (MTT) within the ischemic lesion (figure 2A). The patient's symptoms had completely resolved after the imaging (NIHSS score = 0). His symptoms recurred 30 minutes later for only 5 minutes. Brain MRI repeated 2 hours later, while asymptomatic, showed complete resolution of the abovementioned lesions (figure 2B). Therefore, IV thrombolysis was not indicated. The patient was admitted to the hospital with a diagnosis of TIA for further workup. He was started on aspirin 81 mg and atorvastatin 80 mg daily. Systolic blood pressure values ranged from 103 to 154 mm Hg, with most values between 110 and 140 mm Hg. No clear association between blood pressure and neurologic symptoms was noted during hospital admission. On the third day of hospitalization, the patient was discharged home while he remained asymptomatic and repeat brain MRI was intact (figure 2C).