Part 2: Ischemic Stroke: Evaluation, Treatment, and Prevention

Matthew Brandon Maas, MD, and Joseph E. Safdieh, MD

Dr. Maas is a fellow in Stroke and Neurocritical Care, Harvard Medical School, Departments of Neurology, Massachusetts General and Brigham and Women’s Hospitals, Boston, MA. Dr. Safdieh is an assistant professor of neurology, Department of Neurology and Neuroscience, Weill Medical College of Cornell University, New York, NY.

Question 1

Questions 1–3 refer to the following case.
A 72-year-old man presents to the emergency department complaining of weakness and lightheadedness. The patient reports having passed out twice earlier in the day. He has no history of cardiac symptoms. On initial evaluation, the patient is hypotensive and tachycardic. A gastrointestinal hemorrhage is identified and treated appropriately. Two days later, despite normal hemoglobin level and volume repletion, the patient still complains of weakness. On examination, his grip strength and distal leg strength are normal, but he is found to have proximal weakness, especially in the arms. The possibility of myopathy is entertained, but creatine kinase levels are normal. A diffusion-weighted magnetic resonance imaging (MRI) sequence of the brain is obtained (Figure).
The diffusion-weighted MRI (DWI) in the Figure shows areas of hyperintensity. What other MRI finding would help confirm that the findings seen on DWI likely represent acute infarction?

Neurology Vol 13 Part 2 Figure

Figure. Diffusion-weighted image of the patient in questions 1 to 3.

Click image for full size

  •  Corresponding hyperintensity on apparent diffusion coefficient (ADC) maps
  •  Corresponding hyperintensity on fluid attenuation inversion recovery imaging
  •  Corresponding hypointensity on ADC maps
  •  Corresponding hypointensity on T2-weighted images

Updated 12/03/2014 • jdw | Copyright ©2014 Turner White Communications