Stroke in a young adult: looking beyond the diffusion-weighted imaging sequence

Area of Science:

• Neurology
• Radiology
• Cardiology

Background:

• Transient ischemic attacks (TIAs) can present with subtle or absent acute findings on standard diffusion-weighted imaging (DWI) MRI.
• Younger patients with stroke symptoms require thorough etiological investigation.
• Patent foramen ovale (PFO) is a potential cause of cryptogenic stroke.

Purpose of the Study:

• To highlight the diagnostic challenges of TIA in young adults.
• To emphasize the utility of advanced MRI sequences in detecting early ischemic changes.
• To identify the underlying cause of stroke in a young patient with migraine.

Main Methods:

• A 37-year-old woman with migraine experienced transient dysarthria.
• Initial brain MRI with DWI showed no acute infarct.
• Subsequent MRI with T2*-weighted gradient echo and perfusion imaging identified an intraluminal thrombus in the middle cerebral artery (MCA).
• Follow-up MRI confirmed a small infarct.
• Etiological workup revealed a patent foramen ovale.

Main Results:

• Diffusion-weighted imaging (DWI) was initially negative for acute cerebral infarction.
• T2*-weighted gradient echo and hyperintense vessel sign indicated slow flow and thrombus in a distal MCA branch.
• A small infarct was confirmed on follow-up MRI 24 hours later.
• A patent foramen ovale was identified as the cause of the stroke.

Conclusions:

• Diffusion-weighted imaging (DWI) may yield false negatives in transient ischemic attacks (TIAs), particularly in young patients.
• Advanced MRI techniques, including T2*-weighted and perfusion imaging, are crucial for detecting subtle ischemic events and thrombi.
• Patent foramen ovale should be considered in the etiological workup of young stroke patients, especially those with migraine history.