Post-partum female who woke up with hemiparesis.

PATIENT PRESENTATION

A previously healthy 30‐year‐old female (2‐months post‐partum) woke up with right‐side hemiplegia and the inability to speak. She was last seen normal 8 hours prior by her husband before going to bed. Initial National Institutes of Health Stroke‐Scale Score (NIHSS) was 17. Acute brain imaging with magnetic resonance imaging (MRI) revealed restrictions of diffusion in the medial and posterior left middle cerebral artery (MCA) territory (core <70 cc) (Figure 1A) without corresponding fluid‐attenuated inversion recovery (FLAIR) signal abnormalities (Figure 1B). Acute vascular imaging revealed large vessel occlusions of the cervical/petrous segments of the left internal carotid artery and of the proximal left MCA.

FIGURE 1

Diffusion/FLAIR mismatch. Panel A, Diffusion‐Weighted Imaging (DWI) sequences with a restriction of diffusion (arrows show regions of early onset ischemia). Panel B, Fluid‐Attenuated Inversion Recoverey (FLAIR) sequences without any corresponding signal abnormalities.

DIAGNOSIS

Ischemic stroke with diffusion/FLAIR mismatch

The presence of a diffusion/FLAIR mismatch is indicative of stroke onset being less than 4.5 hours (Figure 1B). , Previous preliminary wake‐up stroke trials have used MRI to serve as the “witness” to when stroke onset begins and as an eligibility requirement for acute interventions (ie, thrombolysis). , MRI also demonstrated a small core (<70 cc) with a large territory of uninfarcted MCA territory, consistent with patient selection for thrombectomy in the extended time window. In our case, the patient was taken directly to the neuro‐cath lab for thrombectomy. Vessel flow was re‐established. Two days later, speech and power were significantly improved (NIHSS 7), and 4 weeks later the patient had no deficits.