Clinical Reasoning: Recurrent strokes secondary to unknown vasculopathy

A healthy 84-year-old woman of Chinese ethnicity presented with multiple separate episodes of focal neurologic deficits (right-sided weakness with aphasia, as well as left-sided weakness) over 2 days, in the context of 3 months of subacute cognitive decline. She had been well leading up to this presentation. CT angiogram showed multifocal constriction of the middle cerebral arteries and bilateral M3 occlusions. Posterior circulation vessels were unremarkable. Cerebral MRI with gadolinium showed multiple foci of restricted diffusion in the bilateral frontal and parietal lobes and diffuse T2/fluid-attenuated inversion recovery changes without abnormal enhancement, consistent with infarction of varying ages (figure 1, A). She was started on low-dose acetylsalicylic acid and deep vein thrombosis prophylaxis and admitted to the hospital.

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