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A 47-year-old man presented to the accident and emergency department with a 3 day history of frontal headache and left arm weakness. He had no past medical history of note, including connective tissue disease, and no recent head or neck trauma. Neurological assessment demonstrated left arm weakness grade 4/5 and left visual and sensory inattention. Initial CT demonstrated ischaemic changes in the right middle cerebral artery territory. Carotid Doppler ultrasound was normal. Given the high index of suspicion for dissection, the patient underwent standard brain magnetic resonance (MR) imaging including axial T1 fat suppression, three dimensional (3D) time of flight and contrast enhanced MR angiography (MRA). T2 weighted brain MR demonstrated two discreet wedge shaped infarcts in …
Competing interests None.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.