A 56-year-old woman with a history of colon cancer had sudden onset of left hemineglect, dysarthria, left facial weakness, forced right gaze deviation, and left hemianesthesia and hemiparesis with 0/5 (Medical Research Council classification) arm strength and 2/5 leg strength. A head computed tomographic (CT) scan 2 hours after the stroke onset showed minor evidence of ischemia. Magnetic resonance imaging (MRI) and MR angiography on day 2 revealed a malignant middle cerebral artery pattern on diffusion-weighted imaging and fluid-attenuated inversion recovery (Figure 1A) with right middle cerebral artery occlusion (Figure 1B). She was transferred to the intensive care unit because of decreased alertness. A transthoracic echocardiogram revealed a left atrial thrombus and a large thrombotic mass in the descending aorta. A CT scan taken on day 4 (Figure 2A) showed similar results to the MRI. On day 6, the right gaze preference persisted but without forced deviation, and the hemineglect had improved. On day 8, a CT scan showed marked resolution of the stroke with associated luxury perfusion, and strength in the left arm increased to 2/5. The patient developed renal and splenic infarcts and was given heparin intravenously. On day 10, neglect and strength improved further, and a CT scan showed only minimal residual ischemia and luxury perfusion (Figure 2B). Several days later, she was able to ambulate with assistance and was discharged to an inpatient rehabilitation facility.
de Assis Aquino Gondim F, Thomas FP. Late "Spectacular Shrinking Deficit"?. Arch Neurol. 2004;61(1):129-130. doi:10.1001/archneur.61.1.129