A 62-year-old woman with hypertension and hyperlipidemia presented with 18 hours of fluctuating right-hand clumsiness and word-finding difficulty. Symptoms were intermittent but never fully resolved, lasting 20–30 minutes at a time.

On arrival:

• NIHSS 2 (mild aphasia, subtle R pronator drift)

• BP 178/92

• Glucose 112

• EKG: NSR

CT head: unremarkable

CTA: did not show one clean blockage. Instead, there was irregular, scattered narrowing of several M2/M3 branches — too diffuse to fully explain the two separate cortical infarcts.

MRI DWI: two acute cortical infarcts (inferior parietal + posterior temporal), noncontiguous, both MCA territory but different branch zones.

Perfusion: small mismatch around each lesion.

Inflammatory markers: ESR/CRP normal

Telemetry: normal

Echo: no PFO, no thrombus

BP variability correlated with symptom recurrence.

Her symptoms continued to wax and wane in the ED — TIA-like episodes despite MRI-proven infarcts.

Differential diagnostic debate included:

• Embolic shower from an occult cardioembolic source

• In-situ branch occlusions from diffuse ICAD

• Early/atypical RCVS

• Vasculitic process despite normal markers

She stabilized with BP optimization, aspirin, and high-intensity statin — but the mechanism remained unclear, and therefore so did the optimal recurrence-prevention strategy.

Open Question for Discussion:

What is the most likely mechanism of stroke in this case, and what single next test or intervention would most directly prevent early recurrence?

Ardeshir  Khademi MD is double board certified in vascular Neurology and Neurology. He has 25 years experience and is an expert in the treatment of neurological conditions with TMS (Transcranial Magnetic Stimulation). He continues his dedicated service of inpatient calls for the Stroke and Neurology Services.