Acute ischaemic larger artery stroke presenting as a subcortical lesion with grey matter sparing: a case report

Large artery infarctions classically involve both white matter and grey matter in the distribution of the occluded artery. Rarely, large artery infarctions can present as isolated white matter lesions. We describe a 38-year-old, right-hand dominant woman, who presented with sudden onset right face-arm-leg weakness together with expressive aphasia. Neuroimaging demonstrated changes restricted to the white matter in the distribution of the left middle cerebral artery territory. Vascular imaging of her head and neck vessels showed irregular narrowing of the intracranial portions of the left internal carotid artery. Vasculitis was suspected due to these findings on imaging, and she was initially treated with steroids. However, due to the negative vasculitis work-up and an inadequate response, the steroids were discontinued, and she was treated with antiplatelets and statins. Early stroke rehabilitation commenced while inward.
Large artery ischaemic strokes can rarely present as white matter lesions when there is adequate collateral circulation, which leads to the sparing of the grey matter.