A 42-year-old man, diagnosed with SARS-CoV-2, presented with nonfluent aphasia, right-sided facial palsy and hemiparesis that started five hours prior. CT head showed left-sided caudate infarct and early ischemic changes in the left putamen. CTA revealed occlusion of the proximal left M1 segment. Patient’s symptoms rapidly improved and mechanical thrombectomy was not pursued. Patient was started on dual antiplatelet therapy. Brain MRI showed acute infarcts in the left posterior parietal, lentiform nucleus, and frontal cortex. Chest CT revealed bilateral subsegmental pulmonary emboli and he was discharged on apixaban.
A month later, he returned with dysarthria and right-sided paresthesia. CTA showed severe left proximal M1 stenosis involving a longer segment. Brain MRI exhibited multiple foci of cortical infarcts within the left MCA territory with no diffusion/ perfusion mismatch. MRA head showed further pruning of the distal MCA branches within the left sylvian fissure with severe stenosis along the mid-M1 and minimal flow anteriorly, with contrast enhancement at the site of the stenosis, suggestive of vasculitis. Autoimmune vasculitis panel was unremarkable. Patient was started on intravenous methylprednisolone 1 gram daily for 5 days followed by a prednisone taper. MRA revealed improved blood flow in the left middle cerebral artery and branches. He was discharged with mild residual aphasia.