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A 70-year-old woman was hospitalized for intermittent, reversible cerebral ischemia causing weakness of the right side for several days, before resolving. A computed tomographic (CT) scan showed no intracranial abnormalities. She was found to have 99% stenosis of the left carotid artery, and a left carotid endarterectomy was performed. Aspirin therapy (325 mg daily) was initiated, and the patient was discharged. Carotid ultrasonography performed as part of routine follow-up 2 years later was normal, without clinically significant stenosis on either side. One month later, the patient was admitted with acute left hemiparesis. A CT scan revealed a new calcified object in the proximal right middle cerebral artery (Panel A, arrow). Thrombolytic agents were not given, because the time of onset of the stroke could not be ascertained. A repeat CT scan obtained 3 days later showed a large infarction in the distribution of the right middle cerebral artery (Panel B). Three days after admission, respiratory distress developed. A CT scan of the chest revealed dense calcific plaques lining the thoracic aorta (Panel C, arrows), the likely source of the embolus in the right middle cerebral artery. The patient was discharged to a long-term care facility, without neurologic improvement, after a prolonged hospital stay. The aortic arch should be considered a potential source of cerebral embolism and infarction.
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