Key result
Enoxaparin prompts rapid cortical lesion resolution and near-complete carotid thrombus regression within days.
Why the study?
Ischemic lesions appearing hyperintense on DWI and FLAIR sequences are generally regarded as established infarcts, and this report presents a patient with early radiological regression of DWI-FLAIR-positive cortical lesions without reperfusion therapy.
Case Report (n=1)
DWI-FLAIR positivity on brain MRI may not always indicate irreversible ischemic infarction, as early clinical and radiological regression can occur without reperfusion therapy in young stroke patients.
Answers are grounded in this paper and cite their sources.
DWI-FLAIR lesions may not indicate irreversible infarction; leaves open whether this challenges the paradigm pending prospective validation.
Introduction: Ischemic lesions that appear hyperintense on diffusion-weighted imaging (DWI) and FLAIR sequences are generally regarded as established infarcts. This report aims to present a patient in whom early radiological regression was observed in DWI–FLAIR-positive cortical lesions even though no reperfusion therapy was given.Case: A 42-year-old man presented with speech disturbance and right-sided weakness that had persisted for four days. His history included uncontrolled type 2 diabetes mellitus, a below-knee amputation for peripheral arterial disease, and clopidogrel and insulin treatments that he had discontinued one month earlier. His HbA1c was 13.4%. Neurological examination revealed global aphasia and right hemiplegia. Non-contrast brain computed tomography showed a hypodense area in the left posterior parietal cortex. Brain MRI showed a large cortical ischemic lesion in the left posterior parietal cortex and multiple small cortical ischemic lesions in the left frontal lobe. All lesions were hyperintense on DWI and FLAIR sequences. CT angiography showed a long-segment thrombus extending from the left common carotid artery into the internal and external carotid arteries. Because of late presentation and FLAIR positivity, neither intravenous thrombolysis nor interventional treatment was performed. Enoxaparin 8,000 IU twice daily was started because of the ongoing risk of embolization. On the third day of treatment, the hemiplegia had resolved completely and the aphasia had partially improved; follow-up imaging showed that the frontal cortical lesions had disappeared completely on both DWI and FLAIR sequences. Repeat CT angiography on day 10 showed that the thrombus had almost completely regressed (Figure 1–3). At one month, only minimal aphasia remained.Discussion/Conclusion: DWI–FLAIR positivity may not indicate irreversible ischemic damage in every patient. In young patients, early spontaneous reperfusion following dynamic distal microembolization may explain the clinical and radiological regression of cortical lesions.Keywords:
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Mengüşoğlu et al. (2026) conducted a case report in Acute ischemic stroke with DWI-FLAIR-positive cortical lesions and carotid artery thrombus (n=1). Enoxaparin was evaluated on Clinical and radiological regression of cortical ischemic lesions and carotid thrombus. Enoxaparin 8,000 IU twice daily led to complete disappearance of frontal DWI-FLAIR cortical lesions by day 3 and near-complete carotid thrombus regression by day 10.
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