72-year-old female with altered mental status and Ischemic Stroke

On the 4-sequence MRI protocol (A-D), the axial FLAIR image (B) demonstrates multifocal ill-defined areas of signal hyperintensity within the midbrain with corresponding restricted diffusion on the axial diffusion weighted trace image (C), consistent with infarctions. Additional foci of infarction were seen in the left occipital lobe, left mesial temporal lobe, both thalami and the cerebellum (images not shown). No definite abnormality is seen on the sagittal T1-weighted image (A) or axial T2* image (D). MR angiography was also requested. MRA maximum intensity projection image (E) reveals thrombus with the distal basilar (white arrow) and proximal posterior cerebral arteries, which is confirmed on the axial source MR angiography images (F, G) (white arrow). Even in retrospect, this finding was not apparent on any of the sequences included in the 4-sequence MRI protocol. MRA imaging adds significant value in cases with clinical suspicion for vascular occlusion or thrombosis.