RESIDENT & FELLOW SECTION Teaching NeuroImages: Complex bilateral corpus callosum infarction after paradoxical embolism Lightning strikes twice George Vasconcelos Calheiros de Oliveira Costa, MD, Mario Henrique Lazaretto Padua, MD, Sheila Cristina Ouriques Martins, MD, PhD, Juliana Avila Duarte, MD, PhD, Rosane Brondani, MD, PhD, and Andrea Garcia de Almeida, MD, PhD ® Neurology 2018;91:e1947-e1948. doi:10.1212/WNL.0000000000006505 Correspondence Dr. Vasconcelos Calheiros de Oliveira Costa george_vcoc@hotmail.com Figure 1 Complex bilateral corpus callosum infarction Axial diffusion-weighted images at the level of the genu and at the supraventricular level (A, B, respectively) show bilateral restricted diffusion area within anterior cerebral artery territory, including corpus callosum and other brain areas. Diffusion tensor imaging postprocessing colored map (C, arrow) demonstrates reduced volume and diffusion anisotropy of callosal commissural fibers. A 47-year-old man developed sudden-onset abulia and alien hand syndrome (AHS). MRI revealed bilateral ischemic injury within anterior cerebral artery territory (a complex bilateral corpus callosum infarction1) due to obstruction of a variant bihemispheric A2 branch by a thrombus (figures 1 and 2), also demonstrated on 3D volume-rendered CT angiography (figure 2). The finding of lower-limb deep venous thrombosis in a patient with right-to-left interatrial shunt accounted for the case, given workup was otherwise unremarkable. MORE ONLINE Teaching slides links.lww.com/WNL/ A738 This case is unique for paradoxical embolization of a variant artery (prevalence 2%–7%2) that led to a complex bilateral corpus callosum infarction presenting with AHS.1 Author contributions G. Vasconcelos Calheiros de Oliveira Costa: concept design, elaboration and critical revision of the case report. M.H. Lazaretto Padua: elaboration and critical revision of the case report. S.C. Ouriques Martins: elaboration and critical revision of the case report for intellectual content. J.A. Duarte: image selection and critical revision of the case report for intellectual content. R. Brondani: critical revision of the case report for intellectual content. A. Garcia de Almeida: critical revision of the case report for intellectual content. From the Departments of Neurology (G.V.C.d.O.C., M.H.L.P., S.C.O.M., R.B., A.G.d.A.), Internal Medicine (S.C.O.M.), and Radiology (J.A.D.), Hospital de Clı́nicas de Porto Alegre, Brazil. Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article. Copyright © 2018 American Academy of Neurology Copyright ª 2018 American Academy of Neurology. Unauthorized reproduction of this article is prohibited. e1947 Figure 2 Vessel anatomy and occlusion Axial gradient recalled echo T2* and sagittal T1-weighted images (A, B) reveal thrombotic occlusion of the variant right bihemispheric A2 branch (red arrows). 3D volume-rendered CT angiography also demonstrates absence of downstream blood flow (C, D, green arrows) and the hypoplastic left A2 branch (D, blue arrow). Study funding No targeted funding reported. Disclosure The authors report no disclosures relevant to the manuscript. Go to Neurology.org/N for full disclosures. e1948 Neurology | Volume 91, Number 20 | November 13, 2018 References 1. 2. Gao X, Li B, Chu W, Sun X, Sun C. Alien hand syndrome following corpus callosum infarction: a case report and review of the literature. Exp Ther Med 2016;12: 2129–2135. Dimmick SJ, Faulder KC. Normal variants of the cerebral circulation at multidetector CT angiography. Radiographics 2009;29:1027–1043. Neurology.org/N Copyright ª 2018 American Academy of Neurology. Unauthorized reproduction of this article is prohibited. Teaching NeuroImages: Complex bilateral corpus callosum infarction after paradoxical embolism: Lightning strikes twice George Vasconcelos Calheiros de Oliveira Costa, Mario Henrique Lazaretto Padua, Sheila Cristina Ouriques Martins, et al. Neurology 2018;91;e1947-e1948 DOI 10.1212/WNL.0000000000006505 This information is current as of November 12, 2018 Updated Information & Services including high resolution figures, can be found at: http://n.neurology.org/content/91/20/e1947.full References This article cites 2 articles, 0 of which you can access for free at: http://n.neurology.org/content/91/20/e1947.full#ref-list-1 Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): All Cerebrovascular disease/Stroke http://n.neurology.org/cgi/collection/all_cerebrovascular_disease_strok e Embolism http://n.neurology.org/cgi/collection/embolism Infarction http://n.neurology.org/cgi/collection/infarction MRI http://n.neurology.org/cgi/collection/mri Permissions & Licensing Information about reproducing this article in parts (figures,tables) or in its entirety can be found online at: http://www.neurology.org/about/about_the_journal#permissions Reprints Information about ordering reprints can be found online: http://n.neurology.org/subscribers/advertise Neurology ® is the official journal of the American Academy of Neurology. 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