Multiterritory Acute Ischemic Stroke with Bilateral Middle Cerebellar Peduncle T2/FLAIR Hyperintensities in the Setting of a Fatal Systemic Arterial Thrombotic Process: A Case Report

Ischemic stroke under 55 years presents a distinct etiological challenge with higher prevalence of non-atherosclerotic causes. We report a fatal case of multiterritory acute cerebral infarction with bilateral middle cerebellar peduncle (MCP) T2/FLAIR hyperintensities in a 50-year-old woman, pursuing two educational objectives: (1) provide a radiological framework for interpreting bilateral MCP T2/FLAIR hyperintensities without diffusion restriction in the context of basilar occlusion; and (2) illustrate a diagnostic approach to multiterritory arterial thrombosis concurrent with systemic infection. A 50-year-old Ivorian woman with hypertension, diabetes, and severe LEAD complicated by right lower limb trophic ulcers and local infection was admitted for sudden-onset right hemiplegia (NIHSS 9) occurring one week earlier. Brain MRI showed acute infarcts in the left corona radiata and right paramedian pons, Fazekas grade 2 leukoaraiosis, a chronic callosal lesion, and symmetric bilateral MCP T2/FLAIR hyperintensities without diffusion restriction or enhancement. MR angiography revealed left M1 occlusion and absent basilar artery flow. Transthoracic echocardiography excluded intracavitary thrombus. Laboratory tests showed leukocytosis (45,190/mm³, 90.7% neutrophils), anemia (Hb 8.1 g/dL), elevated CRP (192 mg/L), and hyperuricemia. The patient died three weeks after admission from sepsis and multiorgan failure following above-knee amputation. Antiphospholipid and thrombophilia work-up could not be completed. Bilateral MCP T2/FLAIR hyperintensities without diffusion restriction or enhancement, in the setting of basilar occlusion and longstanding leukoaraiosis, are most consistent with chronic ischemic gliosis. Multiterritory arterial thrombosis concurrent with active systemic infection should prompt immediate parallel evaluation for thromboinflammatory conditions, including urgent antiphospholipid antibody testing, before irreversible clinical decisions are made.