Thrombotic Thrombocytopenic Purpura (TTP) is a hematologic disorder with varied presentations. We report a case initially mimicking a left MCA syndrome, with MRI showing innumerable microhemorrhages and diffuse dural enhancement, rare CNS findings not previously described in TTP.

A 51-year-old African American male with no medical history presented with sudden expressive aphasia and dysarthria. Last known normal was 2.5 hours prior. He presented with a headache, right facial droop, and right arm weakness with initial NIHSS 5. CT head (CTH) and CT angiogram (CTA) were unremarkable. With no contraindications, TNK 25 mg was administered. Shortly after, his NIHSS increased to 18 with global aphasia, right hemianopia, left gaze preference, and right hemiparesis. Repeat CTH/CTA with perfusion were negative and DSA showed no occlusion. Labs revealed severe thrombocytopenia with platelets of 44, hemoglobin 9.7, creatinine 2.3, schistocytes, elevated indirect bilirubin, high reticulocyte count, low haptoglobin, and worsening cytopenia. ADAMTS13 activity returned low at 15.8%. FFP was administered and Hematology and Nephrology were consulted for plasma exchange (PLEX). MRI Brain with contrast showed an acute left parietal infarct with innumerable microhemorrhages and diffuse dural enhancement, uncommon radiographic features in TTP. The patient received 3 PLEX sessions, methylprednisolone 1g x 3 days, a prednisone taper, and weekly rituximab. He improved and was discharged to acute rehab without focal deficits.

In acute stroke presentations with thrombocytopenia and hemolysis, TTP should be considered. Rare neuroimaging features such as diffuse dural enhancement and microhemorrhages may aid diagnosis.