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Hemiplegia in Lemierre syndrome: a neuroimaging strategy

flow observed in the ophthalmic arteries was orthodromic. A transcranial colorcoded duplex sonography showed patency of the cerebral arteries. MRA, negative for the presence of cerebral lacunar infarctions, confirmed the presence of vascular anastomoses between the left ascending cervical artery, the left occipital and the left vertebral artery, but did not give any information about the presence of reversal of flow. It is known that the intraand extracranial arteries share a common embryonal vascular origin and maintain a common embryonal memory , thus ensuring anastomoses and compensations in situations of occlusion and hypoperfusion. These anastomotic systems are activated depending on the conditions of hemodynamic balance of the vascular territory. In the case of occlusion, a more complex anastomotic system will be activated. As seen in Table 1, collateral circulation of the neck was observed both with color-coded duplex sonography and MRA. However, MRA failed to reveal the anastomosis between the right and left superior thyroid artery and could not give any information about the flow inversions. On the contrary, the transcranial colorcoded duplex sonography gave important information about the cerebral flow direction. Our patient was asymptomatic and the diagnosis of left common carotid and right internal carotid occlusion was therefore an incidental finding. In patients with carotid artery occlusion, diagnostic imaging is necessary to assess not only vascular anatomy and patency, but also conditions of altered perfusion, and compensatory mechanisms. For these reasons, we adopted different imaging procedures in our patient, to make a correct diagnosis; however, in some cases such as the one presented here, the neck and brain color-coded duplex sonography alone is able to give all the necessary information about vascular anatomy, patency, and anastomosis.