A 36-year-old woman presented with abdominal pain followed by fever, confusion, 
right sided weakness and nuchal rigidity. The investigation showed severe 
anemia, thrombocytopenia and left middle cerebral artery (MCA) territory 
infarction. The platelet was given before the lumbar puncture. After that, the 
patient's clinical was deteriorating to quadriplegia and stuporous. Then the 
patient was referred to Siriraj Hospital. The patient was diagnosed thrombotic 
thrombocytopenic purpura (TTP) following pentad of clinical features: 
microangiopathic hemolytic anemia, thrombocytopenia, fever neurologic, and renal 
abnormalities. Magnetic resonance imaging (MRI) and magnetic resonance 
angiography (MRA) of brain showed extensive bilateral MCA and mid basilar artery 
stenosis. That was uncommon findings in TTP. The authors believed that platelet 
transfusion made the clinical deterioration and develop extensive intracranial 
vessels stenosis. Even the plasma exchange was performed but the neurological 
symptoms did not improved. Finally, the patient succumbed from ventilator 
associated pneumonia at 2 months after diagnosis.