Wk 1, Case 1 - Review

Patient History: 69 y.o. male with a past medical history significant for HTN, HLD, MI (S/p stents 2016), and diabetes (on metformin) who presented to the ED as a BAT for left sided facial droop and upper/lower extremity weakness. Patient was in his usual state of health when he went to take a nap. His wife saw him walk into the bedroom at 3:00p (LKN) and heard him yelling for help when he woke up around 4:30p with left sided weakness.

Findings
CT, CTA, CTP report from 12/31/2020:

INDICATION: 69 y.o. male with a past medical history significant for HTN, HLD, MI (S/p stents 2016), and diabetes (on metformin) who presented to the ED as a BAT for left sided facial droop and upper/lower extremity weakness.

Patient was in his usual state of health when he went to take a nap. His wife saw him walk into the bedroom at 3:00p (LKN) and heard him yelling for help when he woke up around 4:30p with left sided weakness.

COMPARISON: CT brain obtained earlier in the day.

TECHNIQUE/PROTOCOL: Axial CT and CTA images of the head and neck. Sagittal and coronal reformats were included. 3D reconstructions were created for vascular evaluation. Dynamic CT perfusion was performed of the brain with contrast. Data was sent to RAPID server for analysis.

NONVASCULAR FINDINGS:

No intracranial hemorrhage. No extra-axial fluid collection.

The ventricles and sulci are normal in size for age. Basal cisterns are clear.

No intracranial mass or mass effect.

Orbital structures are normal.

The paranasal sinuses and mastoid air cells are clear.

Nonspecific peripheral and subpleural fibrosis and ground glass opacities within the visualized lung apices. Correlate with lab results to exclude COVID-19 pneumonia. Partially visualized pericardial effusion.

VASCULAR FINDINGS:

Evaluation limited by suboptimal contrast opacification of the arterial vasculature.

Aortic arch calcifications. Atherosclerotic calcifications at the carotid bifurcations without high-grade narrowing. There is multifocal irregular narrowing of the cervical right internal carotid artery estimated at approximately 50%. Multifocal calcifications noted within the cavernous segments of the bilateral internal carotids, with likely flow-limiting stenosis on the right. There is irregular atherosclerotic narrowing of the right greater than left M1 segments.

There is abrupt cut off within the distal M1 segment of the right MCA, consistent with acute occlusive thrombus. Faint contrast opacification is noted within the distalright MCA territory, likely from collateral flow.

Bilateral ACA and left MCA arteries are patent. Posterior circulation is patent. Basilar artery is grossly unremarkable. The vertebral arteries are not well opacified, particularly on the left, likely due to atherosclerotic narrowing.

CT BRAIN PERFUSION FINDINGS:

RAPID analysis demonstrates asymmetric hypoperfusion primarily throughout the right MCA territory, most pronounced within the subcortical right frontal lobe. Mild hypoperfusion is also noted bilaterally within the posterior circulation. Small focus of hypoperfusion is also noted within the anterior left frontal lobe.

No area of reduced cerebral blood flow or volume is identified to suggest core infarct.

CBF<30% volume (mL): 0

Tmax>6.0s volume (mL): 51

Mismatch volume (mL): 51

Mismatch ratio: infinite

Impressions
Abrupt cut off within the distal M1 segment of the right MCA, consistent with acute occlusive thrombus. Multifocal atherosclerotic narrowing of the right internal carotid artery and right greater than left M1 segments as detailed above. Multifocal atherosclerotic narrowing of the left greater than right vertebral arteries.

RAPID analysis demonstrates asymmetric hypoperfusion primarily throughout the right MCA territory, most pronounced within the subcortical right frontal lobe. Mildhypoperfusion also noted bilaterally within the posterior circulation. Small focus of hypoperfusion within the anterior left frontal lobe. No area of reduced cerebral blood flow or volume is identified to suggest core infarct.

CBF<30% volume (mL): 0

Tmax>6.0s volume (mL): 51

Mismatch volume (mL): 51

Mismatch ratio: infinite

Nonspecific peripheral and subpleural fibrosis and ground glass opacities within the visualized lung apices. Correlate with lab results to exclude COVID-19 pneumonia.

Findings
MRI report from 1/3/2021

INDICATION: 69-year-old male presenting with acute right MCA stroke status post mechanical thrombectomy (performed on 12/31/2020).

TECHNIQUE: Multiplanar, multisequence MR images of the head/brain performed without the administration of intravenous contrast.

COMPARISON: CT head without contrast 1/1/2021, CT stroke protocol with perfusion 12/31/2020

FINDINGS:

Restricted diffusion within the right MCA territory involving the putamen, head of the caudate nucleus, frontal operculum, insula and frontotemporal cortex. Tiny punctate focus of restricted diffusion within the left parieto-occipital lobe (series 6 image 40, series 7 image 15). These areas of restricted diffusion demonstrate T2/FLAIR hyperintensity and heterogeneous signal on ADC maps. Diffuse periventricular and scattered subcortical white matter T2/flair hyperintensities are otherwise nonspecific, but likely related to chronic microvascular ischemic change.

Markedly limited evaluation of the axial and sagittal T1 sequences and limited evaluation of the susceptibility weighted images due to motion artifact.

Small focus of susceptibility along the posterior right putamen (series 14 image 47). No other evidence of acute intracranial hemorrhage. No extra axial collection. No mass effect or midline shift. Clear basal cisterns. Normal size and symmetric configuration of the ventricles. Major intracranial vascular flow voids are present, including the right M1 and M2 segments.

Clear paranasal sinuses and bilateral mastoid air cells. Normal and symmetric orbits.

Impressions
1. T2/FLAIR hyperintense restricted diffusion within the right MCA territory, consistent with subacute infarct. Small focus of susceptibility along the posterior right putamen likely represents hemorrhagic conversion. No other intracranial hemorrhage identified.

2. Punctate focus of restricted diffusion within the left parieto-occipital lobe also demonstrating T2/FLAIR hyperintensity, consistent with additional site of subacute infarct.

3. Major intracranial vascular flow voids on T2-weighted sequences are present, particularly the right M1 and M2 segments.

4. Evidence of chronic microvascular ischemic disease.